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Posts tagged ‘Dysphagia Therapy’

Supraglottic and Super-Supraglottic Swallows and Tongue Pressure-Research Review

keep-calm-and-hold-your-breath-67

Fujiwara, S, Ono, T, Minagi, Y, Fujiu-Kurachi, M, Hori, K, Maeda, Y, Boroumand, S, Nitschke, I, Ursula, V, Bohlender, J.  Effect of Supraglottic and Super-supraglottic swallows on Tongue Pressure Production against Hard Palate.  Dysphagia (2014) 29:655-662.  

The Super- and Supraglottic Swallows are maneuvers used to assist in early airway closure to prevent food or drink from being aspirated prior to the swallow.  

Participants:  19 healthy young staff members of the University of Zurich Dental School (13 females, 6 males) with an age range from 17-40.

Equipment:  Tongue pressure measurements were recorded using the Swallow Scan System using a pressure sensor that forms a “T” shape following the curve of the palate.  Participants were seated upright with their heads immobilized by  a head rest.  

Procedure:  This study looked at normal swallow, Supraglottic Swallow (ss) and Super-Supraglottic Swallow (sss).   Each participant swallowed 5 ml of water at room temperature.  For the SS, a syringe was used to inject 5 ml of water into the floor of the oral cavity with the instructions “breathe through your nose, then hold your breath lightly before and during swallowing.  Cough immediately after you finish swallowing.”  For the SSS the same procedure and instructions were given, plus the additional instruction to put the palms of their hands together in front of their chest and press them hard against each other while they held their breath.

Results:  The perimeters measured  were:  duration, maximal magnitude and integrated value of tongue pressure during swallowing.  “The duration of tongue pressure was significantly longer at the anterior-median part of the hard palate during both SS and SSS than with normal wet swallow.  The maximal magnitude increased significantly only at the posterior part of the hard palate during SS, but at all points during SSS.”  Not only do the SS and SSS increase protection of the airway prior to the swallow, they may also function to strengthen the tongue.  

Variations in Tongue-Palate Pressures with Xantham Gum Thickened Liquids-Research Overview

Steele, CM, Molfenter, SM, Peladeau-Pigeon, M, Polacco, RC, Yee, C.  Variations in Tongue-Palate Swallowing Pressures When Swallowing Xantham Gum-Thickened Liquids.  Dysphagia (2014) 29:678-684.

“Thickened liquids are frequently recommended to reduce the risk of aspiration in patients with oropharyngeal dysphagia.”  We know that tongue-palate pressures increase with thicker liquids, however little is known about the differences in swallowing pressures with nectar and honey thick liquids.

“Liquid boluses are initially held in a chamber along the midline groove of the tongue.  The tongue moves upwards and forwards, compressing a bolus against the palate and squeezing it backwards in a conveyer-belt like fashion.  As the bolus reaches the pharynx, the tongue withdraws from the palate, and sweeps downwards and backwards.” 

Participants:  78 healthy adults.  40 (19 men and 21 women) with a mean age of 27 and 38 (22 women and 16 men) with a mean age of 70.  No participants had a history of swallow, motor speech, gastro-esophageal or neurological difficulties.  

Equipment:  Lingual pressures were measured using the lingual manometry module of the KayPentax Swallowing Signals Lab.  Using a soft silicone strip with three pressure bulbs were placed in the palate and measurements were registered at the anterior, mid and posterior hard palate.  Participants took blocks of 4 repeated sips using flavored (lime, raspberry, diet raspberry or cranberry) water, nectar thick and honey thick liquids.  Sip size was not controlled and cups contained 60 ml of liquid.  The cup was instructed to be removed from the lips following each sip.  The xantham thickener was supplied by Flavour Creations, Inc.  

Results:  Healthy adults do recruit higher tongue-palate pressure amplitudes with nectar and honey thick liquids using xantham gum as compared to water.  The authors warn that “although thicker liquids elicit higher amplitudes of tongue-palate pressure compared to water, the observed values should still be easily achieved by most adults, falling below 40% of maximum isometric pressure values.”  It is also important to remember that although thickened liquids require higher tongue pressures to propel, caution is needed when selecting thickened liquids for patients with reduced tongue strength and that viscosity may become too thick to be effective for oral processing.

