Treatment Goals and Objectives-Dysphagia – Flashcards
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Knowing WHAT to treat is important, it requires the SLP to do what?
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-Identify signs of oral, pharyngeal and esophageal dysphagia -Understand the UNDERLYING PHYSIOLOGY that is the likely cause of the sign.
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What happens if you don't have knowledge of the underlying physiology?
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-You might select a treatment technique or method that is wrong for the problem (e.g. treating a delay when the problem is reduced CP functioning) -A sign may have more than one possible physiologic cause
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Knowing WHY to treat requires the SLP to understand what?
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the functional improvement that is sought Example: we've increased tongue control with exercises but the patient is still NPO = NO GOOD
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Knowing HOW to treat requires the SLP to understand what?
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-the physiology of the swallow (otherwise it's "shooting in the dark") -Requires that the SLP know which treatment techniques have an evidence-base for improving (or compensating for) that impaired physiology.
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Knowing how LONG to treat requires understanding of what?
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-Etiology -Prognosis -Outcomes data -NOMS has been around for 10 years (National outcome measures)
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What is the short term goal based on?
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based on physiology that determines what is wrong or impaired which will then determine functional short term goals Physiology ; Functional Short Term Goals
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Once you have the functional short term goals then you can identify what?
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treatment objectives
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How do we observe a SIGN?
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on either the clinical swallow study or during an instrumental examination like MBS
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Loses food from the front of the mouth (anterior spillage) or can't form a cohesive bolus. What phase is this SIGN an example of?
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Oral Prep
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Food/liquid in pharynx or airway before the swallow or residue in valleculae or pyriform sinuses after the swallow. This is an example of what phase for this SIGN?
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Pharyngeal phase
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Can't move the bolus to the back of mouth or loses bolus over back of tongue while trying to move bolus back (premature spillage). This is an example of what phase for this SIGN?
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Oral Transit
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T/F: short term goals cannot be written from the SIGNs observed
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FALSE! they can be written fro the signs observed. Get the sign then make it into a short term goal
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Why are short term goals not FUNCTIONAL?
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Because it doesn't man anything to the non-SLP e.g., insurance
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If the sign is poor oral transit-can't move bolus to back of mouth. What would the short term goal be?
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Pt will improve oral transit ability
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If the SIGN is the pt has residue in the valleculae. what would the short term goal be?
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Pt will reduce residue in the vallecualae
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If the SIGN is the pt loses food from the front of the mouth. What would the short term goal be?
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Pt will decrease loss of food from front of mouth
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functional Short term goals are written in terms that who can understand?
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Payers, consumers and other health professionals so everyone understand improving the pt's health and safety
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T/F: functional short term goals should address WHY the skill needs improvement.
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true
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If the short term goal is pt will improve ability to move food back of mouth. How do you make that into a functional short term goal?
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pt will improve ability to move food back of mouth TO REDUCE ORAL RESIDUE THAT MIGHT FALL INTO THE AIRWAY
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If the short term goal is to decrease residue in the valleculae what would the functional short term goal be?
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decrease residue in the valleculae THAT MIGHT FALL INTO THE AIRWAY AFTER THE SWALLOW
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If the short term goals is pt will reduce anterior loss of food what would the functional short term goal be?
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pt will reduce anterior loss of food SO THAT MORE FOOD WOULD BE CONSUMED
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Attending to physiology helps determine what?
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WHAT to treat
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SIGN: residue in pyriform sinuses after the swallow Functional STG: pt will reduce residue in the pyriform sinuses to reduce risk of aspiration after the swallow what would be the different physiologic causes?
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reduced pharyngeal wall movement or reduced CP opening
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SIGN: residue in pyriform sinuses after the swallow Functional STG: pt will reduce residue in the pyriform sinuses to reduce risk of aspiration after the swallow Different physiologic causes: -reduced pharyngeal wall movement -reduced CP opening what would be the reworded functional STG?
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pt will increase pharyngeal wall movement to reduce pyriform sinus residue which may cause aspirated after the swallow or pt will increase CP opening to reduce pyriform sinus residue which may be aspirated after the swallow
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What are the treatment objectives?
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smaller, more measurable steps used to achieve the functional short term goal.
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How should treatment objectives be chosen?
