Carbonated Beverages

carbonated

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

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

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

Research of carbonated beverages shows:

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

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

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

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

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

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

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

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

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

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

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.

What in the World?

I haven’t been on here in a while.

 Why?  You might ask……

Well, things have been rough at work.  My caseload continually started dropping, but I thought it was not too big of a deal because, after all, I was the Rehab Director and I had those director-type things I needed to do.  Make sure documentation is completed and accurate, checking daily for G-codes, reviewing every chart prior to submission to medical records, daily meetings, keeping all staff up to date on what was new with our company.

Unfortunately, the hospital didn’t see my value in that area and decided that I had a month to increase my caseload (yup, that included marketing my own services) or elimination of my position.

Our company, who contracts us to the hospital, decided that the best option was to have me start covering a local nursing home as well.

I’ve worked at that nursing home in the past and swore I would never go back.

Fortunately, a friend of mine has connections with a contract traveling company.  One day I’m emailing a recruiter, the next day, we’re talking on the phone.  By the end of the week, I had a phone interview with a school.  Yup, you heard me, a school system.  By the next week, I had a full-time job offer, guaranteed 40 hours/week, willing to work with my travel/speaking schedule and mine to start the following week.  I had the difficult job of talking to my supervisor and going part-time at the hospital, so that I could work full-time at the school.

Basically, my outpatient caseload now is 3 and the nursing home has less than 3.  My outpatient caseload equals 4 hours a week.  I think I made the right decision.

The bad thing was that in order to not give notice, I had to work at the school, cover the nursing home and the hospital for 2 weeks.  That doesn’t sound bad, but I do think I’m still recovering from working so much.

What will I miss most about my hospital job, other than the 3 outpatients I’m keeping on…………..

1.  Modified Barium Swallow Studies.  I love modifieds.  I love diagnosing dysphagia and working on that treatment plan to improve my patient’s swallowing ability.

 2.  Outpatients.  I love working with adults.  I love working with them and helping to improve aspects of their lives.  I also love that moment, when they’ve attained their goals and the gratitude they show.

 What will I NOT miss……….

 1.  Productivity.  That’s right.  I’m not a factory.  Some patients take longer than others.  Sometimes, outpatients need 2 hours, most times an hour will do.  45 minutes is not sufficient even though that’s the magic number from a business stand point.

 2.  Swallowing evaluations for EVERY patient diagnosed with CVA, whether it’s actually a CVA or not.  Sometimes they get it right.  I’d say it’s been about 20% correct diagnosis since we became a stroke certified hospital.  Not that I don’t love evaluations and swallowing evaluations.  When I know it’s not a stroke going in, the patient has passed the 3 ounce water swallow screen multiple times and nursing reports no difficulty with meals or pills, it seems like an enormous waste of tax payers money and my time.

 3.  I took the job as rehab director because I wanted to learn to be a manager.  I really wanted to get into the managerial aspect of therapy.  I did NOT want a title, expectation to maintain the same productivity, however take the blame when I didn’t have time to do something.  Also, I’m not into marketing.  It’s not what I do or what I went to school to do.

So yes, I work in the school system now.  I’m adjusting.  I like the kids.  I have yet to like the artic, but I was really excited the other day when a first grader who substituted k/t and g/d actually started using t and d in words.  It’s the little victories.

Will I quit dysphagia therapy or will my passion for it waiver.  Never.   I will continue to read research on dysphagia.  I will continue to speak on the topic of dysphagia.  I know that I will soon get back into the practice of treating dysphagia full time.

Just for now, I need a change in pace in my work setting and boy did I ever find that!

 

G-Codes and Insurance and Rehab Optima…….Oh My!

I work in a critical access hospital.  I see patients in acute care, outpatients and do all MBSS in our facility.

 I am also the Rehab Director of our deparment.

 Our regional manager implemented G-Codes in our facility in early January.  We have been in-serviced on G-Codes and using them in our documentation.

 What are G-Codes?

 These are required codes when working with Medicare Part B patients.  There are 7 codes from which SLPs can choose to use with their patients.  These areas define the most relevant area with which we are working with our patient and must include an impairment modifier for each.

 ASHA offers information on G-Codes and has created a wonderful list of all the codes and modifiers here.  ASHA also recommends using ASHA NOMS which directly correlate with the impairment modifiers.