The authors also warn that there are limitations to the findings including:

  1. That the sweetness of the flavoring may have contributed to the observed pressure differences compared to the water.
  2. Sip volume was not controlled and the influence of the sip size on tongue pressures is unknown.
  3. Participants with dentures had to remove their top plates to avoid damage from glue from the sensors.
  4. Different thickening agents may encourage different results.

Tongue

I think this area will take an interesting turn with the amount of people getting their tongues pierced.  What are your thoughts?

Books to Read….The Source for Dysphagia

Source dysphagia

This has been my go-to guide for quite some time!  I have often referred to this book as my Dysphagia Bible.

If you are looking for a go-to book for information about assessment, treatment and dysphagia in general, this is the book you need to purchase!

The Source for Dysphagia by Nancy Swigert

Swallowing Exercise Aid (SEA)

I saw a tweet about this new Swallowing Exercise Aid yesterday.  I was extremely curious and decided to check out the article.

We’ve had some new research come out on the Chin Tuck Against Resistance (CTAR) and Jaw Opening Against Resistance (JOAR) as well as Isometric Progress Resistive Oropharyngeal Therapy (IPRO).  The common theme here is resistance.

Kraaijenga, SAC, et al.  Effects of Strengthening Exercises on Swallowing Musculature and Function in Senior Healthy Subjects:  A Prospective Effectiveness and Feasibility Study.  Dysphagia (2015) DOI:  10.1007/s00455-015-9611-8.  

This article looked at using a Swallowing Exercise Aid (SEA) in connection with 3 exercises (CTAR, JOAR and effortful swallow with resistance.)  

Ten healthy senior males with a median age of 60 were used in the study.  Inclusion criteria included absence of dysphagia or history of dysphagia.  

Exercises were completed 3x/day for 6 weeks including CTAR, JOAR and effortful swallow with resistance (swallowing with the mandible down and mouth closed).  The SEA device used was the Therabite Jaw Mobilization device with a Therabite Active Band.  The SEA device was used as resistance for all 3 exercises.  

Both CTAR and JOAR were completed isokinetically and isometrically.  For the isokinetic portion, each was completed 30 times with a 1 second muscle contraction.  For the isometric portion, each person was to complete static completion of the exercise for 60 seconds 3 times with a 60 second rest period between hold.  After an additional 60 second break, the person swallowed 10 consecutively using an effortful swallow while pushing the mandible down against the SEA and keeping the mouth closed.  Each exercise session was approximated to last 15 minutes.

Each participant was given written instructions on completion of the exercise.  They were sent 3 daily texts as reminders and used tally sheets to record exercise logs.  Participants were advised to stop exercises if they experienced pain or distress.

Outcomes were recorded prior to and 2 days after the 6 week exercise period.  Outcomes were measured by used of a dynamometer, the Iowa Oral Performance Instrument (IOPI), MRI and Videofluoroscopic Swallow Study (VFSS).  Outcomes measured included:

  • Maximum chin tuck and jaw opening strength.
  • Maximum tongue strength and endurance
  • Suprahyoid mass (Anterior Bell of the Digastric, Mylohyoid, Geniohyoid)
  • Hyoid bone displacement

Outcomes measured following 6 weeks of exercise indicated a significant increase in all of the above along with increased mouth opening and no pain.  Compliance with the program was reported at 86%.  

This program has huge implications for our patients with head and neck cancer.  I’m excited to see where this study may lead.

  

Course Alert-Dysphagia Practice-Moving Toward More Comprehensive Treatment Protocols

Dysphagia Practice:  Moving Toward More Comprehensive Treatment Protocols

NSS

This course if available from Northern Speech Services.  The course description includes:

This clinically focused course brings together six master clinicians to discuss evidence-based interventions that can contribute to a more comprehensive intervention approach when working with persons with dysphagia. These additional interventions will include the benefits of electrical stimulation, effects of lung volume and subglottic air pressure on swallow function, appropriate use of water protocols, strategies to successfully manage persons with dementia, and counseling techniques to address negative emotions and attitudes that block successful treatment outcomes. Offered for 1.2 CEUs – 12 contact hours. Topics and presenters include:

