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Compensation - Short term adjustments to facilitate safe oral intake. Adjustments to: posture, food, patient Rehabilitation - Improvement in swallow physiology that permits increased/expanded safe oral intake Prevention - 1) Avoiding or minimizing negative outcomes: food or liquid restriction, nutrition/hydration deficits, infections, and infection (e.g, pneumonia) 2) Preventing or minimizing dysphagia in high risk populations

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3 parts to Dysphagia Management

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- to the patient (e.g., posture changes) - to the food (e.g., thick liquids) - to the swallow (e.g., hold breath first, wash with liquid) goals: - safe swallow (e.g., protect airway) - increased oral intake (of safe food, liquid) - NOTE: these goals require the use of compensation technique

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Compensation: Short term adjustments & goals

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Rebuild impaired functions: - weakness, slowness, incoordination - typically involve motor-based exercises - may include sensory stimulation activities Goals: - to improve the impaired swallow mechanism - to improve safe oral intake - to increase eating efficiency (e.g., shorter meals)

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Rehabilitation:

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No

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Can we use rehabilitation strategies to prevent dysphagia?

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1. What is the purpose (intended purpose) of the technique? 2. What are the "how to" details of the technique? 3. What is the impact on the swallow mechanism? 4. Does this technique fit the needs/limitations of my patient?

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Questions to ask when Choosing a Technique:

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Food/liquid modification

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What is the most common 'intervention' for dysphagia?

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- Not scientifically validated (no comparison to other approaches) - Not linked to assessment strategies - (e.g., not prescriptive) - Not culturally sensitive (limited global application)

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Problems with the National Dysphagia Diet: an attempt to 'standardize' food modifications

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Level 1: Dysphagia Pureed - Homogenous, very cohesive, pudding like; requires bolus control, no chewing required Level 2: Dysphagia Mechanically Altered - Cohesive, moist, semi-solid foods; requires chewing ability Level 3: Dysphagia Advanced - Soft-solid foods that require more chewing ability Level 4: Regular - All foods allowed

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The 4 levels in the National Dysphagia Diet

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Wright reported lower nutritional intake. Germain reported better nutritional intake. The discrepancy suggests that modifying diets for aspiration reduction should not be done in the absence of nutritional consultation.

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Evidence regarding diet modifications

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Nutritional specialists

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Who should dysphagia clinicians consult when recommending diet modifications?

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91% of the patients examined had been consuming overly restrictive diets. Meaning they could have safely ingested diet levels higher than they had been. 4% were on diet levels above where they could safely tolerate. 5% were at the appropriate dietary level.

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What did Groher and McKaig discover about patients who were on a mechanically altered diet?

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1. A qualified dysphagia clinician should directly be involved in any decision to modify an oral diet 2. patients should be monitored and reevaluated at regular intervals to evaluate if their diet is on target or needs to be modified further in either direction.

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The findings from Groher and McKaig give us tow important management points:

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1. delayed onset of swallowing 2. impaired oral control of thin liquids (NOT reduction of aspiration nor hydration)

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Survey of SLP's: Why thicken liquids?

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thickening liquids was an effective 'therapy' strategy

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85% of clinicians believed that . . .

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8%; 60% = nectar 33% = honey 6% = pudding

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___% of all patients in long term care use thickened liquids.

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nectar: syrup

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Thickened liquids are used frequently in the management of adult dysphagia with the most frequent being ____ or _____ consistency.

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less; nectar-thick; less

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Honey and spoon-thick liquids were considered ___ accepted than _____ liquids. The longer the use of the thickened liquid the ____ accepted.

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dislike; reduced; dehydration

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A high rate of ____ of thickened liquids among adult patients with dysphagia suggests that ____ fluid intake may further the risk of _____ in this patient population.

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increased; dehydration

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Acute stroke patients with dysphagia have ____ rate of _____ at admission and discharge from hospital.

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1. Thickness of liquid (thin, thick, ultrathick) 2. Manner of presentation (spoon versus cup)

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Bolus factors that influenced aspiration rates during the fluoroscopic swallowing exam:

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ultrathick; spoon

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_____ thick liquids presented by _____ resulted in the lowest rates of aspiration.

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thin; cup

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____ liquids presented by ___ resulted in the highest rates of aspiration.

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lowest; greatest

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Aspiration rates were ___ for honey-thickened liquids and ___ for thin liquids (combined with a chin-down posture)

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interpreting the results of swallowing evaluation and in making clinical recommendations.

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Beware of patient fatigue when

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5; 10 also, the rate of residue increases more for the larger volume.

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Thickening material results in reduction of aspiration rates for __ mL the benefit is not the same for __ mL.

