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.

CTAR (Chin Tuck Against Resistance)

Yoon W.L., Khoo JKP, Liow SJR. Chin Tuck Against Resistance (CTAR):  New Method for Enhancing Suprahyoid Muscle Activity Using a Shaker-Type Exercise. Dysphagia (2014) 29: 243-248.

I was beyond excited to pick up my newest edition of the Dysphagia journal. I’ve never said I wasn’t a nerd. There was an article in the journal about chin tuck against resistance. I’ve always used what I call Modified Shaker exercises. My patients are generally elderly. Most have heart conditions or COPD. They are unable to do the Shaker as it was intended.
Most of my patients either use the Neckline Slimmer (available on Amazon) which offers 3 different levels of resistance through springs. They complete exercises exactly as if they were completing the Shaker, but don’t have to lie on the floor and struggle to get up.

This article looked at using Chin Tuck Against Resistance (what I would call a Modified Shaker) to improve activation of the suprahyoids.

Look at patients with dysphagia from Pharyngoesophageal Segment (PES) dysfunction, we look at strengthening the suprahyoid muscles. These muscles assist in hyolaryngeal excursion and therefore play a part in esophageal opening.

CTAR vs Shaker:  Both have a component of isometric versus isokinetic. The isometric portion fo the Shaker is holding the head up for 1 minute with a minute rest x 3 repetitions. The difference is, with CTAR, the patient is holding a 12 cm inflatable rubber ball and performing a chin tuck against it while seated. The Shaker the patient is lying flat on the floor and lifting their head only as if they were looking at their toes.

The isokinetic portion is 30 repetitions of up and down head movement 3 times.

This study used 40 healthy individuals (20 male, 20 female) 21-39 years of age. All participants completed the Shaker and CTAR both isometric and isokinetic as indicated above. Data was collected over one session.

What the researchers found:

CTAR:  The Chin Tuck Against Resistance was less strenuous than the traditional Shaker, with increased sEMG values during isometric and isokinetic movement. There was a significant increase for the isometric portion of the exercise. These patient had greater muscle activation using the rubber ball and a chin tuck!

Effort was required for the chin tuck, but not for the release.  The authors felt is might benefit to have the patient release compression of the ball slowly.

There was greater muscle activation for the isokinetic movement than for the isometric movement during the traditional Shaker. The Shaker also yielded considerable greater effort to lower the head to the mat.

“Clinical trials are now needed, but the CTAR exercises appear effective in exercising the suprahyoid muscles and could achieve therapeutic effects comparable to those of Shaker exercises, with the potential for greater compliance by patients.”

Overall, CTAR was an effective in exercising suprahyoid muscles in healthy participants.

This looks promising in giving us an alternative for our patients for the Shaker exercise!!

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!

I-PRO

I-PRO.  Nope, it’s not a new app for the iPad.  It stands for Isometric Progressive Resistance Oropharyngeal Therapy.

Isometric is a sustained movement.  Wikipedia:

  • Isometric exercise, a form of resistance exercise in which one’s muscles are used in opposition with other muscle groups, to increase strength, for bodybuilding, physical fitness, or strength training.”
 
Our field has definitely moved in the direction of exercise-based dysphagia therapy investigating resistance, intensity, repetitions.
 
Evidence has shown us that resistance has a huge impact on our exercise.  Look at sticking your tongue out 10 times, compared to pushing your tongue against a tongue depressor 10 times.  Weight lifters don’t build muscle or strength by simply moving their arms up and down.  They add weight and continue to increase that weight.
 
I’ve been reading articles by Dr. Joanne Robbins for a while.  She has compared exercises using the Iowa Oral Performance Instrument or (IOPI).   Her research consistently looks at subjects given 8 weeks of therapy or exercise.  She’s researched patients using the IOPI vs. no exercise and found that those patients given a regimen of exercise for the tongue using resistance increased tongue mass (as measured by MRI), tongue strength (as measured by the IOPI) and actually lowered Penetration/Aspiration scores, meaning decreased penetration and/or aspiration.
 
                                   
 
In another study, she found that there was no difference in using the IOPI vs. using a standard tongue depressor, pushing the tongue against the depressor elevated, anterior and lateral (both sides).
 
Dr. Robbins has also created her own lingual strengthening device called the MOST (Madison Oral Strengthening Therapeutic) which is now called SwallowStrong.  This device works much like the IOPI, however provides various sensors, exercising different areas of the tongue (the IOPI utilizes a single bulb.)
 
             
 
I was excited to find this article:

Juan JHind JJones CMcCulloch TGangnon RRobbins J.  Case Study:  Application of Isometric Progressive Resistance Oropharyngeal Therapy Using the Madison Oral Strengthening Therapeutic Device.   Top Stroke Rehabil. 2013 Sep-Oct;20(5):450-70. doi: 10.1310/tsr2005-450

I-PRO is definitely a (new?) tool for your dysphagia toolbox!

This study looked at a single patient.  A 56 year old female, 27 months s/p CVA.  This patient had undergone behavioral interventions (“swallow-specific maneuvers (eg, supraglottic swallow), swallowing sensory stimulation/enhancement (eg, thermal stimulation), postural strategies (eg, head turn), and dietary modification”), UES dilatations and G-Tube with expectoration of saliva.   She also had outpatient services including, as the authors state “traditional dysphagia therapy and an intensive, daily home practice program including swallowing-specific maneuvers (eg, Mendelsohn), range of movement exercises, and electrical stimulation (E-stim) during saliva swallowing tasks.”

Following traditional therapy:  Video Fluorscopic Swallow Study (VFSS) was completed to see the anatomy and physiology of the swallow, looking at 12 swallows and 4 bolus consistencies.  Patient was observed with liquid pooling on the vocal folds, liquid pooling in the pyriform sinus, minimal right-sided UES opening, aspiration of liquids and decreased lingual strength as measured by the IOPI.

The patient then was introduced to 8 weeks of I-PRO Therapy with a focus on the anterior and posterior tongue, followed by 5 weeks of detraining and 9 weeks of I-PRO maintenance with decreased frequency.

During the 8 weeks of I-PRO, the patient completed 10 lingual press exercises (anterior and posterior portions of the tongue) 3x/day, 3 days/week.

Detraining included 5 weeks of no lingual strengthening.   After the detraining session, patient was found to have decreased isometric pressure with reduced UES oepning.

A 9 week program of I-PRO Therapy followed the detraining, which included a less intense I-PRO program.   After the maintance program, anterior lingual pressure returned to the same level that it was after the 8 weeks of intervention.

 Quality of Life was measured using the SWAL-QOL, a diet inventory was completed, lingual pressures and volumes were measured pre and post therapy.
 
Post I-PRO therapy, the patient went from total NPO with expectoration of saliva to a full, unrestricted oral diet, lingual pressure and volume increased with transference to increased swallowing pressure, post-swallow residue was decreased per follow-up VFSS, UES and pharyngeal pressures increased with increased UES opening (as measured by manometry) and quality of life increased.
 
The patient had improved swallow safety, increased to oropharyngeal intake.
 
Exercise needs to count for our patients.  According to exercise science literature, 10 reps, 3 times/day, 3 days/week for 8 weeks is what is recommended.
 
Can’t afford the devices ranging from roughly $900-$2500??  Invest in some tongue depressors to add to that toolbox!  We all have those anyway, right??

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.

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!