  • When Exercise Programs Are Appropriate for Persons with Dysphagia: Diagnostic Groups Examined Cathy Lazarus
  • Using Maneuvers and Positioning Strategies in the Current Healthcare Environment: Who Can Benefit? And Which Patients Benefit from Sensory Therapy? Cathy Lazarus 
  • Electrical Stimulation: Finally, Something Good To Say About Using It! Ianessa Humbert
  • Rational Emotive Therapy Techniques To Address Psychological Barriers To Successful Swallowing Therapy: Patient Disappointment and Depression Related to Changes in Swallowing Behavior Robert Arnold 
  • Special Considerations for Persons with Cognitive Loss: Memory Strategies and Environmental Adaptations Jennifer Brush 
  • Water Protocols: Rationale and Patient Selection Criteria Kathy Panther 
  • Esophageal Conditions Relevant To Dysphagia Practice Robert Arnold
  • Interventions for Respiratory Disorders: Effects of Lung Volume and Subglottic Air Pressure on Swallow Function, Including Clients with COPD and Trachs/Vents Roxann Diez Gross 

Content Disclosure: The content of this online CE course does not focus exclusively on any specific proprietary product or service. Presenter financial and non-financial disclosures may be found by clicking on the Presenter & Disclosures tab.

Course Format: Audio course with downloadable handout that follows along with the lecture (can be listened to online or downloaded as mp3 files).  Supplementary videos are also provided when prompted throughout this e-course.  Audio recorded in front of a live audience in October 2011. 
I really think this will be my next course.
This course is offered as a Webinar for $149.

Myths in Dysphagia

Maybe you’ve heard of the Dysphagia Therapy Group Professional Edition on Facebook.  Maybe you’re even a member.  It’s definitely worth a look!

https://www.facebook.com/groups/343282762350392/permalink/973310226014306/?comment_id=973424432669552&offset=0&total_comments=25&notif_t=group_comment_mention

One of the  conversations started by a very active member and a friend, became a very hot topic.  Myths heard regarding dysphagia is a hot topic in the SLP world.  Below is a sample of some of the myths that were posted.

If a pt is having trouble swallowing, and SLP cannot eval until the afternoon or next day, put them on puree with nectar thickened liquids bc that’s the safest diet for everyone.”

“Thicker liquids are always safer than thins, so when in doubt, go thicker.”

“If a pt isn’t able to swallow, they should be referred for mbs or fees.”

“Straws are always a no-no.”

“Monitoring temperature for a spike a half hour eating will tell if pt has aspirated.”

“Monitoring O2 during PO intake will tell if pt has aspirated.”

“I had an slp say once that a trach pt can’t aspirate. .”

“A runny nose (absent of other s/sx [signs/symptoms]) indicates aspiration.”

“An NPO (nothing by mouth) recommendation is always a good choice for a pt who aspirates on everything.”

“ALL dementia and Alzheimer’s patients qualify for ST…”

“Chest xrays only show how a person breathes and nothing to do with aspiration”

1) The cuff should be inflated at all times to prevent aspiration. 2) The patient must tolerate cuff deflation for an accurate swallow eval. 3) a Gtube should be recommended if no consistencies are safely tolerated. 4) you should sign off the case if nobody is following your recommendations, 5) a waiver is a good idea when a patient is “noncompliant” so you CYA, 5) other professions should “automatically” understand SLP jargon and interpretations in eval and therapy notes.”

“People who aspirate are all doomed to death by aspiration pneumonia.”

“Patients with dysphagia should never be in reclined during PO”

“Any patient who has “aspiration pneumonia” in their diagnosis must have dysphagia.”

“AND.. Everyone who aspirates will develop pneumonia”

“I accidentally forgot to thicken the patient’s liquids…they didn’t aspirate though…they didn’t cough or anything. Ugh.”

“Any pt who requires pills crushed in purée really needs a swallow eval, even if they have no problem at meals.”

“6) an MBS is a pass/fail exam. 7) an slp can not/should not discuss end of life/hospice options with families, 8) when a patient demonstrates understanding it means they will carryover the strategies into dynamic mealtime behaviors.”

“A patient with no teeth or poor dentition is not capable of managing solid consistencies.”