 The bottom line…..if you don’t use the G-Codes and Modifiers, you won’t get paid.  You can only use one code at a time although you can treat multiple impairments at one time.  (i.e., you may code for swallowing, however treat both dysphagia and expressive communication).

 ASHA offers an on-demand webinar explaining G-Codes for $99 for ASHA members and $129 for non-members.  The Specialty Board on Swallowing and Swallowing Disorders also offers a webinar by Nancy Swigert for $25.00.

 Insurance

 I don’t know how it is in other states, but here in Indiana, insurance has been a major roadblock for therapy.

 Medicaid often severely limits our sessions.  They will often give us 12 or 24 sessions.  When you have a patient that just had a stroke and is severely aphasic, 12 sessions at 2 times a week, 12 sessions at 1 time a week followed by a home program, typically does not cut it.  This is what we are allowed.

 Even if that patient has Medicare as a primary.  The Medicare is unlimited.  We are not under caps being a Critical Access Hospital.  Medicaid as a secondary limits the sessions because the patient cannot afford to pay the 20% out of pocket.

 BCBS typically gives us 20 sessions if they are primary, 60 sessions if they are secondary.  They will not pay for a cognitive therapy code if CVA is the primary medical diagnosis.  There is a list of diagnoses, small I might add, that I can use with specific codes for reimbursement.

 If you live in Indiana and have a stroke with BCBS as your insurance…..please don’t have cognitive issues only requiring cognitive therapy.  They won’t pay for that.

 I dread to see all the upcoming changes in therapy approvals for insurance with all the healthcare reform coming.  It has definitely changed to this point.

 Rehab Optima

 Our company primarily staffs nursing homes.  We have an acute care hospital contract for a critical access hospital.

 Our company recently switched from Casamba Smart to Rehab Optima.

 WOW

 Smart wasn’t necessarily functional for us, but RO is definitely not.  We have had nothing but issues since we started!!

 Hopefully it gets better!

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.

NSOMES-To Use Them or Not to Use Them…..That is the Debate

This topic may seem a little off the dysphagia path, but it’s not, trust me.  I have actually thought a lot about NSOMES in my therapy as of late.  Not only does NSOME, at least in my eyes, stand for Non-Speech Oral Motor Exercises, I also use the term for Non SWALLOWING Oral Motor Exercises.  This was the March topic for the SLP Chat, which was a very interesting conversation.  I also went to a session on NSOME’s at our state convention, which actually turned into an artic course using core vocabulary which upset me immensely since I was hoping to learn a little more about NSOME’s.

 

 

First, let’s start with these exercises.  What are they?  Non-speech (swallowing) imply that these are movements that are not concurrent with producing sounds or swallows.  These are the typical stick out your tongue 10 times, move your tongue from corner to corner of your mouth.  These are actions that we use to “strengthen” the speech/swallowing mechanism by having our patients move the articulators.

 Now I’m switching to all swallowing-hey that’s what my blog is about.  It’s my blog!!  So, anyway, who hasn’t been to a facility and observed the SLP there.  What do they usually do for swallowing exercises.  Stick out your tongue, try to touch your nose with your tongue, move your tongue from corner to corner of your mouth, stick out your jaw…….all of these 10 times, 3 times a day.  So, 30 times total.  How many of these patients truly get better with only these exercises??  In my experience, very few.

 Robbins, et al wrote a very good article about neural plasticity in swallowing.  I actually reviewed that article in an earlier blog.  One principle is that plasticity is experience specific, or that to make neural changes (i.e. to the swallowing mechanism) the experience has to be specific to the actual movement.  So, to improve the swallowing mechanism, you have to practice swallowing.  To make neural changes to the swallowing system, the patient has to SWALLOW!  What a novel idea.

 Dysphagia therapy is quickly moving to a very exercise-based therapy.  No, not the typical stick out your tongue exercises.  When you exercise the swallowing system, there are very few researched techniques, however they do exist.  With all the changes in therapy and in insurance, healthcare, now is most definitely the time to move to evidence-based practice, if you haven’t already jumped on board.  I have my list of exercises that I use that are swallowing-specific and have evidence to support them.

