MannaQure

                                                  






How Did I Ever Find MannaQure?

This always happens to me during the ASHA convention.  I get to a point that I am, well, maybe a bit silly and start Tweeting about crazy things.  This is the time that my following rises the most.

This year was no different.  As I was Tweeting various pictures of our friend Mary, I had a new follower called MannaQure.  Naturally, I was wondering what my Tweets had to do with my nails.

I first looked at the website.   MannaQure is a comprehensive dysphagia and dysarthria evaluation.  Not only is it an evaluation, but it is designed for Spanish speaking patients.

I was wondering about the name.  I couldn’t make the connection.  On the website, it states that:  “Manna”-Found in the book of Exodus, the food that was miraculously provided for the Israelites in the wilderness during their flight from Egypt. “Manna”-Mentioned in the bible, spiritual nourishment of divine origin. MannaQure is pronounced Manna.”


What Is MannaQure?


I found the MannaQure booth the next day in the exhibit hall.  The protocol for this evaluation has the questions/instructions written in English, in Spanish with pronunciation for those that do not speak Spanish and just in Spanish for those that are able to speak Spanish.  All on the same protocol.


It looked like a fairly comprehensive evaluation, with a few questions regarding cranial nerves.  I would love to have more time to look over this evaluation.


The complete set sells for $225.  The Examiner’s Manual alone is $125, 25 Questionnaires are $45 and 25 Protocols are $55.


If you work with Spanish Speaking patients, this may be an evaluation to look at.

Pudding and a Straw

                                                                                

Picture from: http://www.busymomboutique.com

Haven’t you always wanted a very simple exercise that will work and strengthen the entire swallowing mechanism using resistance?  I do as well.  I have an exercise that I use all the time with my patients.  I am usually chastised by my co-workers when having patients use this exercise.  Patients give me a strange look until they try it.

This exercise has no fancy name.  I call it……..Pudding with a Straw.  It is exactly as the name implies.  The patient drinks pudding through a straw.

So first, let’s look at the evidence…….  I take into account that, from reading research…..I know using a straw increases labial activation.  A thicker, heavier bolus can add resistance to the swallow and can actually increase the movements both orally and pharyngeally with the swallow.   Using an effortful swallow increases sensory input to the swallowing mechanism.  Swallowing is a sub maximal event as a whole, but when the patient focuses and purposefully uses a more effortful swallow, there is an increase in the muscle contraction of the entire swallowing mechanism.

I take all of this into account and then try the method myself, to see what I feel.  When I drink pudding through a straw, not a Panera smoothie straw, not a regular drinking straw, a cocktail straw/coffee stirrer size straw, I can feel a difference.  My lips purse together with increased effort.  My tongue retracts and tightens, my jaw tightens.  I then suck enough pudding through the straw to swallow and use an effortful swallow.  At one time, I have incorporated straw use with a safe consistency bolus for most, an effortful swallow and a weighted bolus.  I have also used the entire swallowing structure.

I believe it is important and necessary that we look at the swallowing mechanism as a whole, a process, rather than 4 parts.  It’s great to break the swallowing system down into phases for descriptive purposes, but every part of the swallow is connected in some manner and every part of the swallow deserves some attention.

Now, keep in mind, not every patient can start at the level of a small cocktail straw/coffee stirrer or even the pudding.  I can modify the straw by either using a larger diameter straw (Panera smoothie straws seem to be the largest I’ve found at this point).  Regular drinking straws also work very well.  Not only can I change the diameter of the straw, I can change the size of the straw by cutting it in half or in thirds.  The shorter the straw, the easier the task.

Now, keep in mind, the viscosity of pudding can be varied as well.  Many times I will use a thickened liquid or applesauce for patients that are not able to start with pudding.  I may work up to yogurt, without the fruit.  Then with the pudding, in my experience, I have found that sugar-free pudding seems to be the thinnest, followed by home-made, then Snack Pack pudding.  Snack Pudding, the chocolate seems to be the lesser viscous, followed by butterscotch, with vanilla having the thickest viscosity.  Room temperature vs. refrigerated also makes a difference.  Room temperature pudding is a little less tedious for the patients, while with the refrigerated, I’m also adding the temperature aspect to my sensory portion of therapy, in addition to the difficulty of the task.

I don’t write a goal for the patient sucking pudding through a straw.  We may be working on lingual strengthening, pharyngeal strengthening, tongue base retraction, labial seal.  I don’t write my notes as “the patient was able to drink a Snack Pack cup of refrigerated chocolate pudding.”  We were working on using an effortful swallow, straw sucking for increased labial seal, weighted bolus for resistance.