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Patients in the combined liquid condition (water plus thickened liquids) ingested less-thickened liquids and had greater daily fluid intake than those in the thickened-liquid-only condition.

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'free water' protocol vs. thickened liquids only

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Allowed patients with dysphagia, including those considered to aspirate thin liquids, access to water between meals. Few instances of dehydration or chest infection.

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Frazier Water Protocol

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- increased lingual-palatal pressure - slower bolus transit - increased pharyngeal pressure - Greater UES relaxation (all tested in healthy adults)

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Physiologic impact of thickened liquids?

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- Chemosthesis - tactile sensation from the bubbles - Less penetration/aspiration (patients) - Increased pharyngeal transit time (not in all studies) - Less residue than thick liquids - Increased lingual-palatal pressure - Faster laryngeal elevation (elderly healthy) (only EFFECT studies, mostly on healthy adults)

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How might carbonation affect a patient's swallow?

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- Sour taste may reduce aspiration in patients with dysphagia (neurogenic) due to faster oral onset and reduced pharyngeal delay - Sour and sweet increased spontaneous swallows after initial swallow (nursing home) - Healthy adults - multiple tastants - sweet, salty, sour, etc. (Increased swallow effort & increased swallow speed (not in all studies); good for pts with weakened/ slow swallow)

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How might taste affect a patient's swallow?

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taste; texture; greater; greater

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Thickening liquids can alter the ___ and ___ of the original liquid. And the deviations seem to be ____ as the thickness becomes ____.

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prevent (reduce) aspiration but little evidence that this effect translates to reduced pneumonia risk. Lots of conflicting information, more research needs to be done.

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Thickening liquids MAY

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compensatory; Adjustments intended to enhance airway protection and/or promote increased oral intake. No information on duration of these strategies but the patient should be monitored for patient acceptance and clinical benefit over time.

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Food/liquid modifications are _____ strategies.

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No; thickened liquids may have a physiologic impact on the swallow mechanism if used as part of a focused rehabilitation program.

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Does food/liquid modification have any rehabilitative effects on the swallow mechanism?

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abnormally.

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Swallowing therapy often teaches patients to swallow

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- Postural adjustments - Supraglottic swallow (SGS) - Super-supraglottic swallow (SSGS) - Mendelsohn's maneuver - Effortful swallow - Masako maneuver - tongue/hold - Oromotor exercises

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Behavioral therapy strategies

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Lying down or side lying (and variations) - reduce impact of gravity during swallow or on residue (consider esophageal issues - reflux) - side lying should consider pharyngeal asymmetry (the stronger side should be the down side) - this position uses gravity to direct the bolus toward the stronger hemipharynx C - short term use P - less aspiration? R - increased effort?

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Postural adjustments: Body Compensatory? Prevention? Rehabilitation?

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increased hypopharyngeal pressure on the bolus, contributing to increased maximum opening of the PES and reduced duration of sphincter opening during the swallow. the changes may be helpful in strengthening the swallow in some patients.

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Physiologic result of lying down

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Extension - chin up Flexion - chin down Head rotation - R v L

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Postural adjustments: Head

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- widens the oropharynx - help move the bolus from the mouth into the phayrnx when poor oral transport is present - increases PES intraluminal pressure (less relaxation) and changes the coordination between pharyngeal and PES swallow pressures which can complicate an existing swallowing problem.

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Extension - Chin up

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- This technique may be good for Patients with difficulty transporting the bolus but may contribute to swallowing difficulties in patients who have airway protection or PES deficits.

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Extenstion - Chin up: good for/not good for

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- narrows the oropharynx - reducing the distance between the hyoid bone and the larynx - may facilitate airway protection - prevention - may facilitate increased lingual pressure - may create weaker pharyngeal contraction - considered compensatory

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Flexion - Chin down

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- pharyngeal weakness - PES dysfunction - Multiple swallow deficits - e.g., poor lip seal

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Flexion - chin down may not be well suited for patients demonstrating:

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1) Narrows one side (the side you're turning your head & other side is enlarged) of the oropharynx (and maybe the entire pharynx) 2) Reduces contralateral PES pressure (Facilitates increased PES opening & Expected to increase the amount swallowed); redirects materials away from the weaker/ surgical side 3) Short term use 4) only if reduced residue means less aspiration!

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Head Turn: 1) What does it do to the swallow structures? 2) How does it help the swallow physiology? 3) Compensatory? 4) Prevention?

