Dysphagia – Treatment (Adults) – Flashcards

Re-establish oral feeding while constantly maintaining adequate • Hydration • Nutrition • Safety Eating should be... - Enjoyable - Efficient - Safe

• Diagnostic work-up unveils: - Diagnosis - Physiologic swallowing function - Response to trial treatment procedures - General aspects of patient status • Treatment should address physiological causes of dysphagia

Symptoms: Subjective evidence of disease or problem • coughing, throat clearing • complaint of food sticking in throat or chest Signs: Objective evidence of disease or problem • nasal regurgitation • laryngeal penetration, aspiration • residue in the valleculae/pyriform sinuses Physiological deficit: Disordered muscular/mechanical function that underlies symptoms or signs

• Patient Barriers: - Depression and apathy - Fatigue - Expectations - Poor Oral Hygiene • Clinician Barriers: - Adequate tools - Adequate knowledge • Clinicians must practice evidence based treatment • Patients may be harmed when the clinician does not have adequate tools and knowledge

• Compensatory Treatment Procedures - Redirect or improve flow of food through oropharynx - Do not usually change physiology of patient's swallow • Therapy Procedures - Designed to change patient's swallowing physiology • Indirect vs Direct Therapy - Indirect therapy involves exercises using no food or liquid - Direct therapy incorporates small amounts of food or liquid while implementing swallowing techniques

• Improves magnitude of upper esophageal sphincter relaxation and opening o Increases anterior excursion of larynx (elevation) - likely due to increased contraction of specific suprahyoid muscles o Hyolaryngeal excursion assists with CP opening • Lie supine and raise the head to look at toes o Both isometric (holding a sustained posture) and isokinetic (repeating a movement) exercise o Number of repetitions specified o Duration of hold is specified

• Postural Techniques • Improving Sensory Awareness • Diet Modification • Intraoral Prosthetics • Augmentative Devices

• Changes in body posture • Potentially change dimensions of pharynx and direction of the food flow without increasing patient's work or effort during swallowing • Postural techniques can: - eliminate or reduce aspiration - improve oral and pharyngeal transit times - improve bolus clearance

• Maintains bolus in anterior oral cavity • Positions tongue base toward posterior pharyngeal wall • May improve airway protection o May narrow laryngeal airway entrance and improve bolus drive (Welch et al, 1993) o May widen vallecular space in some patients Contraindications: • Poor lip closure • Poor oral transfer of bolus

• Uses gravity to assist with bolus transfer • May improve oral transit • *But, can reduce laryngeal closure* Evidence: • Rasley et al. (1993). Prevention of barium aspiration during videofluoroscopic swallowing studies: value of change in posture. Contraindications: • Poor laryngeal excursion • Reduced laryngeal closure/ airway protection

• May narrow pharyngeal recesses on weak side • Redirects bolus to stronger side • May be used in combination with chin tuck Evidence: • Ohmae et al. (1998). Effects of head rotation on pharyngeal • function during normal swallow. • Logemann et al. (1989). The benefit of head rotation on • pharyngoesophageal dysphagia. Contraindications: • Cervical vertebral problems which prohibit patient from turning head

• Uses gravity to direct bolus to stronger side • Used when both unilateral oral and unilateral pharyngeal weakness is present on same side Evidence: • Rasley et al. (1993). Prevention of barium aspiration during videofluoroscopic swallowing studies: value of change in posture. Contraindications: • Bilateral weakness or opposite oral and pharyngeal side weakness

• Provide a preliminary sensory stimulus prior to patient's swallow attempt - can prime the oropharynx before a swallow • May alert the central nervous system • May increase sensory awareness ^input through CN VII, IX and X ^integration at brainstem level > Can result in improved oral and pharyngeal transit times • Bolus characteristics which may improve timing and coordination of oral and pharyngeal swallow phases - Sour bolus - Cold bolus - Carbonated bolus - Bolus requiring chewing - Large volume bolus • Increased downward pressure of spoon against the tongue when presenting food in the mouth • Self-feeding • Thermal-tactile stimulation (therapeutic)

