The SLP and the Dining Room

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I can’t even count how many times I have started work in a new building or started a new PRN job and been told meal times so that I can go sit with patients during their meals for their therapy time.  It’s easy, right.  I go sit in the dining room and “observe” 8 patients for signs and symptoms of dysphagia that I’ve already identified and remind patient A to use a chin tuck and patient b to eat at a slower pace.

This is how I learned dysphagia therapy.  What was taught to me was to sit with them during the meal to work on trials, observe those trials and remind them to use their strategies.  The reality:  I tried to do my “job” however Mrs. Smith needed more coffee, could I be a dear and run Mrs. Brooks to the bathroom?  I could never do my “job” because I was a waitress.  With no tips.

Not only could I not do my “job”, I was not doing anything for those patients!  That is not rehabilitation.  Look at it this way, if we never stress the system and remain at status quo, how will it improve?  If I’m trying to run a 5k, I’m going to push myself to keep going a little further.  If I continue to run around the block, I will never build the strength and endurance for a longer run.  If we never challenge the swallowing system with a more difficult bolus, then how will my patient upgrade their diet.

Therapy should not be in the dining room.  Just like I don’t want a physical trainer to show up in the middle of my meal, our patients don’t want us popping in at their meal time and “working” with them.

Let’s challenge our patients and stop the observation!

The Patient Exercising Their Right to Choose (Formerly The Non Compliant Patient)

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EDIT 1/4/17.  Due to a recent Facebook post, I wanted to change some wording on this post.  As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.

Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”  

There was post recently on the Special Interest Group (SIG) 13 email blast.  An SLP was asking what to do with a noncompliant patient.

When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged.  The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.

My belief system is not the same, fortunately for my patients!

First, think about this.  Aren’t the noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about?  The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make.  They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe.  The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety.  That is the patient that may be most at risk for aspiration pneumonia.

In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity.  I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.

The best thing we can do for our noncompliant patients is to educate and rehabilitate.  Why not make them safer with the consistency they choose?

The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care.  If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow.  I recently wrote a post about oral care which you can find here.

It’s important to remember that we want the patient to succeed with the diet they choose to consume.  We can recommend a safe diet and we can advise but we have to focus on the rehabilitation.  Just remember, not everybody that aspirates develops aspiration pneumonia.  There are functional aspirators.

You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia.  Just because that patient does not choose the diet you recommend does not mean you give up on them.  If they are willing to put in the work and give you some time (they will have to buy-in to your program)  THOSE are absolutely  patients with whom we should work.

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

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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?

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

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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.