Dysphagia Therapy

“Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes”

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If you are considering joining or starting a head and neck cancer program, this is the read for you!

I was searching through articles this morning and found this very article stating the importance of a team approach and a systematic approach to head and neck cancer!

“Head and neck cancer guidelines recommend multidisciplinary team monitoring and early intervention.”

Prophylactic treatment for head and neck cancer has been found to increase maintenance of tongue muscle mass, preserve some taste and have an overall improved swallow.   The SLP should be right in there, from the beginning to determine baseline swallowing function and to provide education for what may happen to the swallow.

“We need patient care using a systematic approach for head and neck cancer.”

Read the research.  Keep up with the new approaches and utilize them in  your therapy.  Dysphagia assessment and treatment approaches are ever-evolving and you have to stay current to provide your patients with the best care possible.

With the multidisciplinary Approach:

  • Improved outcomes
  • Better survival rates
  • Maximize results through use of a coordinated pathway
  • Increase efficiency in care delivery
  • Reduce cost
  • Shorten the length of the hospital stay
  • Improve overall patient outcomes

Who should/may be on the multidisciplinary team:

  • Head and Neck Surgeon
  • Medical Oncologist
  • Radiation Oncologist
  • Nursing
  • Speech Language Pathologist
  • Dietician
  • Social Worker
  • Administrative Professionals (Systems Analyst, Clinical Research Coordinator)

“A significant impact of Head and Neck Cancer is typically the impact on swallowing and inadequate nutritional intake.”

The SLP plays a vital role in the assessment and treatment of swallowing.

“Prophylactic and ongoing Speech Language Pathology services can be vital by impacting swallow function, nutritional status and overall quality of life.”

We’re not just one and done.  Even though the patient may not initially have difficulty with swallowing early in their treatment doesn’t mean it will never happen.   You need to check up on the patients throughout their course of treatment and even after their treatment to continue to assess the impact on swallowing.

Collecting Data:

Patients undergo a pre-treatment MBSS (Modified Barium Swallow Study) and/or FEES (Flexible Endoscopic Evaluation of Swallowing).  Also completed with patients:

Prophylactic Exercises Included:

  • Lingual strengthening
  • Masako Maneuver
  • Effortful or Supraglottic Swallow
  • Mendelsohn Maneuver
  • Shaker
  • Therabite (incisal opening less than 40mm)
  • EMST (increase airway clearance/protection)

*Exercises completed 2x/day, 6 days/week

References:

Dance Head and Neck Clinical Pathway (D-HNCP)

Messing, B. P., Ward, E. C., Lazarus, C., Ryniak, K., Kim, M., Silinonte, J., … & Sobel, R. (2019). Establishing a multidisciplinary head and neck clinical pathway: An implementation evaluation and audit of dysphagia-related services and outcomes. Dysphagia, 34(1), 89-104.

 

They won’t follow my recommendations so let’s burn them at the stake!!

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OK, so we’re probably not going to be burning any patients at the stake. I’m fairly certain that you may lose your license for that!

I’m sure we’ve all been there though.  We do a thorough assessment of a patient.   We obtain instrumental assessment just as we were advised.  We make recommendations based on the assessment and instrumental assessment. Then the patient decides they don’t want to follow those recommendations. They decide that they don’t care for the thick liquids and they’re just going to drink regular liquids. So then what do you do with this immaculate plan of care that you’ve taken hours to write.

Some People say that if patients don’t follow recommendations then we need to educate the patient and discharge them due to noncompliance.

Why would you discharge a patient because they don’t follow your recommendation? Isn’t this the person that probably needs your help more than any other?

So think about this scenario. You go to the doctor and find you put on a few extra pounds.   The doctor may recommend that maybe you need to add exercise to your day. Your first thought is sure pal where do you think I’m going to add this exercise into my day? Before I start waking the kids to hours before they actually have to be up so that I can get them out of bed?  Should I add it in at the end of my day after I worked a full time job to go to my PRN job(s) and then to cheer on my kids in whatever sporting events they might be participating this season?  Maybe you don’t understand what I do and how busy I am and I’m top of everything else I have to do at home and at work, I’m expected to keep up with journal articles and best practices. So you tell me when I’m going to add exercise into that day and still have time to sleep at night.  You probably don’t say that.   You may think it as you tell the doctor you’ll do your best try to get a little more exercise.

You go back to the doctor and you’ve only exercised a couple of days in the last four weeks. Now how would you feel if your doctor then said, you know, you haven’t done what I’ve asked you to do and if you continue this lifestyle you are going to end up with high cholesterol, high blood pressure, diabetes, or a number of other conditions. So since you are not following my recommendations, I’m going to sign off on you as a non compliant patient.

