Swallowing

Be the Change

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Let’s face it, we’re not all leaders. Some of us are happy going to our jobs and just done at the end of the shift. Many of us tend to get on social media and complain about issues that we feel are out of our control.

The problem is that just voicing our concerns on social media does not solve the problems. We have to look beyond ASHA and our boss to make these changes.  Now don’t get me wrong, ASHA, management, your state association can be a great start.

You might be asking what are some of these gripes and complaints. Productivity is the big one. We are often asked to work billable time for the majority of our day not allowing us any break for consultation or paperwork that is required of us.  How many of us go in to work,  clock out to maintain our productivity while completing paperwork, making phone calls or some of the necessary but not billable time possible while maintaining 90% productivity or more.   Maybe the reason the productivity expectations exist and the reason that it keeps getting higher is because people are actually meeting these standards. When we give 100% the next expectation will be 110%.

So maybe we can sit and stew about the fact that I’m working on my own time or maybe I can join my state association or ASHA and help bring about change to that productivity.

Another frequent complaint is the lack of instrumental assessment.  Some facilities will not allow instrumental assessment,  however have you presented the cost associated with an pneumonia or with any re-hospitalization compared to the cost of an instrumental assessment?  How can you possibly build an accurate plan of care for your patient when you can’t assess your patient?

When we actually think outside the box that’s when we can get things done.

Continue to educated yourself.  Stop being so complacent with your job.  Stop using non-evidenced based practice and the same oral motor exercises that have been used for 25 years.  Keep up with new practices.  Be a champion and advocate for yourself and for the profession you hopefully love.

When you start standing up for yourself and demonstrating efficiency and competence in your job is when we can show other medical professionals the value in the Speech Language Pathologist in the area of dysphagia.

Stop just posting to gripe on social media and make a change!!

Carbonated Beverages

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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.

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

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patient

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.  

In the News-Seen around the Web

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Find out why it’s harder to swallow after the age of 50!

coffee

Nearly 40 percent of older Americans are living with a swallowing disorder known as dysphagia.

Although it is a major health problem associated with aging, it is unknown whether the condition is a natural part of healthy aging or if it is caused by an age-related disease that has yet to be diagnosed, such as Parkinson’s disease or amyotrophic lateral sclerosis (ALS).

Following a recent study, researchers at the University of Missouri have established a model that identifies aging as a key factor in the development of dysphagia, which may lead to new therapeutic treatments.

“As people age, and especially once they’re 50 and older, their ability to swallow quickly and safely deteriorates with each advancing decade,” says Teresa Lever, assistant professor of otolaryngology at the School of Medicine and lead author of the study.

“For years, we haven’t known why. Through our research with mice, we now know this disorder can occur naturally and independent of another disease.

“Our next step is to study this model to determine why age-related dysphagia, also called presbyphagia, occurs and identify ways to prevent it.”

Pneumonia Risk

Individuals with presbyphagia generally experience slow, delayed, and uncoordinated swallowing that compromises airway function. This puts older individuals at risk for developing life-threatening malnutrition and aspiration pneumonia, which is caused when food or saliva is breathed into the lungs or airways.

These risks are increased when an individual has an existing health condition, such as a neurodegenerative disease, head and neck cancer, or a major surgery.

Videofluoroscopy has long been the gold standard for diagnosing swallowing disorders in humans. A video fluoroscopic swallow study is a radiologic examination of an individual’s swallowing function that uses a special X-ray device called a fluoroscope.

The patient is observed swallowing various foods and liquids mixed with a contrast agent that can be seen by fluoroscopy in order to evaluate his or her ability to swallow safely and effectively.

Same Symptons in Mice

However, because a long-term study of the swallowing ability of an individual as he or she ages is unfeasible, Lever and her research team studied the swallowing function of healthy mice throughout their approximate two-year lifespan.

“We have a miniaturized fluoroscope and swallow test protocol that are unique to our lab that we can use to determine if a mouse has dysphagia,” Lever says. “By studying the swallowing function of healthy mice over their lifespan, we found they exhibit many of the same symptoms of dysphagia as healthy aging adults.”

15 Signs and Metrics

The researchers established 15 metrics that could be compared to human swallowing function. These metrics include functions such as swallow rate, pharyngeal transit time—the time it takes liquid to be swallowed through the pharynx , or throat, and into the esophagus, or food tube—and the number of ineffective swallows through the esophagus.

The researchers found that healthy aging mice develop symptoms of swallowing impairment that closely resemble the impairments seen in older adults: generally slowed swallowing function, impaired tongue function, larger size of the amount swallowed, and an increase in the time it takes liquid to travel through the throat to the stomach.

“We’re about to change the landscape of dysphagia intervention,” Lever says. “For years, we’ve only been able to treat the symptoms and have been unable to address the root causes of dysphagia.

“Though more research is needed, this knowledge sets the stage for us to study ways to prevent, delay or potentially reverse swallowing disorders using new therapies.”

The study was published online by the journal Dysphagia. Funding from the University of Missouri and the National Institutes of Health helped support the project.

Source: University of Missouri Republished from Futurity.org under Creative Commons License 4.0.

*Image of “coffee” via CIAT/Flickr

Source:  http://www.theepochtimes.com/n3/1315567-why-its-harder-to-swallow-after-age-50/

Exercises, Techniques, Compensations

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Maneuvers/Exercises

 
 

To close vocal cords prior to the swallow.

 

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

 

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

 

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

 

Research shows:

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

For early closure at the entrance to the airway.

 

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

 

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

 

Research shows:

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

To assist in laryngeal elevation.