Now I do time my patients and keep track of the time.  I will time the patient to see how long it takes to complete the task.  As the patient gains strength with the task, the time should decrease.  You can also use e-stim or sEMG with your patient as they are completing the task.

I don’t stress if the patient needs the entire session time to complete the task.  This is what I want them to do!!  I want the patient to use an effortful swallow.  I want to apply the rules of neuroplasticity and use a specific swallowing task, applying resistance and specificity.  My patient is swallowing, using both an effortful swallow with a focus of tongue to palate contact and using a weighted bolus with the thick pudding.

I challenge you to try this exercise.  Try the vanilla with the coffee stirrer/cocktail straws and feel what the exercise does for you!

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

 

Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.

 

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, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial.

 

Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.

 

Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.

 

Wheeler-Hegland, K.M., Rosenbek, J.C., Sapienza, C.M.  (2008). Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  Journal of Speech, Language and Hearing Research, 51, 1072-1087.

 

Burkhead LM.  Applications of Exercise Science in Dysphagia Rehabilitation.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia) June 2009; 18: 43-48.

 

Park JW, Kim Y, Oh JC, Lee HJ.  Effortful Swallow Training combined with Electrical Stimulation in Post Stroke Dysphagia:  A Randomized Controlled Study.  Dypshagia (2012).  DOI: 10.1007/S00455-012-9403-3.

 

Bulow M, Olsson R, Ekbert O.  Videomanometric Analysis of Supraglottic Swallow, Effortful and Non Effortful Swallow and Chin Tuck in Healthy Volunteers.  Dysphagia.  (1999); 14(2):  67-72.  DOI: 10.1007/PL00009589.

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!

Swallowing and Dysphagia Rehabilitation: Translating Principles of Neural Plasticity into Clinically Oriented Evidence

I’m back to the research!  I took a brief break last month.  Since I was covering 3 buildings and transitioning into the school system, I thought blogging about research might be pushing the limits a bit.  Not to mention creating slides for a presentation in Montana.

In looking into creating some new slides for a presentation, I came across an amazing article written by several amazing researchers in the field of dysphagia.  If you have access to the ASHA journals and are looking for some great evidence base for your dysphagia therapy, this is the place to begin.

Robbins J, Butler SG, Daniels SK, Gross RD, Langmore S, Lazarus CL, Martin-Harris B, McCabe D, Musson N, Rosenbek JC.  (2008).  Swallowing and Dysphagia Rehabilitation:  Translating Principles of Neural Plasticity into Clinically Oriented Evidence.  Journal of Speech, Language, and Hearing Research, 51: S276-S300.  

This article breaks down the principles of neural plasticity.   Neural plasticity is defined as “the ability of the brain to change.”  Central Nervous System Plasticity refers to “the ability of neuronal systems to alter functino in response to changes in input, both physiological and pathophysiological.”  One thing the authors warn is that just because neural plasticity may result in a behavioral change, not all behavioral change results in neural plasticity.

There are 10 basic principles of neural plasticity.  They are:

1.) Use It or Lose It

2.) Use It and Improve It

3.) Plasticity is Experience Specific (Swallow to Improve Swallowing)

4.) Repetition Matters (How many times you repeat an exercise)

5.) Intensity Matters (Longer training does not necessarily imply more difficult training)

6.) Time Matters (Time after incident)

7.)  Salience Matters (Purposeful movement related to the behavior being trained)

8.)  Age Matters (Younger brains are more responsive, but plasticity occurs across the life span)

9.) Transference (“The ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity” such as LSVT or EMST)

10.) Interference (“the ability of plasticity within a neural circuitry to impede the induction of new or expression of existing, plasticity within the same circuitry”)

Techniques, compensations, maneuvers and exercises we have our patients use were broken down into 4 groups.  Sensory Methods, Compensatory Methods, Motor with Swallow and Motor without Swallow.

The following is adapted from charts the authors created demonstrating behavioral vs. neural change within each group.