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Should be chosen based on the physiologic cause of the sign/symptom
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what are the types of treatment objectives?
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-Compensatory -Facilitation or therapeutic -Diet
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What are compensatory treatment objectives?
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Designed to compensate for, not improve the lost function. (Can't fix but work around ex: dysarthria)
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Compensatory treatment objectives are most often used when?
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During meals
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what are the types/components of compensatory treatment objectives?
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• Postural changes • Increased sensory input • Food placement • Food presentation
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What are common compensatory techniques?
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Chin Tuck Head rotation Head Tilt Multiple Swallows Alternating Liquids and solid Supra-Glottic Swallow Super Supra-Glottic Swallow Effortful Swallow Cough/Throat Clear Mendlesohn Maneuver Modify volume and speech of food presentation
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What is the chin tuck?
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The patient puts their chin to the chest before the swallow and maintains this position until the swallow is completed.
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when do you use a chin tuck? what does it do?
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Used with a delayed swallow. Widens the vallecular space, so that the bolus will hesitate in the valleculae rather than falling into the airway. This is when the head of bolus is going beyond the head of the mandible to the pyriform sinuses *used also to help epiglottis deflection and laryngeal elevation and BOT retraction, clinically (helps with bolus propulsion, epiglottis retroflexion, and laryngeal elevation)
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what is the rationale for the chin tuck?
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Rationale: helps bolus propulsion because narrows the space between the base of tongue and the posterior pharyngeal wall (oropharygneal space). So that when trigger swallow and base of tongue goes back to give bolus propulsion then there is less room it has to cross. It will be a lot stronger and quicker
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What is a read rotation?
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The patient is asked to turn their head to the paretic side (weaker side) until the swallow is completed. Turning the head toward the weak side compresses "closes off" that side of the pharynx allowing the bolus to descend on the unaffected side. ALWAYS TURN HEAD TO WEAKER SIDE (if residue is on one side that's the weaker side)
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what is the head tilt?
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Head is tilted toward the stronger side so bolus goes down the weaker side. Opposite of head rotation Food and liquid descend the stronger side of the larynx.
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What is laying on side or side lying?
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For bedbound patients The patient lays on his/her side (the stronger side) in order to decrease gravitation pull and divert food toward the stronger side. Don't sit up because might not be able to head rotation. Not usually common
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What is multiple swallows technique?
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The patient is asked to take 2 or 3 swallows per bolus of food or liquid. Helps clear the valleculae and/or the pyriform sinuses of any residue that might be aspirated AFTER the swallow. (Residue then swallow again)
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What are alternating liquids and solids technique?
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The patient is taught to alternate taking a solid then a liquid bolus. One consistency can help to clear the other from any pharyngeal areas. Not always liquid clearing the solids some swallow solids better than liquids. Ex: swallow liquid then swallow pudding
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What is the rationale for alternating liquids and solids?
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Rationale: Poor bolus propulsion for solids but liquids help wash it OR he has liquid residue in the valleculae that is washed away or taken away with a solid bolus of food because muscles put more effort for the solid bolus
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What is the supraglottic swallow technique?
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The patient is taught to take a small breath, swallow, cough immediately and then swallow again. A voluntary breath hold usually adducts the true vocal folds before the swallow and the immediate cough allows the patient to expectorate any penetrated material, which is moved into the esophagus by the last dry swallow. (swallow-cough-swallow) supra= above glottis=above the glottis
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What is the supra-superglottic swallow technique? What does it help with?
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The patient is asked to hold their breath tightly and bear down. Then they complete a supraglottic swallow. Effortful breath hold adducts the true and false folds and can increase the anterior tilt of the arytenoids for better laryngeal closure.
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What is the effortful swallow technique? what does it help with?
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The patient is instructed to "squeeze hard with all your throat muscles" during the swallow. Increases base of tongue retraction which propels the bolus to descend the pharynx.
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What is the Mendelsohn Maneuver technique? What is theory? Is it successful?
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The patient is taught to hold the larynx at the most elevated position during the swallow for 3 to 5 seconds. The theory is to increase extent and duration of laryngeal elevation, thereby increasing the duration and width of cricopharyngeal opening-not what actually happens **No success clinically, but have used it as an indirect exercise to increase strength and range of motion of base of tongue retraction and laryngeal elevation
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What is the modify volume and speed of food presentation technique?