 

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

 

The Mendelsohn can be used to:

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

Evidence shows:

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

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

 

Resistive exercise.

 

The Masako should not be used with any bolus.

 

Increases:

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

Shaker–

To assist in laryngeal elevation and cricopharyngeal opening.

 

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

 

Increases efferent drive of hyolaryngeal excursion and PES opening.

 

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

 

Research shows:

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

Increase strength of the overall swallow.

 

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

 

Can add various bolus textures to increase resistance and strengthening.

 

Research shows:

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

Exercise

 

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

 Lingual exercise with resistance SwallowStrong Device (Formerly the MOST)

Research shows:

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

Mastication exercises

 

Use changes in:

texture

viscosity

temperature

sour

 

Weighted bolus

 

Add viscosity and use challenging bolus

 

 

Back of tongue exercises

 

Pull tongue straight back

Yawn and hold tongue at most retracted state

Gargle and hold tongue at most retracted state

(From Jeri Logemann’s book)

 

Oral manipulation exercises:

 

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

 

Suck Swallow

 

Increases the speed of initiation of the pharyngeal swallow

 

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

 
 

Postures

 

Chin Tuck–

 

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

 

Research shows:

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

Head Turn–

 

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

 

Research shows:

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

Head Back–

 

Uses gravity assistance to help with lingual deficits.

 

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

 

Side Lying–

 

To help clear pharyngeal residue by altering gravity.

 

May help to clear pharyngeal residue.

 

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

 

Sensory Stimulation Techniques-

 

Tactile Thermal Stimulation

 

Thermal Gustatory Treatment

 

Deep Pharyngeal Neuromuscular Stimulation.

 
 

Therapy Techniques

Pharyngocise

CTAR (Chin Tuck Against Resistance)

 

Tips to Remember in Therapy:

 

Murray, Larson and Logemann 1998 found:

 

    Lip Strength:

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

    Increase in muscle activation as bolus size increases.

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

    Straws=increased activation.

 
 Tongue:
 

     General tongue movement patterns for bolus transport is quite

              stereotypical.

 

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

 

      Tongue presses against the hard palate segmentally and sequentially.

 

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

 

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

 

Laryngeal Protection:

 

     3-Tiered Protection of the airway:

         Inversion of epiglottis over laryngeal aditus.

         Closure of false vocal folds.

         Closure of true vocal folds.

Gelmix Thickener

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I was really excited to see Gelmix at the ASHA Convention this year.  I’ve heard a lot about Gelmix, but have never had the opportunity to try it until now!What is Gelmix?

Gelmix is a “healthy thickener” as it is USDA Organic.  Gelmix was formulated to thick breast milk, formula and other liquids.  Gelmix is also free from common allergens including:  gluten, corn, lactose, casein and soy.

Gelmix is made from Carob Bean Gum.  Carob Bean Gum is widely used for its gelling and thickening properties.  The other two ingredients in Gelmix are Organic Tapioca Maltodextrin and Calcium Carbonate.

Gelmix is activated in warm liquids, so you must warm the liquid prior to thickening it with Gelmix.

Gelmix can be used for term infants and children under 3 to thicken to a “light honey-thick consistency.”  For children over 3 and adults, Gelmix can be used to thicken liquids to a “spoon-thick consistency.”

Gelmix is contraindicated for infants under a gestational age of 42 weeks or under 6 pounds.  It also cannot be used with infants with suspected allergy to galactomannans.

Gelmix is available in an 8.8 oz jar (250 grams) which will thicken up to 624 fluid ounces for $29.99 or you can buy the “stick pack” which contain 5 stick, individual serving packets for $5.99.  Each stick will thicken 4 oz of liquid to nectar consistency.

The instructions for thickening with Gelmix:

  • Warm desired amount of liquid (between 100-120 degrees F for best results).
  • Sprinkle in Gelmix per usage instructions.
  • Mix well until Gelmix is completely dissolved.
  • Wait 5 minutes for the mixture to thicken and cool to a safe feeding temperature, mix again before serving.

Usage Instructions:

Infants and Children under 3:

  • Half Nectar:  Add 1 scoop for every 3-4 ounces of liquid.
  • Nectar-Thick:  Add 1 scoop for every 2 ounces of liquid.

(For infants and children under 3 years old, do not use more than one scoop Gelmix per 2 ounces of liquid.  To avoid gassiness, start with lowest concentration, particularly for infants 6-12 pounds.)

Adults and Children over 3:

  • Nectar-Thick:  Add 2 scoops per 4 ounces of liquid.
  • Honey-Thick:  Add 3-4 scoops per 4 ounces of liquid.
  • Spoon-Thick:  Add 4-5 scoops per 4 ounces of liquid.

Gelmix may gradually thicken over time.

Time for a Trial



Last night, I thought what a great time to try Gelmix and combine it with the #thickenedliquidchallenge.   I heated up my water and some milk.  I mixed the Gelmix in, per recommendations for honey thickened liquid.

 

I used a whisk to mix the thickener because when using a spoon, the water was extremely clumpy.  The milk actually became more of a pudding thick liquid.

The water was a little discolored, as with almost all thickened water.  The Gelmix really didn’t add a flavor to the water.

 

The milk was not discolored at all and had no added flavor.

The texture was another thing.  I am just not a honey-thickened liquid person.

I miserably failed the #thickenedliquidchallenge and will be donating to the National Foundation of Swallowing Disorders (NFOSD).

The Gelmix seems to be a good option for a more organic thickener, if you have access to heating your liquids.  It seems to be a great option for babies and would love to hear your thoughts on using Gelmix with babies!