“All patients could benefit from a chin tuck.”

9) patient advocacy ends with leaving a message for the doc (who never reciprocates communications). 10) irritable doctors should be avoided and communications abbreviated.”

“There is no need to refer a post op cervical surgery patient showing signs of dysphagia as he is definitely going to improve eventually”

“Piecemeal deglutition is abnormal.”

“Feeding tubes prevent aspiration pneumonia.”

“Penetration of barium on MBS is reason to downgrade liquids.”

All patient’s with dysphagia require a spouted beaker”

“When I worked in a SNF (skilled nursing facility), my favorite myth from CNAs was (when a pt was coughing during meals) “raise your arms!” Or “eat some bread” Really??”

“Well it’s not RLL (right lower lobe) pneumonia, so we know they didn’t aspirate.”

“If pt aspirated on all liquid textures, go with the thickest”.

Carbonated liquids are nectar-thickened liquids …”

“A cough always indicates aspiration”

“Alternating bites of food with sips of liquids to clear the oral cavity.”

“Absence of a gag reflex means someone can’t swallow anything safely …”

“Edentulous patients should be put on a puréed diet.”

“Penetration means downgrade. Stop the MBS if you see aspiration. If you have an NPO pt you should never use PO (oral) trials in therapy. MBS at every 30 days.”

“Don’t do a Modified if the family doesn’t want a PEG (feeding tube).”

“the patient is belching frequently, so the SLP should train the patient to not ‘gulp air while swallowing”

“They would swallow if you gave them food they liked better.”

“Straws can not be used with thickened liquids.”

“Thickened liquids at meals only”….

“Aspiration = pneumonia.”

“Objective studies are to see if patient is aspirating” (vs looking for dysfunctions and WHY)”

1) If a pt is on purée, they need their meds crushed.
2) A trache will ‘tether’ the larynx.
3) If a pt aspirates on pudding, don’t try anything else because pudding is the easiest.”

“I had a ‘dietary staff member’ tell my patients wife that whole milk is nectar thick so don’t add thickener.”

“Resident is NPO but it is “OK” to give medication by mouth (with water or food)”

“Lack of gag reflex alone indicates swallow eval when pt is otherwise okay with po intake.”

“Frazier water protocol won’t cause pneumonia. You can just hook them up to vitalstim without doing exercises and it’ll fix the swallow.”

There is a lot of education to provide!  Thanks everyone for your input and thanks Vince for letting me steal part of your idea!

The Swallow in Detail

The Swallow in Detail

 

Taken from: *Dysphagia Foundation, Theory and Practice by Julie Cicheroand Bruce Murdoch*

 

Hunger

Smell of food, empty stomach or electrolyte imbalance informs hypothalamus of the need to eat.

Brainstemactivates nucleii of CN VII and IX to promote secretion of salivary gland juices to prep for bolus

 

Chewing 

Bolus in mouth.  CN VII ensures good lip seal (orbicularisoris) while CN V relays sensory info to brainstem to constantly modify the fine motor control of bolus prep.

Motor activity to CN V, VII, IX, X, XII to create an enclosed environment within the mouth to prepare the bolus.

Cheeksprovide tone (buccinator CN VII).

Soft palate tense and drawn down towards tongue (tensor velipalatini CN V and palatopharyngeusCN IX)

Tongue is drawn up towards the soft palate (palatopharyngeusCN X, styloglossus CN XII).

Hyoidbone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow movement of the mandible).

Bolus prepared by closing (temporalis, masseter, meial pterygoid,lateral pterygoid, CNV) and opening (mylohyoid and anterior belly of digastric CNV, geniohyoid CNXII &C1-C3.)

Bolus pushed around the mouth by actions of the tongue to create a consistent, homogenous texture (hypoglossus, genioglossus,styloglossus and 4 groups of intrinsic muscles of the tongue CN XII). Taste sensations (CN VII and IX) provide info to cortex to stimulate areas of brain required to coordinate the swallow (insulaand cingulatecortex).

 

Voluntary initiation

Once bolus is adequately prepared.

Soft palate elevates slightly (levator veli palatini and palatopharyngeusCN X).

