Measuring Lingual Range of Motion

For so long, we have focused on lingual strength and range-of-motion.

The Iowa Oral Performance Instrument (IOPI),  the SwallowStrong and the Tongue Press have all been developed to give us visual and numeric strength measurements of the tongue.

We finally have a measurement scale for lingual range of motion.

C.L. Lazarus, H. Husaini, A.S. Jacobson, J.K. Mojica, D. Buchbinder, K. Okay, M.L. Urken.  Development of a New Lingual Range-of-Motion Assessment Scale, Normative Data in Surgically Treated Oral Cancer Patients.  Dysphagia (2014) 29:489-499.

This study compared results in treated surgical patients vs. healthy patients.   36 patients s/p oral tongue surgery with significantly decreased tongue range-of-motion and 31 healthy individuals.

The scale was validated by correlating range-of-motion with performance status, oral outcomes and patient-related Quality of Life.

The scale was made to define lingual deficits.  This is a tool that can be used for baseline and post surgery tongue range-of-motion and to track changes over time with recovery and therapy.

Lingual protrusion was measured using the Therabite jaw range-of-motion measurement discs.

Protrusion Scores:  (100) Normal:  > or = 15 mm past the upper lip margin

(50)   Mild-mod:  >1mm but <15mm pasat the upper lip margin

(25)   Severe:  Some movement but unable to reach upper lip margin

(0)     Total:  No movement

Lateralization Scores:  based on ability of the tongue to touch the commissures of the mouth.  Measure both right and left side.
(100)  Normal:                      able to fully touch the corner of the mouth.
(50)    Mild-Moderate:  50% reduction of movement to corner of the mouth                                                in either direction.
(25)    Severe:  >50%           reduction in movement.
(0)      Total:                          No movement.

Elevation Scores:    

(100)  Normal:  complete tongue tip contact with the upper alvoelar                                       ridge.
(50)    Moderate:  tongue tip elevation but no contact with the upper                                       alvoelar ridge.
(0)      Severe:  No visible tongue tip elevation

Total Scores were assigned by adding the protrusion score+ right lateralization score + left lateralization score + elevation score divided by 4.

Scores were 0-100:      

0=severely impaired/totally impaired
25=Severly impaired
50=mild-moderate impairment
100=normal

During this study, tongue strength was measured using the Iowa Oral Performance Instrument.

Jaw range-of-motion was measure using the Therabite jaw range-of-motion measurement discs.

Saliva flow was measured using the Saxon test where the patient was asked to chew a sterile 4×4 piece of gauze for 2 minutes then spit the gauze in a cup.  The gauze was weighed before and after mastication.

The Performance Status Scale was used to determine diet type, speech uderstandability, impact of surgery on ability to eat socially.

Quality of Life was measured using the Eating Assessment Tool-10 (EAT-10), MD Anderson Dysphagia Inventory (MDADI) and Speech Handicap Index (SHI).

The study found that lingual range-of-motion can negatively affect all aspects of a patient’s life and correlates with performance and quality of life.

Research Tuesday Post-Effects of Barium Concentration

I finally got back into the swing of things with Research Tuesday.

My article for the month is:  Stokely S., Molfenter SM, Steele CM.  Effects of Barium Concentration on Oropharyngeal Swallow Timing Measures.  Dysphagia (2014) 29: 78-82.

This study was completed as prior studies suggest that various aspects of the swallowing process, including timing measures may vary depending on the concentration of barium presented to the patient.

Subjects:  20 healthy adults

Given:  3 non cued swallows of 5 ml of barium (“thin” 40% concentration and “ultrathin” 22% concentration).

Results:

Longer stage transition durations (“the interval between the bolus head crossing the ramus of the mandible and the onset of hyoid elevation) with the 22% concentration.

Longer pharyngeal transit times (“the interval between the bolus head crossing the ramus of the mandible and closing of the UES”) were observed with the 40% concentration.

Longer durations of UES opening with 40% concentration.

