Direct Therapy Procedures – Flashcards

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Oral sensory stimulation for direct therapy procedures
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reduced oral sensation, tactile agnosia for food, delayed onset of oral swallow, delayed triggering of pharyngeal swallow, swallow apraxia
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Oral sensory stimulation: thermal stimulation
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delayed/absent swallow reflex
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Oral sensory stimulation: tactile stimulation
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delayed pharyngeal swallow
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Oral sensory stimulation: tactile stimulation methods:
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suck/swallow, quick downward pressure on tongue, massage- nuk massage brush
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Oral sensory stimulation: food selection: tastes
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sour taste (50% lemon juice + 50% barium for MBS; lemon ice) lemon ice recipe (21 meal supply) 1 scoop (8 tsp.) thick it 2 scoop (16 tsp.) lemonade powder 1 tsp. sugar 1/8 tsp. salt 16 oz water
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food selection: temperature
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cold; alternating cold/hot
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food selection: volume
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larger bolus
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food selection: textures
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chewable, carbonated
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Oral sensory stimulation: desensitization
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hypersensitive reflexes
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Massages (myofascial release)
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-manual therapy technique to be used to correct restrictions in muscle and connective tissue and improve one's ability to develop adequate muscular tension for functional swallowing -to improve myofascial system (fascial mobility, muscular mobility, muscular strength) to release tissue restrictions and provide manual soft tissue mobilization for functional swallow -sample techniques: oral cavity techniques strap elongation suprahyoid techniques hypolaryngeal glides infrahyoid techniques
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Exercises: Oral musculature: strengthening and range of motion
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lips, tongue: TheraSpoon, Jaw: TheraBite
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IOPI system (Iowa Oral Performance Instrument)
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device to be used for quantitative measurement and exercises for tongue strengths and lip strengths
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Exercises: Oral musculature: Bolus Control
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gross manipulation (help patients maninpulate bolus in mouth), bolus holding (use gauze or something you can hold on to), bolus propulsion
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Exercises: Oral musculature: Mastication exercise
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Use gauze or something to chew on, cross bar
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PHARYNGEAL MUSCULATURES: Tongue base exercises
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difficult to voluntarily activate
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PHARYNGEAL MUSCULATURES: Tongue holding (Masako maneuver)
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-to strengthen pharyngeal muscles and thus improve pharyngeal wall contraction -contraindication: aspiration may occur if performed with food or liquid
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PHARYNGEAL MUSCULATURES: airway entrance
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pushing/pulling exercise with hands against chair. practice holding breath safely; add voice to increase closure of vocal folds
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PHARYNGEAL MUSCULATURES: laryngeal elevation (falsetto)
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too benign, not specific enough, DONT USE!
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PHARYNGEAL MUSCULATURES: Head lift exercise (Shaker exercise)
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-reduced cricopharyngeal/UES opening -reduced laryngeal opening -reduced base of tongue retraction
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PHARYNGEAL MUSCULATURES: Head lift exercise (Shaker exercise) CONTRAINDICATIONS
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-cervical spine disorder -tracheostomy -uncontrolled high blood pressure and certain cardiac -problems -within 1 hour after tube feeding -unable to exercise independently -history of reflux?
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PHARYNGEAL MUSCULATURES: Effortful Pitch Glide increases:
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-anterior hyoid movement -hyolaryngeal approximation -laryngeal elevation -pharyngeal shortening -pharyngeal wall medialization
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PHARYNGEAL MUSCULATURES: Effortful Pitch Glide components:
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-falsetto -pharyngeal squeeze
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PHARYNGEAL MUSCULATURES: Effortful Pitch Glide Instructions:
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shift /i/ from modal pitch to highest pitch forceful "ee" at the highest pitch
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PHARYNGEAL MUSCULATURES: Expiratory Muscle Strength Training (EMST)
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-respiratory strengthening exercise per resistive loading with a pressure threshold device -to increase activation of hyolaryngeal muscles and laryngeal closure -may improve cough, speech, breathing, and swallow function
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SWALLOWING MANEUVERS: task-specific exercises Effortful Swallow
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reduced tongue based retraction; "give me a strong swallow"
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SWALLOWING MANEUVERS: Supraglottic swallow
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-reduced or late VF closure -delayed pharyngeal swallow -"take a breath, hold bolus in mouth, swallow, then cough"
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SWALLOWING MANEUVERS: Super-supraglottic swallow
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-reduced closure of the airway entrance -"effortful supraglottic swallow"
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SWALLOWING MANEUVERS: Mendolsohn maneuver
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-reduced laryngeal elevation -REDUCED cricopharyngeal opening -discoordinated swallow -"hold hyoid bone as high as possible when you swallow"
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SWALLOWING MANEUVERS: Lateral Press of Thyroid Cartilage
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-unilateral laryngeal dysfunction -unilateral pharyngeal dysfunction -head turning is equivalent to this procedure -"press against damaged side"
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SWALLOWING TREATMENT PROGRAMS: Transcutaneous electrical stimulation: VitalStim Therapy
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-using mild electrical signals, delivered through electrodes attached to throat -to stimulate the muscles of the swallowing mechanism (laryngeal elevation)
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SWALLOWING TREATMENT PROGRAMS: Transcutaneous electrical stimulation: E-Stim
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-a small electric current is passed across the skin into the muscles in the anterior neck through surface electrodes -designed to facilitate laryngeal elevation and pharyngeal contraction -best outcome when paired with an appropriate and functional therapy program