Slight elevation of hyoid bone (suprahyoid muscles contracting on rigid mandible with slight relaxation of infrahyoid muscles.

Pharyngeal tube is elevated (stylopharyngeus CN IX, palatopharyngeusand salpingopharyngeus CN X).

Tongue delivers bolus to force bolus distally towards posterior wall of the pharynx in a “piston-like” manner using hard palate for resistance. Sensation by CN XI and by CN X (pharyngeal plexus).

 

Larngeal elevation

1st motion for tongue to propel bolus into oropharynx is elevated anterior direction toward roof of mouth (mylohyoid and anterior belly of digastric, CNV; stylohyoid and posterior belly of digastric CNVII; palatoplossusCN X; genioglossus, hyoglossus and styloglossusCN XII; geniohyoid CN XII and C1-C3) affects hyoid elevation in an anterior direction.

Soft palate seals off nasopharynx.

Superior constrictors begin medialization of the lateral walls.

Larynx elevated and moved anteriorly in relation to hyoid bone by thyrohyoid CNX.

 

Laryngeal closure

During laryngeal elevation-vestibule closes and rises relative to thyroid cartilage (cricothyroid and intrinsic laryngeal muscles CN X).

Opposition and elevation of arytenoid cartilages provide “medial curtains” of pyriform recesses (aryeppiglottic folds).

Pressure exerted on base of epiglottis causing it to tip and cover the laryngeal vestibule.

Medial constrictors (CN X) “strip” the pharynx by medialization following on from superior constrictors.

Palatedescends (palatopharyngeus CN X), constrictors “strip” and tongue moves posteriorly (styloglossus CN XII) to close oropharynx.

Once the bolus has reached pharyngeal areas innervated by the internal branch of the superior laryngeal nerve swallow reflexive and cannot be stopped.

Anterior and elevated movement of larynx allows cricopharyngeus to be stretched (UES) and opened.

Inferior constrictor finishes medialization and bolus in esophagus.

 
 

Resting state

CNX

Cricopharyngeus resumes tonic state.

Glotticopens and larynx lowers.

Ifbolus present should cough.

Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and the pharyngeal phase with all consistencies should take 1 second.**The ability to contain a bolus is prognostic.**The swallow is a positive pressure phenomena where the pressure is always on the tail of the bolus.

 
 

Triggering the pharyngeal swallow response:

 

        The bolus stimulates CN IX, X, XI in the medullary reticular formation

        (nucleus tractus solitarius) (NTS).

 

        Incoporates (NTS) input from V, VII, XII

 

        NTS signals motor nuclei in teh nucleus ambiguus to help fire IX, X,

        XI.

 

        Nucleus ambiguus innervates muscles of the velum, pharynx, larynx,

        and upper esophagus (IX, X, XI) producing the pharyngeal swallow

        response.

 

       Strongest ties to the NTS=anterior faucial arches, posterior tongue at

       the lower edge of the mandible, valleculae, pyriform sinuses and

       laryngeal aditus.

 

       The anterior faucial arches have a strong connection between the

       sensory receptors and NTS via afferent fibers of the glossopharyngeal

       nerve (IX) creating a trigger point for younger adults.  (Swallows in

       older adults may trigger lower.)

Exercises, Techniques, Compensations

Maneuvers/Exercises

 

Supraglottic Swallow

 

To close vocal cords prior to the swallow.

 

For dysphagia accompanied by reduced or late vocal cord closure or delayed pharyngeal swallow.

 

Changes timing of PES opening, duration and timing of hyoid excursion and laryngeal closure, timing of BOT movement.  Closes vocal cords earlier in the swallow, prolonging hyolaryngeal excursion before and during swallow.

 

Logemann recommends 10x/day x5 min with 5-6 swallows each time.  (Frymark et al 2009)

 

Research shows:

  • 13/15 subjects with CVA showed abnormal cardiac findings (Chaudhuri et al 2005)
  • laryngeal elevation was prolonged until postswallow exhalation was completed.  6/8 people had increased hyoid/laryngeal elevation after inhalation.  5/8 swallows with visible movement of arytenoid cartilage and vocal fold closure (Bulow et al 1999)
 

Super Supraglottic Swallow

 

For early closure at the entrance to the airway.