Sensory Methods: (From the literature)

Bolus Effects                                                                        Behavioral                                            Neural

Volume                                                                                   Yes                                                             No

Viscosity                                                                                 Yes                                                             No

Temperature                                                                        Yes                                                            No

Taste Enhancement                                                         Yes                                                             No

Stimulation

Thermal-Tactile Stimulation                                      Yes                                                              Yes

E-Stim                                                                                      Yes                                                              Yes

DPNS                                                                                         No                                                              No

Occluding Trach                                                                 Yes                                                             No

Visual Feedback                                                                 Yes                                                             No

Compensatory Methods: (From the literature)

Chin Tuck                                                                               Yes                                                             No

Head Rotation                                                                     Yes                                                              No

Head Tilt                                                                                 Yes                                                             No

Head Back                                                                               No                                                             No

Side Lying                                                                                Yes                                                             No

Breath Hold                                                                             Yes                                                           No

Bolus Consistency                                                              Yes                                                            No

Motor with Swallow:  (From the Literature)

Mendelsohn*                                                                           Yes                                                            No

Super Supraglottic                                                             Yes                                                            No

Supraglottic                                                                            Yes                                                            No

Effortful Swallow *                                                                 Yes                                                            No

Tongue Hold *                                                                          Yes                                                            No

Swallow (Frequency)                                                          Yes                                                            No

(* has the potential for plasticity)

Motor without Swallow:  (From the Literature)

ROM                                                                                               Yes                                                          No

Strengthening-Tongue*                                                      Yes                                                          No

Strengthening-Respiratory *                                            Yes                                                          No

Tongue Control                                                                       Yes                                                            No

Shaker *                                                                                        Yes                                                             No

LSVT  *                                                                                           Yes                                                              No

Pharyngeal Exercises*                                                           No                                                               No

Gargling                                                                                         No                                                               No

Vocal Exercises                                                                           No                                                               No

Velar Elevation                                                                            No                                                               No

Airway Closure/Breath Hold                                              Yes                                                               No

So, some of the techniques, compensations and exercises we use do create a behavioral change, including increased airway protection to reduce or eliminate penetration/aspiration, better control of the bolus, etc.  Few cause an actual neural change.

Looking at each principle and each category the authors created a great table which I will summarize.  Looking at 5 categories 1.) Sensory Methods Bolus Effects 2.) Sensory Methods Stimulation 3.) Compensatory 4.) Motor with Swallow  5.) Motor without Swallow:

1.) Meets all 10 principles, with a question on Time Matters

2.)  Meets all 10 principles with a question on Time Matters

3.)  Meets all 10 Principles, however questioning interference.

4.)  Meets all 10 principles except interference

5.)  Meets all 10 principles except Salience Matters

There are many areas that continue to warrant research in the field of dysphagia.  One thing we need to keep in mind that the authors point out:  “the primary role of swallowing rehabilitation is to effect change (i.e. improved strength, duration and timing of movement) in the physiologic components of swallowing, which will have a direct influence on bolus flow kinematics through the aerodigestive tract.”  Also “The immediate lesson for the swallowing clinician, however, is that training-even the training of a patient who is aspirating and at high risk for pulmonary or other health consequences-appears preferable to merely observing and documenting.”

Whether we’re using dry swallows or bolus swallows with our patient, we need to keep them swallowing.

I absolutely think this article is a MUST read for any dysphagia therapist.

Of course, after writing this article, I realized, I already blogged about it!   Talk about needing some plasticity for memory skills!!!  So, I will also post the original blog here as well!

Neural plasticity refers to the ability of the brain to change.

The 10 principles of plasticity are 1.) Use it or lose it, 2.) Use it and improve it, 3.) Plasticity is experience specific, 4.) Repetition Matters, 5.) Intensity matters, 6.) Time matters, 7.) Salience matters, 8.) Age matters, 9.) Transference and 10.)Interference.

For principle 1, Use it or Lose it, the simple act of swallowing will not improve the swallow in a person with dysphagia. They need to use the function with increasing competence. The question remains what are the best treatment strategies for swallowing. It makes sense that those patients that are NPO and have not swallowed in years will “lose” their swallow function. Simple saliva swallowing drills can help a person return to oral feedings.

Principle 2, Use it and improve it, there are many different treatment techniques including expiratory muscle strength training, lingual strengthening, Shaker, Mendelsohn, Masako and effortful swallow. Keep your patients swallowing to strengthen those muscles, but as they swallow, challenge the patient and challenge the swallow system. To merely sit and observe as a patient eats a meal is by no means therapeutic. To feed a patient during a meal is by no means therapeutic. Building the competence of a system is imperative, not just allowing a patient to complete the simple act of swallowing.

Principle 3, Plasticity is experience specific, to focus and rehab the swallow may or may not affect other aspects, such as dysarthria or voice deficits and vice versa. Does simply completing OME with patients improve the swallow?? If we have the patient complete voice exercises, that do not involve the swallow, how will that improve the swallow function. It’s a different function to complete the exercises without a bolus than it is with a bolus. 