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SWALLOWING TREATMENT PROGRAMS: Oral Hygiene Program
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-twice daily brushing to remove dental plaque from teeth -suctioning of oral secretions to decrease bacterial load -keeping oral mucosa moist soothes and hydrates the lips and oral tissue
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SWALLOWING TREATMENT PROGRAMS: Water protocol (Frazier Rehab Center's Water Protocol)
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-don't use with patients who are impulsive or TBI patients who can't drink safely
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SWALLOWING TREATMENT PROGRAMS: McNeil Dysphagia Treatment Program (MDTP)
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-systematic, exercise-based therapy for severe dysphagia in adults -includes daily transcutaneous NMES with functional swallowing activities following a dietary hierarchy with advancing steps of altered bolus volume (load) and consistency -emphasize "swallow hard and fast" -treatment sessions: 1 hr/day, 5x/week x 3 weeks=15 sessions;limited home assignments -studies showed increased/improved laryngeal and hyoid elevation, lingual-palatal pressures, FOIS score, and oral and pharyngeal temporal events
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SWALLOWING TREATMENT PROGRAMS: Lee Silverman Voice Treatment (LSVT)
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-five essential concepts: 1. voice (think loud/think fast) 2. high effort 3. intensive treatment 4. calibration 5. quantification -treatment sessions: 1 hr/day therapy, 4x/week x 4 weeks = 16 sessions; limited home assignments -to improve lingual motility, quicker swallow, and reduce vallecular residue (safer swallow) -no change in penetration
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MEDICAL INTERVENTION: Vocal Fold Paralysis: 1. Vocal fold medialization: Paralyzed vocal fold
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-vocal fold injection -thyroplasty and/or arytenoid adduction -patient is still able to swallow, therefore surgery is for voice
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MEDICAL INTERVENTION: Vocal Fold Paralysis: 2. Nerve-to-muscle pedicle
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-transferred from the omohyoid muscle to the paralyzed posterior cricoarytenoid -inspiratory activity of the omohyoideus mediated by the ansa hypoglossal results in phasic VF abduction (increasing VF opening) which may be adequate to allow increased ventilation and at the same time protect the airway against aspiration (from Lu)
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MEDICAL INTERVENTION: Cricopharyngeal Dysfunction: 1. Crocopharyngeal myotomy
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-cut slit into cricopharyngeus muscle to relax muscle
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MEDICAL INTERVENTION: Cricopharyngeal Dysfunction: 2. Cricopharyngeal dilation
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-insert tube through mouth to cricopharyngeal opening (in trachea) to widen the cricopharyngeal area
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MEDICAL INTERVENTION: Cricopharyngeal Dysfunction: 3. Botox
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-inject to weaken the muscle -difficult to reach the muscle
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MEDICAL INTERVENTION: Oral/Velopharyngeal deficits: 1. Palatal lift
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-Lifting palate into elevated position -prevents nasal regurgitation
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MEDICAL INTERVENTION: Oral/Velopharyngeal deficits: 2. Palatal Obturator
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-obturating surgical defect, fistula, or cleft palate (closes defect)
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MEDICAL INTERVENTION: Oral/Velopharyngeal deficits: 3. Palatal Augmentation (lowering/reshaping) prosthesis
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-improving tongue-palate contact (makes upper denture thicker)
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ALTERNATIVE FEEDING: 1. Decision making parameters
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-time taken to swallow a single bolus: 10 seconds of oropharyngeal transit -aspiration: 10% of every bolus
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ALTERNATIVE FEEDING: 2. Rationale for oral/nonoral feeding
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-complete oral feeding if - (1) no aspiration (2) oropharyngeal transit times 10 secs or less -oral feeding plus nonoral supplement if - (1) no aspiration, (2) oropharyngeal transit times more than 10 secs -complete nonoral feeding if - aspiration on all foods regardless of intervention
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ALTERNATIVE FEEDING: 3. Alternative feeding
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-nasogastric tube (temporary) -PEG (Percutaneous endoscopic gastrostomy) (goes through stomach) -Pharyngoesophagostomy -Jejunostomy (goes through big intestine, used if patient has GERD)
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CASE: A male patient who suffered from a cervical spine injury and is now wearing a Halo neck brace, which keeps his head secured in a level, forward facing position. he demonstrates markedly reduced laryngeal elevation due to fixed head/neck positions. What treatment approaches could improve his laryngeal elevation?
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Effortful pitch glide
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CASE: A male patient who underwent a left hemilaryngectomy due to laryngeal cancer. He exhibits obvious signs of aspiration with liquids. What are treatment approaches that could reinforce airway protection during liquid swallowing?
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-modified diet (avoid thin liquid in beginning) -Head turn to left , chin tuck -super-supraglottic -lateral press of left thyroid cartilage
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QUIZ: The liquid diet should be AVOIDED for which condition?
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Poor laryngeal closure
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QUIZ: Foods of thicker consistency, such as puree or soft chewable items, are appropriate for which condition?
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-Poor airway protection -delayed swallowing reflex
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QUIZ: Which taste could best facilitate the triggering of swallowing response?
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Sour
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QUIZ: Tilting the head to the right side is appropriate for which condition?
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Left facial weakness
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QUIZ: Placing foods on the right side of the mouth is most appropriate for which condition?
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Left lingual paralysis
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QUIZ: Which compensatory strategy should NOT be recommended for patients with delayed swallowing reflexes?
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head tip-back posture
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QUIZ: Using the chin tuck posture to prevent aspiration is based on what rationale?
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-This posture places the epiglottis in a more overhanging position in relation to the airway -The posture widens the valleculae to prevent bolus from entering the airway ALSO: -pushes tongue base backward toward the pharyngeal wall
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QUIZ: Which physiological change is a result of the head-turning posture?
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-Pyriform sinus is closed on one said that in turn redirects foods to the stronger side of the pharynx ALSO: -increase pressure on thyroid cartilage to improve VF adduction -places epiglottis in a protective position to narrow laryngeal entrance
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