 

Facilitates timing and extent of laryngeal closure at specific levels of the larynx.

 

For dysphagia secondary to reduced closure of the airway entrance, with increased PES relaxation pressure and duration of hyoid excursion and laryngeal movement, with decreased time between PES opening and onset of hyoid movement and BOT movement time between PES opening and the onset of vocal fold adduction and laryngeal closure (Frymark et al 2009)

 

Research shows:

  • 13/15 subjects with CVA showed abnormal cardiac findings (Chaudhuri et al 2005)
  • increased extent and duration of tongue base motion to the posterior pharyngeal wall, max laryngeal elevation and laryngeal vestibule/true vocal fold closure with increased bolus clearance (Logemann 2006)
 
 

Mendelsohn Manevuer

 

To assist in laryngeal elevation.

 

 The Mendelsohn is an exercise of resistance/endurance to increase tongue-base/pharyngeal wall pressure and contact duration with increased supra hyoid constriction and PES opening.

 

The Mendelsohn can be used to:

  • increase timing of laryngeal elevation
  •  increase peak pharyngeal pressure
  •  increase PES opening duration
  •  increase duration of laryngeal elevation
  •  facilitate clearance of residue

Evidence shows:

  • sustaining laryngeal elevation for 1.5 seconds or more with increase in sub mental muscle group (anterior belly of digastric, mylohyoid and geniohyoid) (Ludlow et al 2007)
  • increased extent and duration of tongue base motion to the posterior pharyngeal wall with max laryngeal elevation and laryngeal vestibule/true VF closure with increased bolus clearance (Logemann 2006)
 

Masako Technique-Increases anterior motion of the posterior pharyngeal wall at the level of the tongue base.

 

Resistive exercise.

 

The Masako should not be used with any bolus.

 

Increases:

  • anterior motion of the posterior pharyngeal wall at the level of the tongue base
  • strength of tongue base and pharyngeal constriction
  • efferent (motor) drive of tongue base
  • pharyngeal clearance
 

Shaker

To assist in laryngeal elevation and cricopharyngeal opening.

 

Exercise of resistance/endurance to increase laryngeal anterior excursion and opening of the PES.

 

Increases efferent drive of hyolaryngeal excursion and PES opening.

 

Targets the anterior belly of the digastric, mylohyoid, geniohyoid (hyoid elevation muscles).

 

Research shows:

  • decreased post-deglutitive aspiration from decreased PES opening and enduring effect in maintaining oral nutrition (Easterling 2002)
  • significant effects to swallowing (as did traditional therapy) with reduced post swallow aspiration (Logemann et al 2009)
 

Effortful Swallow

Increase strength of the overall swallow.

 

Exercises of resistance and endurance to increase tongue base retraction, lingual propulsive force, oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, duration of pharyngeal pressure and PES relaxation.

 

Can add various bolus textures to increase resistance and strengthening.

 

Research shows:

  • increased force-generating ability for swallowing muscles (Frymark et al 2009)
  • evidence of early elevation of the hyoid at initiation of the effortful swallow (Bulow et al 1999)
  • increased motoric output (activation) of submental swallowing muscles (Sapienza et al 2008)
  • heightens pre-swallow sensory input (Logemann 2006)
  • combined with NMES is resistive with increased extent of laryngeal excursion in post-stroke patients (Park et al 2012)
 

Exercise

 

Lingual exercise with resistance (tongue depressor)/Iowa Oral Performance Instrument

 Lingual exercise with resistance SwallowStrong Device (Formerly the MOST)

Research shows:

  • 8 weeks of training, 3 sets, 10 reps 3x/day using IOPI, lingual strength increased, improved swallow with liquid bolus with reduced Penetration/Aspiration scores (Robbins et al 2008) (Robbins et al 2005)
  • 3 groups, 1 with no exercise, 1 with tongue depressor and 1 with IOPI.  Exercise 5 days/week for 1 month, 10 reps 5x/day for lateralization, propulsion and elevation.  Change in both exercise groups with little difference between IOPI/tongue depressor.  No change in endurance. (Lazarus et al 2003)
  •  
  • 8 weeks lingual training, isometric exercises using IOPI with increased isometric and swallowing pressure, increased airway protection.  2 subjects with increase lingual mass.  (Robbins et al 2007)
 