Results:  “For all temporal measures of interest (stage duration, pharyngeal transit time and duration of UES opening) significantly shorter duration were seen with the 22% concentration than with the 40% concentration.”

“The 22% w/v “ultrathin: solution may act more like a true thin fluid such as water than a 40% w/v solution.  Although lower concentrations of barium appear less opaque on fluoroscopy, the study by Fink and Ross together with our own use of a 22% w/v concentration for several years, suggests that this concentration is adequate for visualization.”

The barium we use will and does effect timing events in the swallow.  If the barium solution is more concentrated, we can expect longer timing events in the swallow.  We need to be aware of the barium we use and mix it according to manufacturer’s directions or use a standardized recipe when assessing the events of the swallow.

Ampcare………A new name for NMES

I love the ASHA convention.  Why?  It gives me an opportunity to not only see all the new products and offerings in the world of Speech Pathology, but a chance to sit down with the company reps to ask my questions and to actually try the product.

Ampcare is not new in the sense that they just started the company.  Ampcare has actually been around and researching NMES (Neuromuscular Electrical Stimulation) for swallowing rehabilitation since 1993.

I actually touched on Ampcare in a previous post regarding electrodes for NMES, however at that time, they were working on FDA approval of the device, so there was little information available.  I had received an email from Ampcare discussing their product, however it was very nice to sit down with Russ and Rick and to have them explain why they are superior in the NMES market.

The Electrodes:

The AmpCare electrodes are larger than other available electrodes.  The reason for this is the smaller electrodes concentrate on a smaller area, creating a “hot-spot” which can be painful for our patients.  The larger electrodes not only even the distribution of the stimulation, increasing patient comfort, they are made to fit directly over those submental muscles that target hyolaryngeal elevation and that anterior movement of the hyoid.

The electrodes offer low impedance (10 Ohms).  The electrodes are latex-free.  The VitalStim Electrodes offer impedance of 30 Ohms or less.  This means more current running to a smaller area.

The electrodes were comfortable and I was able to tolerate a higher intensity of stim with the electrodes in place.

The electrodes can be placed as shown above or on the face to target the muscles of the jaw.

The electrodes are also cost-effective.  There are 4 electrodes per package.  Which, if used in only one placement, hyoid or face can last 10 sessions.  The cost for 10 packages of electrodes (40 electrodes) will be $119.50.  To buy 400 electrodes or 100 packages the cost would be:  $895.  That would be 400 electrodes or 2000 sessions!

Price Comparison:

Freedom Electrodes:  12 Electrodes, single use $159 ($13.25 each)

Vital Stim Electrodes:  12 Electrodes, single use $209.00 ($17.42 each)

Alternative Electrodes:  40 Electrodes, single use $ 108.50 ($2.71 each)

AmpCare Electrodes:  40 Electrodes, Use 5 times $119.50 ($1.20 each or with 5 uses-.24 cents each)

 

The Posture Device:

The posture device alone costs $100.00

The posture device was created to help those who need a little assistance in achieving and/or maintaining good posture while eating.  The Restorative Posture Device (RPD) is indicated for those patients with :

  •  Head and neck alignment issue causing increased swallowing difficulty.
  • Forward head on neck posture resulting in decreased range of motion.
  • Weakness in the neck musculature.

This can also be used as a resistive device for a chin down exercise, similar to the Shaker or using the Neckline Slimmer as an alternative to the Shaker.

The NMES Device:


The biggest difference in Ampcare, to me, is the actual device.  The device actually allows you to set your own parameters.  The comparison between the Ampcare device and the VitalStim device is below.

Ampcare                                                            VitalStim

Treatment Time                  5-30 minutes                                                       up to 60 minutes

Ramp                                          1 second                                                               ?

Output                                       0-100 mAmps                                                    25 mAmps

Frequency                                5-50 Hz                                                                 80 Hz

Channel                                    Single or Co-Contraction                           Dual

Phase Duration                     50-250 MicroSeconds                                 300 MicroSeconds

Cycle Time                                5/15, 5/20, 5/25                                              59/1

The main differences between the devices is the frequency, which can be adjusted for comfort level and to increase the mAmps with the Ampcare device.