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weak; tongue is too weak to redirect bolus

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If pt has CN damage to X & XII, residue will pool on ____ side because ____

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1) Choose a technique & verify that it's a good technique for your pt 2) Instruct your pt on the technique & make sure they understand how it works 3) Always Verify & Monitor to make sure pt can do it & there's a benefit. 4) Surveillance (worse the pt, greater the surveillance)

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4 general steps to follow with a pt and the compensation technique

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- a preswallow breath hold with no extra effort - swallow - voluntary cough - glottal closure horizontally

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Supraglottic Swallow (SGS)

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- a preswallow breath hold with an effortful breath hold (extra effort/bear down helps to facilitate glottal closure) - swallow - voluntary cough - glottal closure horizontal and anterior

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Super-supraglottic swallow (SSGS)

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With biofeedback using an endoscope to check for the breath hold or effortful breath hold

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How can you ensure that pt is doing the suproglottic swallow correctly?

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degree of closure and "certainty" of closure

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SGS & SSGS difference:

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1) Reduced airway protection from reduced glottal closure 2) Swallowing incoordination 3) Reduced laryngeal movement

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The Supraglottic and Super Supraglottic Swallow may be best suited for patients who demonstrate... (3 things)

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1) short term use 2) reduced aspiration in some cases 3) not well determined; could be, based on pt needs

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The Supraglottic and Super Supraglottic Swallow: 1) Compensatory? 2) Prevention? 3) Rehabilitative?

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1) Increased laryngeal elevation 2) Increased anterior laryngeal movement 3) Increased tongue base movement 4) Increased PES opening 5) Increased swallowing coordination

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Possible Physiologic effects of the Supraglottic and Super Supraglottic Swallow?

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You inhale before a cough. If you have residue/liquids on your vocal folds, then you will inhale those.

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For pt with residue problems, why is it better to clear throat as opposed to cough?

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Listen for breathy vocal quality & for cough

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How can you check for glottal closure without imaging?

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Mendelsohn Maneuver

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What is a maneuver to prolong the swallow?

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- Squeeze swallow at apex! - Intended to prolong and extend hyolaryngeal elevation; May prolong PES opening (not uniform)

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How does the Mendelsohn Maneuver work? What is it intended to do?

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1) may be for short term use, but unlikely since it's difficult to teach 2) may be used as part of a systematic therapy program - Improved coordination of swallow following therapy with maneuver 3) Reduced post swallow residue and reduced aspiration have been reported

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Mendelsohn Maneuver: 1) Compensatory? 2) Rehabilitative? 3) Prevention?

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1) ↑ duration of lateral pharyngeal wall movement 2) ↑ peak contractions of pharyngeal muscles 3) ↑ duration of pharyngeal muscle contractions 4) ↑ tongue-palate pressure duration 5) ↑ velopharyngeal sphincter pressure 6) ↑ amplitude and duration of swallow sEMG 7) ↓ preopening UES pressure 8) ↑ maximum hyoid excursion following therapy

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8 Possible Physiologic Effects of the Mendelsohn Maneuver

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1) Difficult to teach (Variable instructions; Hard to monitor for both patient and practitioner) 2) Prolongs apneic pause during swallow (not good for pts with respiratory dz or incoordination; Simple check on respiration - hold breath for 5 secs then check resp. pattern)

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Concerns for the Mendelsohn Maneuver

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Biofeedback (specifically sEMG to show pt how they're swallowing & to make sure they're actually swallowing)

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What to use for a maneuver that is hard to teach and monitor?

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Maybe not, can be relaxed but not open enough so materials can go through

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For Mendelsohn Maneuver, if UES is relaxed, is it open?

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1) Increased force on bolus - greater swallow effort 2) Increased tongue base movement 3) May see greater or less hyoid and larynx excursion 4) Increased oral pressures (tongue-palate) 5) Increased duration of swallow (by milliseconds) 6) Greater UES relaxation 7) Effort increases with use in therapy 8) May be a positive esophageal effect

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Physiologic Impact of Effortful Swallow

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- Effective in neurogenic dysphagia as part of therapy - Effective as part of exercise-based therapy program

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Functional Impact of Effortful Swallow (when would it be effective)

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airway protection & degree of post swallow residue

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Effortful swallow has NO impact on ___ and ____

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diffult to teach and monitor

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Difficulty with Effortful Swallow?

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1) Not usually immediate/short term 2) Yes, as a systematic therapy program 3) Only if reduced aspiration or residue

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Effortful Swallow 1) Compensatory? 2) Rehabilitative? 3) Prevention?

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Biofeedback with sEMG - makes their swallow harder & you can make sure they're doing an actual swallow

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Best way to monitor effortful swallow?