Now think of this patient that has possibly had some life altering issue. Maybe they’ve had a stroke or maybe they were recently diagnosed with Parkinson’s disease and all of a sudden have a swallowing problem.  In walks Susie SLP who says everything you eat and drink is going down into your lungs so what I’m going to need you to do is put this delicious thickener in your drinks and then purée all your food.   If you don’t do this, you can aspirate, develop pneumonia and possibly die.   

Some patients try.   They really do. Like you tried that new diet that eliminated all sugar. You did really well until somebody brought in a cake that was just a little too tempting. It’s the same thing for patients. They see other people eating during commercials on TV for whatever restaurant is seen being advertised. They try the thickener in their drinks and say heck with this I’ll take my chances with pneumonia.

The bottom line is, the patient is the one that makes the final decision. Our license and our CCC allows everyone know that we have completed the requirements to practice speech language pathology in each state or in a given facility. Our license does not state that we are now food police and have to monitor every item that goes into our patient’s mouth. If we make recommendations that are ethical and driven by best practice for our patient why would anybody take away our license because the patient decided to not follow all of our recommendations.

Document document document.

Educate educate educate.

Have a conversation with your patient and explain to them why you made the recommendation and what is going on. Educate on oral care and compensation if tested and effective during instrumental assessment.    Let the patient decide on their plan of care with you and the care team.   Maybe the decision is to not follow diet recommendations but to follow a plan for oral care and rehabilitation for the swallow.   

Stay tuned to more information on why your patient may refuse!   

ISO-SED

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A huge thanks to Jolie Parker for sending me an ISO device for this blog post!!

I am always trying to find an exercise that is fairly easy for my patients.  A great exercise is the Shaker.  The guidelines for repetitions are provided!  Not many exercises come with instructions for reps.  The Shaker focuses on the suprahyoid muscles and assists with UES opening, reducing pyriform sinus residue.

The problem with the Shaker is that it is very difficult to complete.

One thing I do know about exercise is that by adding resistance, you are adding “weight” to the exercise.  Now, most people don’t run to the gym to lift “air weights”.  They left weights and then add to the weight to increase muscle and strength.

I recently wrote a post about an article for CTAR or Chin Tuck Against Resistance.  Another great article to read is about an exercise called Jaw Opening Against Resistance.  CTAR is very similar to the Shaker, however the patient remains seated upright and use a device for the resistance.

Initially, I used the Neckline Slimmer as resistance.  The Neckline Slimmer is a tiny little device with a spring inside.  You push down using your chin on the top until you can no longer push.  The bottom portion of the device is on your chest so you are doing a chin tuck.  The spring offers resistance.  The spring is also interchangable and comes in low, medium and high resistance.

Neckline Slimmer

The trouble with the Neckline Slimmer, which was created to help people eliminate a double chin, doesn’t last as long as I long as I would like it to last.  It also can be a little painful for my elderly patients, who are very thin especially.   The plate that rests against the chest often hurt the patient.

Now, if you are on Facebook and “like” anything dysphagia-related, you have probably seen the ISO device.  This is a device created for the CTAR and JOAR exercises!  It is a larger device with padding on both the chest piece and the chin piece.  The device is made from a flexible polycarbonate and is easy to hold and to use.

isosed

A video demonstrating use of the ISO Swallowing Exercise Device (ISO SED) can be viewed here.

The ISO SED can be purchased for $99, however can be used with multiple patients as it has chin pad covers.  The ISO was used with considerably more ease than the Neckline Slimmer, is more durable and less painful.

If you are interested in checking out the ISO SED, you can find more information here.

Clark, H.M. (2005).  Therapeutic exercise in dysphagia management:  Philosophies, practices and challenges.  Perspectives in Swallowing and Swallowing Disorders, 24-27.

Burkhead L.M., Sapienza C.M., Rosenbek J.C. (2007).  Strength training exercise in dysphagia rehabilitation:  Principles, procedures and directions for future research.  Dysphagia; 22:  251-265.

Clark, Heather M. “Neuromuscular Treatments for Speech and SwallowingA Tutorial.” American Journal of Speech-Language Pathology 12.4 (2003): 400-415.

Wada, Satoko, et al. “Jaw-opening exercise for insufficient opening of upper esophageal sphincter.” Archives of physical medicine and rehabilitation 93.11 (2012): 1995-1999.

Yoon, Wai Lam, Jason Kai Peng Khoo, and Susan J. Rickard Liow. “Chin tuck against resistance (CTAR): new method for enhancing suprahyoid muscle activity using a Shaker-type exercise.” Dysphagia 29.2 (2014): 243-248.

Course Alert-Evidence Based Practice

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critical_thinking_skills

Image from:http://thecollaboratory.wdfiles.com/local–files/philosophy-of-thought-and-logic-2011-2012/critical_thinking_skills.jpg …

Northern Speech Services has a new course called:  Evidence-Based Practice In Adult Dysphagia Management: What The Evidence Says About Commonly Selected Rehabilitation Interventions.  This is a webinar by Ianessa Humbert, Catriona Steele and Phoebe Macrae.