The other difference is the Cycle time.  VitalStim cycles 59 seconds on, 1 second off.  This means a muscle contraction of 59 seconds.  Ampcare has variable cycles with the time on always at 5 seconds.  You can adjust the stim off from 25 to 20 to 15.  The theory with this is that we are targeting Type II muscles, those fast-twitch muscles that contract and relax rapidly and fatigue easily.  Contracting a muscle for 59 seconds is not a natural activity.  A muscle contraction of 5 seconds is longer than the normal contraction time of the muscle during a swallow.

The Program:

Ampcare teaches and uses what they call ESP (Effective Swallowing Protocol).  This protocol involves 30 minutes of stimulation including 30 minutes of Mendelsohn Maneuver, Effortful Swallow and chin down (Shaker) exercise using the RPD.  All swallows with stimulation on are completed with dry swallows.

When I asked AmpCare about the progress and maintenance of skills they see with patients, 3 of 5 patients they case studied were increased from NPO to an oral diet with no decrease in function since the end of therapy.  They also have a video that they demonstrate showing the effect of the stim with the fluoro on with tremendous movement of the hyoid causing increased laryngeal elevation.

In summary, the differences of AmpCare:

  •  A 5 second “on” stimulation, mimicking more of the Type II muscle contraction.
  • During the 5 seconds of stimulation, the patient exercises using a dry swallow as resistance.
  • Food is presented to the patient during the “off” time of the cycle (time without stim)
  • A posture device is used for a chin down resistive exercise, comparable to the Shaker
  • Electrodes are place above the hyoid only, without the downward pull on the suprahyoids
  • Frequency is lower, presenting increased comfort for the patient
  • Electrodes are larger, targeting a larger area with larger dispersion of the stimulation

If you have any questions, the company can be reached by email.

Trainings are available by searching the website.  Training costs just over $300 and includes freebies (One package of FDA 501k cleared Ampcare E-Series Electrodes, One posture device and the course material).

**I do not currently use the Ampcare system, nor do I endorse it at this time.

Dysphagia App

What’s changing on Dysphagia Ramblings??

NOTHING!!

I’m adding to enhance my blogging to include app reviews. Not only will I start reviewing apps (officially) on my blog for dysphagia apps, I will also include some cognitive, language, etc apps.

My first review? Of course it has to be Dysphagia by NSS

App: Dysphagia

What it is: A teaching tool that can be used for families, healthcare professionals, students and SLPs. This app can help as a visual tool in teaching the mechanics of the swallow.

Price: $9.99 ($3.99 for only the normal swallow version called Normal Swallow)

System: iOS (iPhone, iPod Touch and iPad)

Version: 1.3

This app is simple to use, offers amazing graphics and creates a new, animated teaching tool for SLPs educating others in dysphagia.

When you first open the app, you have a picture of the lateral view of the oropharyngeal region called Normal Swallow, Lateral View.

 

At the bottom of the screen is a play button (the little arrow pointing to the right by the white turning blue line). Above the line is a purple rectangle that tells you what percentage speed you are playing the video. You can touch that rectangle and change the speed of the app from 1% to 100% depending on how fast or slow you want the app to run.

 

At the top of the screen is a menu rectangular purple button. When you touch this button, it allows you view the menu of available swallows to watch. You have the option of:

Normal Swallow, Lateral View
Normal Swallow, AP View
Example of Penetration with Aspiration
Impairment of Bolus Transport
Impairment of Initiation of Pharyngeal Swallow
Impairment of Anterior Hyoid Excursion
Impairment of Laryngeal Vestibular Closure
Impairment of Pharyngeal Contraction
Impairment of PES Opening
Impairment of Tongue Base Retraction

 

Pros of this app:

It offers excellent graphics to teach a swallow and the components of the swallow. If you have taken the MBSImP course, you will recognize the animations.

It’s very easy to slow down or speed up the rate of the play of video to enhance learning for all viewers.