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1) Increased anterior bulge of posterior pharyngeal wall; Increased BOT/PPW contact 2) No evidence of compensation, prevention or rehabilitation 3) Reduced airway closure, Increased post swallow residue, Increased delay in swallow initiation; Aspiration risk

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Tongue Hold or Masako Maneuver: 1) What does it do to the swallow structures? 2) Benefit of the maneuver? 3) Negative issues of the maneuver

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1) Reduced pharyngeal contraction pressure 2) Shorter pharyngeal pressure durations 3) Greater UES relaxation (for younger) BUT less UES relaxation (for older) 4) Increased lingual and pharyngeal muscle activation 5) Increasing tongue protrusion increases variability in lingual-palatal pressure 6) NO IMPACT on pharyngeal swallow pressures - FEW POSITIVE EFFECTS, no exercise benefits

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Physiologic impact of Tongue Hold or Masako Maneuver

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OroMotor Techniques

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Frequent approach to 'exercising' the swallow mechanism

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1) speech motor exercises 2) no specificity (technique doesn't match pt problem) 3) Rehabilitative

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OroMotor Techniques: 1) Where do most techniques come from? 2) Biggest reason this technique might not provide benefit? 3) Is it Compensatory or Rehabilitative?

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1) Lip movement and resistance 2) Tongue movement and resistance 3) Jaw stretching 4) Speech activities 5) Voice/phonation activities - may focus on range of motion and/or resistance activities

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Oromotor Exercises (OME) could include (5 things)? May focus on ___ and/or _____

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ENDURANCE (for maintenance) 1) Lip pucker (eee ooo eee ooo) 2) Tongue protrusion/retract 3) sucking/blow 4) falsetto STRENGTH (increased strength, NOT endurance) 1) Tongue bulb (pressing disposable standard-sized tongue bulb against the roof of the mouth with the tongue to measure peak pressure)

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List 4 oral motor exercises for endurance and 1 OME for strength. What were the outcomes of each type?

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You can only get stronger by adding a LOAD to the system

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What do you need for increased strength/ motor growth?

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1) application is often off target....e.g., maintenance vs strength 2) OME do not meet many exercise principles that may improve rehabilitative effectiveness

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OME Rehabilitation: 1) Main problem with using OME 2) What's the rehabilitative effectiveness of dysphagia rehabilitation?

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No real evidence of its impact

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OME Prevention or Compensation?

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- Increase in Motor Units (motor unit recruitment measures how many motor neurons are activated in a particular muscle/how many muscle fibers are activated) - Higher the recruitment the stronger the muscle contraction will be and the more "work" the pt is doing - Ensures the Neuromotor system is being trained

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For biofeedback, when we see the number on the EMG increasing, what does that tell us?

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1) monitoring existing mvmts (look for fatigue) 2) improve mvmts (swallow harder) 3) measure swallow physiology (as a therapy assessment) 4) measure swallow with different consistencies

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Biofeedback helps with ___

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rehabilitative

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When techniques target physiologic change in swallow performance, they are _____ approaches.

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1) SPECIFICITY (to work on swallowing, you should practice swallowing) 2) OVERLOAD (increase the intensity by increasing the resistance/load; also increase the frequency)

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2 factors to consider FIRST with exercise swallow rehab (according to Crary)

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1) increase bolus VOLUME (increases the load) 2) increase bolus VISCOSITY (thicker, more adhesive materials require more movement)

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2 ways to increase RESISTANCE when exercising the swallow mechanism?

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1) Motor learning 2) Muscle effect (takes ab 8 weeks) - There is quicker adaptation over time

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With exercise, what happens to muscles over time?

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1) OVERLOAD - time and load/resistance in training should challenge muscles to create muscle change 2) PROGRESSION - gradually increase intensity (load) & demands (frequency/time) 3) INTENSITY - amount of load used 4) ADAPTATION - alter muscle condition by repeatedly practicing a movement/skill 5) REVERSIBILITY - if you don't use it, you lose it - "detraining" 6) SPECIFICITY - specific to goal 7) RECOVERY - rest between repetitions

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What are 7 Exercise Principles that should be considered when doing swallow rehab?

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8 wks

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How long does it take to see changes in exercise?

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Physiologic reserve; with age or disease

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Difference b/w maximal strength and strength you need to swallow? Why might this different decrease?

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1) Neurologic inhibition 2) Hyolaryngeal elevation 3) A blous

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3 general factors needed for a swallow to occur

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Adjunctive

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Term for a type of modality added to therapy but should not be done on its own as therapy.

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1) Surface Electromyography (sEMG), also for biofeedback 2) transcutaneous electrical stimulation (E-stim, e.g. VitalStim), NOT for biofeedback

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2 adjunctive modalities commonly used in exercise-based rehab? Could you use them for biofeedback?