Principle 4, Repetition matters, number of repetitions of an exercise will affect the neural changes made by that exercise. Many of the effective exercises involve systematic repetition such as LSVT, isometric lingual exercises and the Shaker. Simply completing a movement or an exercise 10 times 3 times a day may not cut it. The Shaker uses 90 repetitions and 3 repetitions of holding the head up and seems far more effective than simple OME alone. 

Principle 5, Intensity matters, there is building evidence that intensity is critical for swallowing therapy. Evidence is still pending for particular dosage recommendations that are therapeutic for the swallow. If you are training for a fight, to run, to lift weights, etc, how can you improve without an intense workout. We’re working with a muscular system with swallowing and should apply the same exercise science rules to swallowing as we do to any other training.

Principle 6, time matters involves the length of your session. A person is going to benefit more from a longer session, 30-60 minutes then they will a 15 minute session. 

Principle 7, Salience matters, therapy has to be purposeful for swallowing. You can’t have the person stick out their tongues 15 times and expect their swalow to improve. Simple, repetitive movements and strength training are likely not going to improve swallow function.

Principle 8, Age matters, although neural plasticity does occur throughout the lifespan, a younger system will be more responsive to the changes. This may imply that older adults need a more strenuous or a program with a greater length of time.

Principle 9, transference defined as “the ability of plasticity within one set of neural circuits to promote concurrent or subsequent plasticity.” Evidence from NMES (neuro muscular electrical stimulation) applies to this principle. This continues to be a principle that needs further investigation for implications to the swallowing system.

Principle 10, interference results from inappropriate use of E-stim. E-stim can either facilitate or inhibit the corticobulbar excitability. A simple change in Hz can change the excitability which is why there is extensive study out there now on NMES.

These principles can and should be incorporated into therapy. The more a therapist understands the swallowing system, exercise physiology and neural plasticity, the better prepared they are to treat a dysphagic patient.

Bonnie Martin-Harris and colleagues found 14 physiologic components in the swallowing system,
~lip closure
~hold position/tongue control
~bolus preparation/mastication
~bolus transport/lingual motion
~initiation of pharyngeal swallow
~soft palate elevation and retraction
~laryngeal elevation
~anterior hyoid excursion
~laryngeal closure
~pharyngeal stripping wave
~pharyngeal contraction
~pharyngoesophageal segment opening
~tongue base retraction
~esophageal clearance

Our role as a therapist is to improve the strength, duration and timing of the swallowing movements, with regards to the above components.

We have different options with different interventions including bolus effects by altering volume, viscosity, thermal, taste, tactile or temperature. We can use e-stim. Compensatory strategies including the chin tuck, head rotation, head tilt, head back and side lying positions. We can use maneuvers such as the Mendelsohn, Supraglottic swallow, Super Supraglottic swallow, effortful swallow, double swallow or the Masako. We also use lingual exercises and the Shaker. 

The Mendelsohn can alter the extent and duration UES opening as well as aiding in hyolaryngeal excursion.

The supraglottic and super supraglottic swallows facilitate the timing and extent of laryngeal closure at specific levels of the larynx.

The effortful swallow help to increase base-of-tongue retraction and results in increased tongue propulsive force, increased oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, longer duration of pharyngeal pressure and UES relaxation.

The tongue hold maneuver increases anterior motion of the posterior pharyngeal wall at the level of the tongue base.

You can find increased tongue base-pharyngeal wall pressure and contact duration when performing the effortful swallow, tongue-hold, Mendelsohn and super supraglottic swallow.

Robbins and her group demonstrated that lingual muscles have a propensity for increasing strength and mass and that as a result of non-swallowing exercises, improvement in swallowing pressures on liquid boluses occurred, penetraion Aspiration Scores were reduced and dysphagia-specific quality of life improved. 

The Shaker exercise increases swallowing function through decreased aspiration following the swallow. 

There is still a need for research from this article including looking at variables of repetition, intensity and time for rehabilitation and finding the appropriate site, stimulation frequency, amplitude, phase duration, optimal frequency and length of an individual stimulation treatment including potential effects.

When presented with a patient with dysphagia, research the disorder. If you are requesting an MBSS ask that the therapist look at muscle movement rather than just the absence or presence of aspiration/penetration. Treat the system as a whole and as a muscular system. We can actually learn much from our PT and OT friends on exercise physiology and use that to design our dysphagia therapy programs to better serve our patients.

Article and references can be found at: http://jslhr.asha.org/cgi/content/full/51/1/S276.