It’s easier to show patients and healthcare professionals the swallow process and easier than a traditional swallow study video to visualize the components of the swallow.

Cons of the app:

It is limited to a few swallow deficits. You can’t show your patient their true swallow using this app, however it would be impossible to have that function!!

This is an excellent app to add to your dysphagia technological toolbox!! It is excellent for students, patients, families, caregivers and SLPs that are not familiar with MBSS to demonstrate the function of the swallow.

My grade: A

It Takes A GOOD Therapist

I was sitting and thinking today. There are so many therapists that I have seen that are sub-par, (none of my friends of course!) It made me stop and think that every patient, client and student deserves to have the best of the best as far as therapy goes. I don’t want to take my children to a sub-par doctor, why shouldn’t I expect expertise from my therapist???

 Dysphagia, in that respect, is no different than any other specialty. In fact, dysphagia may be a little more so in needing expertise. Dysphagia is life and death most of the time. I’ve actually seen patients die from poor choices in diet and from upgrading too soon to an inappropriate diet. Residents in nursing homes have died from uneducated staff. This is not acceptable. This is my own personal list of what it takes to be a GOOD therapist, from a dysphagia perspective, of course.

 1. You need a therapist that is knowledgeable, to the point that the therapist can make any and all patients, client, etc. understand dysphagia. Every patient/client is entitled to understand their diagnosis and to understand the therapy you are providing. I can’t count how many patients have come to me for therapy, after having previous dysphagia therapy and never understood what the actual problem is!

 2. The dysphagia therapist should very much understand the process of the swallow. It’s not enough to know that people aspirate or penetrate and then give them a cookbook sheet of oral-motor exercises to complete every day 10 times, 3 times a day. The dysphagia therapist needs to know the muscles, the structures, the nerves and their functions.

 3. Don’t underestimate all the new treatments that are available. So many people will absolutely not touch VitalStim because “it’s not researched enough.” VitalStim and NMES is one of the most researched areas in our field. If you are able, go to these courses and learn what they are about. Read the literature. Make your own educated opinions. I always find that taking a little from each and every course that I go to, and putting it together to create my own therapy plan is more successful than the cookbook sheet of oral motor exercises.

 4. Do a COMPLETE assessment of each and every patient. It is not enough to simply sit with the patient at a meal and watch for them to cough or choke. You need to assess all the cranial nerves, do a complete chart review, palpate the structures and functions during the swallow. The 3 ounce water swallow challenge is a new assessment procedure that can give some valuable assessment data. Not so sure I completely believe in it yet, however am using it before all my MBS’s to test the validity on my own terms.

 5. When you complete an MBSS, don’t focus on aspiration, penetration, premature spillage, etc. Those are merely symptoms of a bigger dysfunction. You need to look at all the functions of all the structures and report on those. Yes, the person may aspirate, but why and what are you going to treat?? Bonnie Martin-Harris is publishing and providing CE courses next year on the MBSImP, which will be a standardized manner, in which to assess swallowing function during the MBS.

 6. NEVER, ever, ever upgrade a patient diet on a Friday, leave for the weekend, and come back on Monday to check how they are doing?? Doctors do not start a new medication then leave the person hanging for days on end. How can you functionally assess a person’s ability to manage the diet upgrade if you are not there to monitor??

 7. I so very often see therapists treat, by sitting with a patient at a meal, watching them eat, assisting with compensations and strategies and then doing the cookbook oral motor exercises with the patient. Don’t get me wrong, oral motor exercises can be functional, as a home exercise program in addition to ACTUAL swallowing therapy and compensations/strategies have their place, but they are not therapy. These compensations/strategies and OME do not promote the muscle changes required to constitute rehabilitation, which is what we do. You cannot improve the swallow without having the patient complete swallowing tasks.

 It is often debated, what do we, as SLP’s call ourselves?? Some demand Speech Pathologists, Speech Language Pathologists, Speech Therapists, etc. I prefer Speech Therapist, because I rehabilitate people.