• Must use judiciously - Downgraded diet significantly affects patient's desire to eat, quality of life, potentially hydration/nutrition levels • Solid Textures - Dysphagia-Pureed, Level 1 - Dysphagia-Mechanically Altered, Level 2 - Dysphagia-Mechanically Advanced, Level 3 - Regular • Liquids - Thin - Nectar-like - Honey-like - Spoon-thick* • Decrease or increase the volume of food or liquid • Alternating food and liquid • Changing the temperature of the food • Consider taste, spices and smells • Multiple dry swallows following solid bolus

• Multiple Swallows - Break bolus into smaller portions - Bolus swallow followed by dry swallow - Can reduce residue post-swallow • Alternate solids w/ liquids - Provides "liquid wash" - Can help clear residue • Small bites/sips - Can help control bolus flow - Can reduce residue post-swallow • Periodic throat clears - Can eject penetrated material

• Augment the configuration of the palate to improve oral transit • Palatal Obturator - Closes off a surgical or anatomical defect • Palatal Reshaping Device - Recontours the hard palate to interact with the remaining tongue • Palatal Lift - Lifts the soft palate into an elevated or closed position to facilitate velopharyngeal closure

• Syringe • Syringe with extension • Nosey Cup • Straw

• Designed to change or improve swallowing physiology • Specificity o Exercise program should target the physiologic maneuvers utilized during swallowing • Techniques: o Resistance Exercises o Range of Motion Exercises o Sensory-Motor Integration Techniques o Swallow Maneuvers o Biofeedback

• Lingual resistance exercises involve pressing specific portions of tongue against hard palate • Lingual, labial, buccal strength • Some tools provide visual feedback

• Used to improve tongue base to pharyngeal wall contact and improve pharyngeal clearance of bolus Tongue is protruded and held in forward position during swallow (saliva swallow) • Causes tongue base to be positioned anteriorly encourages an increase in pharyngeal wall contraction and bulging to achieve contact with anteriorly displaced tongue base Steps • Protrude the tongue maximally (as far as they can) but comfortably and hold tongue between the central incisors • Hold it and do not let go • Saliva swallow while holding tongue between incisors

• Improves magnitude of upper esophageal sphincter relaxation and opening o Increases anterior excursion of larynx (elevation) - likely due to increased contraction of specific suprahyoid muscles o Hyolaryngeal excursion assists with CP opening • Lie supine and raise the head to look at toes o Both isometric (holding a sustained posture) and isokinetic (repeating a movement) exercise o Number of repetitions specified o Duration of hold is specified Steps • Lie down in supine position • Raise head and look at toes without raising shoulders off the ground • Isometric: 1-minute sustained head-raising with a 1-minute rest between each trial, x3 reps • Isokinetic: 30 consecutive head raisings, at constant speed, for strengthening *Patients with cardiac conditions or hypertension need doctor approval before engaging in these exercises *Only appropriate for medically stable patients

Improve extent of movement of lips, jaw, tongue, pharynx, larynx, and vocal folds. Always pair exercises with a swallow! • Lips o ROM • Jaw o Therabite® or Dynasplint® • Tongue o ROM • Pharynx o Tongue hold maneuver • Larynx o Shaker head lifts • Vocal folds o Exercises to encourage vocal fold closure

o Appropriate for patients struggling to trigger a swallow response, delay or absent pharyngeal swallow • Using temperature and tactile sensation to prime oropharynx o Cold touch application is applied to anterior faucial pillars o Then followed by volitional swallow by patient; start with saliva swallow • Goal: increasing sensory input to brainstem (via CN IX, X, etc.) may help trigger swallow response o Mechanoreceptors in the skin responds to deformation of the skin/tissue which triggers response • May shorten pharyngeal swallow response by stimulating the glossopharyngeal nerve o Sensory response may improve with therapy