Mastication exercises

 

Use changes in:

texture

viscosity

temperature

sour

 

Weighted bolus

 

Add viscosity and use challenging bolus

 

 

Back of tongue exercises

 

Pull tongue straight back

Yawn and hold tongue at most retracted state

Gargle and hold tongue at most retracted state

(From Jeri Logemann’s book)

 

Oral manipulation exercises:

 

cheese cloth with bolus, toothetter, sucker, gauze (resistive to increase coordination)

 

Suck Swallow

 

Increases the speed of initiation of the pharyngeal swallow

 

May want to have the person suck a thick bolus through a straw, such as applesauce, thickened liquids, yogurt or pudding.

 
 

Postures

 

Chin Tuck

 

To assist in closing the airway by narrowing airway.  Also varies pressures in pharynx and PES during the swallow, duration of timing of swallowing events and displacement of anatomical structures during the swallowing.

 

Research shows:

  • More aspiration with chin tuck than with NTL or HTL, however more adverse affects with thickened liquids (dehydration, UTI, fever) (Robbins and Hind 2008)
  • Significant change in pharyngeal contraction pressure, duration of pharyngeal contraction pressure, larynx to hyoid bone distance, hyoid to mandible distance before the swallow with decrease in angle between mandible to posterior pharyngeal wall, angle between epiglottis to PPW of trachea, width or airway entrance, distance from epiglottis to PPW.  (Frymark et al 2009)
  • Effective in 72% of patients, but may be contraindicated in those with weak pharyngeal contraction pressure as it decreases pharyngeal contraction pressure and duration (Robbins et al 2005) (Lazarus et al 2003)
 

Head Turn

 

Closes the weak side of the swallow directing the bolus to the stronger side.  Also decreased PES resting pressure on side opposite of rotation and increased anterior/posterior opening diameter.

 

Research shows:

  • decrease in PES resistance to bolus flow and prolongation of PES opening providing bolus more time to clear from pharynx.  (Frymark et al 2009)
 

Head Back

 

Uses gravity assistance to help with lingual deficits.

 

To assist in oral phase (must have functional airway protection and functional triggering of the pharyngeal swallow).

 

Side Lying

 

To help clear pharyngeal residue by altering gravity.

 

May help to clear pharyngeal residue.

 

Before the person sits upright, have cough to clear final residue.

 

Sensory Stimulation Techniques-

 

Tactile Thermal Stimulation

 

Thermal Gustatory Treatment

 

Deep Pharyngeal Neuromuscular Stimulation.

 
 

Therapy Techniques

EMST

MDTP

sEMG

Pharyngocise

CTAR (Chin Tuck Against Resistance)

 

Tips to Remember in Therapy:

 

Murray, Larson and Logemann 1998 found:

 

    Lip Strength:

    It takes very little lip strength to maintain a small liquid bolus.

    Increase in muscle activation as bolus size increases.

    Simple lip contact with spoon or cup=decreased muscle activation.

    Straws=increased activation.

 
 Tongue:
 

     General tongue movement patterns for bolus transport is quite

              stereotypical.

 

      Timing of movements may vary, movement pattern remained the same.

 

      Tongue presses against the hard palate segmentally and sequentially.

 

     Timing for lingual movements for continuous swallow-differed      substantially from movement timing in discrete swallows.

 

      Full contact of the tongue with the palate not seen in all continuous swallows.

 

Laryngeal Protection:

 

     3-Tiered Protection of the airway:

         Inversion of epiglottis over laryngeal aditus.

         Closure of false vocal folds.

         Closure of true vocal folds.

Dysphagia Tools

Here is a list of dysphagia tools that are commercially available.  Dysphagia Ramblings does not endorse any commercial tool for dysphagia.  