 My challenge to everyone is to examine yourself and your therapy. Look at how you assess patients, how you complete the instrumental exam, how you treat patients with dysphagia. Ask yourself, what am I doing for my patient, what SHOULD I be doing for my patient and how can I do better for my patients, to rehabilitate their swallowing mechanism and therefore do my job and make my patient better??

Put Yourself in Their Shoes

My number one rule-of-thumb, especially when treating my dysphagic patients is to put myself in their shoes.

 First, I need to make this patient and their family member understand just what is going on. No, I don’t explain dysphagia in medical terms, but it is easy to put into layman’s terms when you understand the swallowing process. The patient needs to understand dysphagia, what is compromising their swallowing function and understand how and why dysphagia treatment will make them better and safer. Patients need to understand that this can be a life-threatening dysfunction but that it can be improved through therapy, diet modifications, compensations, etc.

 I also have to remember that one of the joys in life is eating. We all go through our day eating and drinking. It’s how we socialize, what we do at holidays. Our patients do not want to continue on a pureed diet with honey thick liquids when there is therapy available to possibly get them to a higher level. I’ve seen too many people discharged from therapy on an altered diet because the therapist has no idea what to do with them. I’ve also seen patients upgraded before they even really have therapy. Upgraded three days after the MBSS with severe dysphagia and aspiration is not an appropriate upgrade.

 Remember that our job as dysphagia therapists is to rehabilitate, or bring about change to the swallowing system and the musculature of the swallowing system. We cannot bring about change by sitting with a patient during lunch and reminding them to tuck their chin. We cannot bring about a change by having them stick out their tongue 30 times a day and think that’s going to improve the swallow. The only true exercise for the swallowing system is swallowing and challenging the patient with the swallow.

Exercise

Recent and some previous dysphagia literature emphasizes the use of exercise physiology. Researchers such Lazarus et. al, Robbins et.al, Burkhead et. al and Clark have published the need for incorporating exercise physiology into dysphagia therapy. They emphasize the need to understand the muscles involved in the swallowing mechanism, understand their function so that you can exercise those muscles in the manner in which they function for the swallow.

 The best way to work and improve the swallowing function is to swallow. Not only simply swallow, but push the swallow beyond it’s normal capacity. One way to incorporate increasing the load of the swallow is to use the effortful swallow, the masako or the Mendelsohn maneuver. The Shaker is a great load-resistant exercise to increase opening of the UES. These exercises have been researched and shown to be effective. Logmemann credits the research that has been established for the Shaker exercise and the lingual strengthening exercises from Robbins to increase lingual strength, with overall strengthening of the swallow.

 I’ve started an exercise approach to my dysphagia therapy. I started using almost like a “circuit” of swallowing training. I give the patient a list of exercises to complete while in therapy. Depending on what they need to focus their therapy, they complete a circuit of exercises. I use a variety of swallowing exercises including the Mendelsohn maneuver, effortful swallow, lingual resistance exercises, oral manipulation exercises. Most exercises include swallowing as part of the exericise. One of my favorite strengthening exercises is sucking pudding through a straw. I have the patient start with a regular drinking straw and work their way down to using a coffee stirrer. This not only strengthens the tongue, cheeks and lips, it also requires that they swallow. They spend x number of minutes of each exercise.

 Taking an exercise-based approach to swallowing is far superior to simply altering diet consistencies or adding compensatory strategies to each swallow. Rehabilitation should bring about a change to the swallow mechanism. I do not nor will I use compensations or altered diets in my therapy. I may put the patient on an altered diet, but I want to work the system naturally, not with a compensation if I can avoid it! Look to your PT and OT departments. They work the muscles to bring about change and we should be doing the same.

 Logemann, J.A. (2005). The Role of Exercise Programs for Dysphagia Patients. Dysphagia. 20: 139-140.

 Clark, H.M. (2005). Therapeutic exercise in dysphagic manamgent: 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 adn dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language and Hearing Research, 51: S276-S300.

 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. American Journal of Speech-Language Pathology, 12: 400-415.

 Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L. and Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 52, 1483-1489.

 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 Phoniatrice et Logopaedica, 55, 199-205.