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- electrical current causes muscles to contract - "motor level stimulation" - you see the muscles moving so you think it's improving

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How does of E-Stim (transcutaneous electrical stimulation) work?

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- smaller muscles - harder to isolate - run in different directions - deeper - harder to stimulate - - MAY interfere/worsen neuromusclar swallow in the elderly or diseased

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What are the issues with using E-stim on swallow muscles?

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1) sensory level stimulation - lower amplitude, NOT a sign of stimulating muscles 2) motor level stimulation - increased amplitude, feel pulling, grabbing

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2 different levels that your muscles reach with E-stim?

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to strengthen suprahyoid musculature and improve PES opening

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Goal of Shaker Head Lift

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1) face-to-face therapy 2) mass practice with biofeedback used at home 3) virtual reality applications (good for pts in LTC; e.g. Synergy 3D - virtual biofeedback program)

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3 tips for increasing pt adherence of exercise therapy

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1) if pt has PES failure with reside and aspiration due to a poor upward pull on PES from suprahyoid muscles can do this exercise 2) improved PES opening, hyolaryngeal elevation, & functional oral intake; reduced post-swallow residue & aspiration 3) Compliance/adherence - will pt do it and will it be done correctly? No good if pt has trach or fibrosis

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Head Lift (Shaker): 1) Rationale 2) Outcome 3) Issue with this technique?

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adaptation & recovery

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The two exercise principles utilized with the Shaker Head Lift

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1) tongue press (pushing tongue out against tongue blade) 2) jaw opening against resistance 3) chin tuck against resistance

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3 alternatives to the Head Lift exercise with less pt burden

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develop lingual strength to improve swallow (timing & coordination)

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Goal of lingual resistance training?

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1) press the tongue against the hard palate or a tongue blade or require a device such as the IOPI or similar technique 2) reduced lingual function may be directly related to certain dysphagia symptoms 3) increased max tongue strength 4) No specificity, also if you don't use IOPI you don't know the amount of resistance

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Lingual Resistance Training: 1) technique examples 2) rationale 3) results as therapy 4) main issue of using this as rehab?

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1) progression 2) overload 3) adaptation 4) intensity 5) recovery

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The 5 exercise principles utilized with the Lingual Resistance

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1) sEMG - measure the amplitude of muscle contraction 2) IOPI (Iowa Oral Performance Instrument) - to measure and document lip and tongue strength; higher the #, the more force

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Two instruments that can be used for biofeedback and when would you use them?

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McNeill Dysphagia Therapy Program (MDTP)

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systematic, exercise-based therapy program/framework for the treatment of dysphagia in adults; initially developed for patients with chronic, refractory dysphagia

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1) Specific to the functional task at hand - Swallowing! + Simple protocol 2) Frequent to promote sensorimotor learning - Daily + home practice = quicker physiologic change 3) Intense to exercise target muscle groups - 1 hr therapy, little distraction (mass practice for swallow), push patient 4) Uses progressive resistance to build strength and coordination - 11 step systematic Food Hierarchy, pt advances or regress based on clinical performance

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How does the MDTP address the exercise principles of 1)Specificity, 2)Frequency, 3)Intensity, & 4)Progression?

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progressive development, strengthening, and refinement of the muscular components of the swallowing process

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Goal of MDTP

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FOOD - different foods = different responses, bolus accomodation

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During swallow exercises what is the best thing to use as the "load?"

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5ml & 10ml

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2 functional volume measures of a bolus

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"Pharyngocise"

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Program designed to use exercise to prevent dysphagia and related morbidities in head/neck cancer patients; Pts follow a prescribed exercise program DURING chemoradiation for head/neck cancer

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1) Tongue press 2) Hard swallow 3) Falsetto (good for maintenance, voice box adducts & stretches forward, pharyngeal walls constrict) 4) Jaw opening against resistance, may be enhanced with Therabite

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4 exercises that make up pharyngocise?

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1) - enhance functional swallowing - less edema & fibrosis - less deterioration in mouth opening, taste, and salivation 2) pain & fear of pain

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1) Pharyngocise outcomes 2) Pharyngocise issues

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Pt's physiologic needs; biologic plausibility - does it make sense for your pt?

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With therapy it is important to match the technique used to ___

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traditional - only compensation adjustments to prevent complications; recently - exercise approaches to rehabilitate and to prevent deterioration in the swallow mechanism

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How has dysphagia therapy changed?

question

VitalStim

answer

Adjunctive modality that uses electrical stimulation to "improve" the swallow function by getting the muscles to contract harder

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