 Tongue exercises using resistance, i.e. tongue depressor or IOPI.  Robbins et al looked at the IOPI 10x/3xday against the tongue tip, blade and dorsum with improvement with swallowing.  (Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., &amp; Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.)  Lazarus, et al looked at the IOPI vs. a tongue depressor and found that the tongue depressor exercises worked just as well as the IOPI exercises.  (Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normalsFolia Phoniatrica et Logopaedica, 55, 199-205.)  So, I have my patients use a tongue depressor and push their tongue against it using protraction, elevation, depression and lateralization, 10x each, 5x/day, 5 days/week.

 

 

 

 Mendelsohn Maneuver uses resistance with swallowing.  You can continually add resistance if you have the capability to use sEMG with your patients, which unfortunately I do not have at this time.  With the Mendelsohn, you not only have resistance, but the entire exercise involves the act of swallowing, therefore it is a relevant exercise to improve the swallow.  (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.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.) 

The Masako technique is a little bit questionable with therapy.  Yes, it does involve a swallow, however, how often do you swallow with your tongue sticking out???  This exercise should be used with caution, and should never be the only exercise you use, but may be a good exercise paired with another exercise to improve tongue base retraction.  So, possibly have the patient use the Masako and then the Mendelsohn??   (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.)

 The Shaker exercise offers not only resistance using the head as weight, but repetition of the exercise.  Logemann and Eastering both have research for the Shaker exercise available, however use caution with this exercise, particularly for cardiac patients.  I have been to a conference where I learned the Neckline Slimmer (https://www.buynecklineslimmer.com/) using the highest resistance spring can do the same as the Shaker without the strain on the patient.  However, be careful with this as there is no research out there to support this.  The Slimmer can be purchased at many stores including Walgreens and Bed Bath and Beyond.

 The effortful swallow uses an actual swallow with the added resistance by producing force with the swallow.  You have to have the patient not only “swallow hard” but an important component of the effortful swallow is to forcefully push the tongue against the palate, therefore creating pressure for the swallow.  (Bulow, M., Olsson, R. &amp; Ekberg, O. (1999). Videomanometric analysis of suprglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia, 14, 67-72.)  (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.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.)

 There are also exercises that I use that are “swallowing-based” such as changing the consistency, texture, weight of the bolus, one of my favorite exercises (you’d know this if you read my previous blog posts) is having the patient suck pudding through a straw and then change to a smaller straw as the patient progress.  This not only has the person swallow but strengthens the oral phase of the swallow through sucking, which is a natural motion of swallowing (we all use a straw at some point).  Mastication exercises are good, if the patient is not appropriate for an actual bolus, I use a mesh baby feeder or cheese cloth.  Any exercise you can have the patient complete that adds resistance or complication to their natural swallow is what we need.  Remember, evidence-based can also be what YOU trial, track and possibly research.  

 Now, there are times that I do use NSOME’s, I know, right, gasp.  I find that STRETCHING the articulators/swallowing mechanism is quite good for patients that have been through radiation therapy, for example.  If they are unable to move the articulators to the maximum benefit, yes, I will combine oral stretches/massage/myofascial release to the mix (above exercises) for maximum benefit.

 

 Will tongue exercises, jaw exercises, etc work outside of the context of swallowing/speech, I really don’t think they will.  You have to train the muscles to do what they’re supposed to do for function.  To do that, you HAVE to combine exercise/therapy with the intended movement.  You cannot rehabilitate speech without using speech and you cannot rehabilitate swallowing without having your patient swallow, even if it is only their own secretions.  Make certain that what you are doing is working for your patient, if the tongue exercises don’t seem to be changing anything, by the data you track, change what you are doing!  We are therapists adn are trained to use a variety of techniques.  If you are uncertain about where to go next, ask.  Don’t be afraid to ask questions.  

 When having your patients exercise, whether it be the speech or swallowing system, look to your physical therapist for ideas.  They exercise their patients, however they relate the exercise to the actual act (i.e. walking) and combine the exercises with the act of walking.  They don’t have their patients do leg exercises and send them home expecting them to walk with more efficiency.  They also exercise their patients with walking and make it more difficult (without the walker).  

 Remember when using Swallowing Oral Motor Exercises, use plenty of repetition, add resistance and make it worth your and your patient’s time!