I took this course over the weekend.  It was GREAT!  It starts with approximately 35 minutes of review of the anatomy and physiology by Dr. Humbert.  The second section is close to 2 hours and discusses 4 compensations/exercises including:  chin tuck, Mendelsohn Maneuver, Shaker and the Effortful Swallow.  Evidence for each of the 4 techniques is discussed and a look at critically appraising techniques/exercises for dysphagia.  A case study is provided for each.

This course only looks at 4 exercises/compensations, however it also breaks down the critical assessment for each, allowing the viewer to apply the same principle to any exercise/compensation.

I would definitely recommend this course to anyone working with patients with dysphagia.

Carbonated Beverages

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carbonated

Carbonated beverages have hit the dysphagia world by storm.  Much of the recent dysphagia research has focused on the sensory portion of the swallow and how sensory drives the swallowing process.  Part of the sensory process is carbonated beverages.  One of the common misconceptions at this time is that carbonated beverages act as a nectar thick liquid.

Carbonation is a sensory option for dysphagia rehabilitation.   It’s effective through a process called chemesthesis, where the “bubbly” or “fizzy” of the carbonated beverage acts as a Trigeminal irritant.  The Trigeminal Nerve or Cranial Nerve V is one of the major swallowing nerves.  The Trigeminal Nerve has bare nerve endings making it more susceptible to sensory or afferent input.

Rather than acting as a nectar thick liquid, the carbonated beverage actually increases the sensory stimulation for the swallow.  Sensory input (afferent drive) drives the motoric output (efferent drive).

Research of carbonated beverages shows:

No significant effect on oral transit time, pharyngeal transit time, initiation of pharyngeal swallow or pharyngeal retention.  Carbonated beverages sis however decrease penetration/aspiraiton with 5 & 10 ml swallows.  (Saravou & Walshe).

Carbonated thin liquid significantly decreased the incidence of spillover, delayed pharyngeal response and laryngeal penetration compared to non-carbonated thin liquids.  (Newman et al).

Drinks containing chemical ingredients that activate sour and heat receptors alter swallowing physiology greater than water.  (Krival & Bates).

It is likely that sour and carbonated beverages reflect a more organized activation of the submental muscles because of more effective afferent input to the Nucleus Tractus Solitarius.  (Miura, et al).

One of the important issues to consider when looking at research involving carbonated beverages is that the researchers in these studies do not use Coke, Pepsi or Sprite.  They use Ginger Brew, Club Soda or carbonated citrus.

It is vital, as with any other compensation or technique to view the effects of carbonated beverages.  As with other strategies, you may not see the same effect in every patient and sometimes, the strategy you choose may make the swallow worse.

Krival K, Bates C. Effects of Club Soda and Ginger Brew on Linguapalatal Pressures in Healthy Swallowing. Dysphagia (2012). 27: 228-239.

Newman, et al. Carbonated Thin Liquid Significantly Decreases the Incidence of Spillover, Delayed Pharyngeal Response and Laryngeal Penetration Compared to Non-Carbonated Thin Liquids. Dysphagia 2001: 16: 146-150.

Saravou K, Walshe M. Effects of Carbonated Liquids on Oropharyngeal Swallowing Measures in People with Neurogenic Dysphagia. Dysphagia(2012) 27: 240-250.

Miura, Yutaka, et al. “Effects of taste solutions, carbonation, and cold stimulus on the power frequency content of swallowing submental surface electromyography.” Chemical senses 34.4 (2009): 325-331.

Upcoming Articles!!

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One thing I love about the Dysphagia journal, is not only the great research it provides me 4 times a year.  I love the abstracts for the upcoming (now past) Dysphagia Research Society (DRS) conference.  

This year was no exception for exciting new research to come!

Some titles that I am very excited to look into:

  • The Effects of Taste Concentration on SEMG in Swallowing-(Spoiler:  High concentraion sour stimuli elicit higher amplitudes and longer durations on SEMG).  
  • Esophageal Screening as an Adjunct to the Videofluoroscopic Study of Swallowing.  
  • Sour Bolus Facilitates Spontaneous Swallow in Parkinson’s Disease
  • Effects of Age and Sensation on the Anticipatory Stage of Swallowing
  • Physiological Factors Related to Aspiration Risk:  A Systematic Review
  • Pharyngeal Tactile Stimulation Using A Nylon Thread for Enhancing Pharyngeal Sensory Perception

These are just a few of the exciting titles that have caught my attention.  

If you are interested in the Dysphagia journal or the Dysphagia Research Society conference at a discount, make sure to join the Dysphagia Research Society!

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