• VitalStim o Very controversial • Electrical Stimulation o Surface muscle stimulation, e.g., VitalStim® - Stimulates skin and underlying muscle • More positive evidence than negative • Problem with surface stimulation o Cannot activate specific muscles - Activates all muscles for flow of mouth o Difficulty activating deep muscles - Interarytenoids - Lateral arytenoids - Thyroarytenoid - Cricothyrid - Suprahyoid muscles (thyrohyoid) -; not likely to be stimulated • May have better results if used therapeutically • Intramuscular stimulation o Elicits muscle contraction by stimulating nerve and nerve endings o Augmentation of hyolaryngeal movement

• Deep pharyngeal neuromuscular stimulation o Provides sensory stimulation to various points in oral cavity and may improve swallow initiation o Usually conducted with cold applicator such as in thermal-tactile stimulation o Limited evidence for efficacy Swallow Maneuvers • Designed to alter physiology of swallowing to improve safety or efficiency • Creates immediate effect on physiology • Can lead to long-lasting changes over time if maneuver is performed regularly by re-training motor response patterns

• Addition of "super" means a follow-up cough is associated with it • Hold breath while bearing down, take sip, swallow, cough, and clear the airway • Protects airway before/during the swallow and clears the laryngeal vestibule of penetrated material after the swallow • Effects: o Close airway entrance (vestibule) before/during swallow by attempting to narrow airway opening o Close airway at true vocal folds before/during swallow o Utilizes increased effort in breath hold o May increase anterior laryngeal motion and tongue-base movement o May assist in upper esophageal sphincter opening

• Addition of "super" means a follow-up cough is associated with it Instructions: • Take a breath and hold very tightly • Bear down (like you are going to the bathroom) Continue to hold your breath tightly while swallowing - continue holding throughout the swallow • Cough immediately after the swallow - do not inhale prior to coughing - "super-supraglottic" adds cough component

• Hard or forceful swallow • Increase posterior tongue base motion during swallow to increase lingual driving force o Can improve base of tongue to pharyngeal wall contact o Tongue and throat will work very hard during procedure o Can increase lingual driving force o Can increase pharyngeal constriction o Can increase laryngeal elevation - Helps reduce residue and protect airway Instructions: • Swallow normally but squeeze very hard with your throat and neck muscles throughout the swallow • Use all of the muscles in your throat to swallow

• Swallow and hold the swallow at the height of laryngeal elevation • May increase extent and duration of laryngeal elevation to increase duration and extent of UES opening Instructions: • Swallow normally and feel your voice box or Adam's apple lift during the swallow • On the next swallow, use your neck muscles to hold the voice box up for several seconds during the swallow • When you feel your voice box go up, hold it up with your neck muscles and do not let it down • Hold if for several seconds and then breathe and relax

• Videofluoroscopy o Teaching patients about their individual swallowing function o Review study to explain physiology and physiologic deficits • EMG biofeedback o Provides information regarding effort, duration, and timing of events • Ultrasound o Provides feedback regarding tongue movement • Videoendoscopy o Provides information regarding timing and extent of vocal fold closure

• Few studies have examined the therapeutic benefit of medications on oropharyngeal swallowing function • SLP should consider patients medication cycle when determining the most optimal time for tx • Treat the underlying disease • L-dopa - Parkinson's disease; basal ganglia disorders • Anticholinesterase agents and immunosuppressive drugs - Myasthenia gravis • Reflux medication - GERD • Transdermal scopolamine - drooling • Pilocarpine (Salagen™) and Cevimeline (Evoxac™) - xerostomia or dry mouth

Feeling of a dry mouth; reduced salivation, makes transit of the bolus more difficult • Causes o Medication o Autoimmune disorders o Radiation Diagnosis o Sialometry - measures gland secretion (saliva flow). Measured and quantified at rest and after citrus stimulation. • Treatment (increase production or substitute for saliva) o Artificial saliva o Stimulation of salivary secretions by mechanical or systemic therapy (if glands are still functional) - Glands function differently (see text) - Gustatory • Treatment with citric acid foodstuff or sour lozenges - Masticatory • Treatment with gum chewing or sugarless candies

• Swallowing is the best retraining for the swallow • More than one treatment is usually needed to optimize the swallow • Critical to involve the patient and the care providers in treatment planning • Appropriate treatment will be impacted by physical barriers, cognitive status, level of independence, and other factors