Thermal Stimulation

 Ice Fingers

 Laryngeal Mirrors

 ARK Thermal Tip for Z Vibe

 Thermo-Stim

 

Vibration

 Z-Vibe

 Mini Vibrator

 

EMST

 Aspire 150

 

Modified Barium Swallow Chairs

 Transmotion TMM3 Chair

 Hausted VIC Chair

 

MBSS

 Tims

 FEES

 NDOHD

 KayPentax

 

Thickeners

 Thick It

 Thick N Easy

 Thik N Clear

 Simply Thick

 ThickenUp

 Variety of modified food consistencies

 

MDTP

 Course

 

SwallowMist (Misting Device for NPO)

 Swallowmist

 

Measuring Outcomes

 Dysphagia Outcome Severity Scale (DOSS)

 Eating Assessment Tool (EAT-10)

 Functional Independence Measure/Functional Assessment Measure (FIM/FAM)

 Functional Oral Intake Scale (FOIS)

 The Mann Assessment of Swallowing Ability (MASA)

 M.D. Anderson Dysphagia Inventory (MDADI)

 National Outcome Measurement System (NOMS)

 Penetration/Aspiration Scale

 SWAL-QOL and SWAL-CARE-email the author at colleen_mchorney@merck.com

 

Lingual Strengthening

 Iowa Oral Performance Instrument

 Tongue Depressors

 Ora Light

 MOST

 

Modified Shaker**

 Neckline Slimmer

 

Stimulation

 Nuk Massagers

 

Straws

 SafeStraw

 TheraSip Swallowing Trainer System

 TheraStraws

 

Neuromuscular Electrical Stimulation**

 VitalStim

 eSwallow

 SpectraMed Electrodes

 

Modified Utensils

 Wedge Cups

 Provale Cups

 

 

Assessment Tools

 Labial Goniometer

 Stethoscope

 4″ by 4″ Gauze

 Tongue Depressors

 Handheld Mirror (I bought mine at Dollar General)

 Penlight

 Dum Dum Suckers

 Dysphagia Toolbox – Free assessment materials

 

Education

 Blue Tree Publishing

 ASHA Swallowing

The Dysphagia Buy-In: Selling Your Services

My colleague Jonathon Waller, over at the Dysphagia Cafe posted recently. I LOVE his post. If you haven’t read it yet, you definitely need to. Dysphagia Therapy: More Rehabilitation and Less Compensation.

I think the reason I love this post, and asked him if he minded if I expanded on it, was because THIS IS MY LIFE!

I have definitely had the buy-in aspect. I live and work in Smalltown, Nowhere. People typically have not heard about this “dis-fay-gee-ah” thing.

I go into a room to work with a patient or they come to see me as an outpatient and they have NO idea why they’re there. They swallow just fine and have no problem speaking. Even though they cough and choke with every sip of water.

I find the majority of my evaluation is getting the person to “buy-in” to therapy. They’re not going to continue to come in for therapy if they don’t know what I’m doing.

Let’s face it, we’ve given ourselves a bad name at times. Have you ever had that patient that actually comes to you from another SLP with a 10 page list of exercises that they need to complete 10 times each, 3 times a day, including, but not limited to: stick your tongue out, up, side to side, say every /k/ and /g/ word known to man, stick out your jaw and hold it tensed for 5 hours……you get the picture. Now ask these people why they do these exercises and they have no idea.

I explain the swallowing system to the patient. These are muscles that we work with and when we don’t use those muscles or don’t use them as we’re supposed to, we lose the ability for those muscles to perform the way they are meant.

I often teach my patients, it’s like when you hurt your leg or ankle and limp for several days. You then create other problems because you are walking in a manner you were not meant.

I then teach them how I’m going to help. There’s homework. You don’t do your homework, you may not get better. There’s work to be done in my room. However, I can’t fix this in one session. Much like you can’t expect to go to the gym and after one day of lifting weights look like Arnold Schwarzenegger from the 80’s.

I ask them to give me 4-8 weeks along with the home-exercise program.

We use NO compensation in the therapy room. By using those compensations 100% of the time, we’re not teaching them to swallow without and building pathways FOR those compensations. (After all, who wants to tuck their chin, stand on their head and count to 25 when they swallow).

My patients EAT and DRINK in my therapy room. They don’t stick out their tongue at me or say “cook” with an emphasized /k/ sound. They SWALLOW.

Happy Swallowing Rehabilitation. P.S. I’m all for Swallow Pathologists, Dysphagiologists, anything that distinguishes us by what we do!! Maybe Dysphagia Rehabologists?? I say we put it to a vote!