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Larger boluses, for some patients can trigger a faster pharyngeal swallow. Smaller boluses at a slower rate can significantly reduce risk of aspiration in some patients. A weak pharyngeal swallow usually requires multiple swallows. (Small bolus because less residue than a big bolus)
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What are the facilitation/therapeutic treatment objectives designed to do?
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Designed to improve the lost function. Used during indirect therapy and not necessarily with meals.E.g. E.g., Mendlesohn exercise was compensatory now facilitation, Shaker Exercises
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What are the different types of facilitation/therapeutic techniques?
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Neuromuscular stimulation (NMES)-vital stim Shaker Exercises Thermal-Tactile Stimulation McNeil Dysphagia Treatment Program (MDTP) Expiratory Muscle Strength Training (EMST) sEMG with hard swallows IOPI MOST
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What does the Shaker exercises improve?
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improves cricopharyngeal functioning when there is a CP bar
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What is Thermal-tactile stimulation?
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tiny laryngeal mirror and ice it and ice up the fossa pillars. Work for delayed swallow. Stimulate the area but there is NO EVIDENCE BASE that it will facilitate pharyngeal swallow!
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What is McNeil Dysphagia treatment program?
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improve strength at certain weight and frequency then build up from there. SImprove strength and frequency Ex: weight lifting not start with 50 pounds but start lighter. Start nectar thick for 100 fast hard swallows without aspiration then move up to the next food. Make the food weight heavier*
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What is expiratory muscle strength training?
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pt blows into a part and turn to increase resistance. improve expiratory muscles then Improve persons efficiency to protect airway.
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What is vital stem?
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Done with traditional dysphagia therapy and not alone (uses Effortful Swallow) Delivers electrical pulse resulting in resistance for hyolaryngeal movement Various controlled studies showing equivalent result with and without NMES May help some patients, but need to assess with MBS with and without stimulation to be sure for each patient. Provides resistance for muscles to pull (a lot of controversy)
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What is sEMG?
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surface electromyography- measures muscle recruitment in microvolts (Measuring not giving a pulse. See how many microvolts to put out a swallow.)
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What is the IOPI?
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-Iowa Oral Performance Instrument -Lingual manometry -Portable biofeedback -Put balloon between surface of tongue and hard palate and smash together -Works on tongue to get stronger
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What is MOST or swallow strong?
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Madison Oral Strengthening Therapeutic Device Newest lingual manometry device on the market More detailed information of lingual strength (4 sensors-all go on tongue (small))
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What are the different exercises that can be done?
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labial exercises lingual exercises mendelsohn maneuver ecercises masako maneuver oral bulbar exercises shaker exercises
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what is a labial exercise?
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oo and /i/
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what are the different types of lingual exercises?
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resistance exercises (stick tongue out) IOPI MOST
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What is the Mask Maneuver? What does it increase?
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take a gauze pad and hold out and then trigger the swallow. Increases pharyngeal wall contraction. When tongue out then trigger a swallow. Forces the posterior and lateral pharyngeal wall to make the swallow because no BOT retraction when tongue it sticking out
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what does the Oral Bulbar exercises help with?
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velopharygneal closure (blow a kleenex)
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What is the best exercise for swallowing?***
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*is to swallow and should be included in the treatment objective *use of surface EMG is helpful for biofeedback
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What are the diet treatment objectives?
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Involves diet changes in texture or temperature to help compensate for lost function
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when do you modify food or liquid consistency?
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when other treatment and strategies are not feasible
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what are the different types of liquids?
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thin, smh-thick (nectar), and thick (honey)
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what are the different types of foods?
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puree ground mechanical soft regular consistancies
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if there is a problem in the oral prep phase for labial seal what is the treatment?
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labial exercises
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in oral prep: if there is a problem with mandibular strength and range of motion what are is the treatment?
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terabyte exercises (break contraction so can open mouth if have trismus (cant open mouth) for pt with TMJ
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Oral Transit: if there is a problem with lingual control what is the treatment?
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sucking exercises
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Oral transit: pt puts their head back. what type of treatment is this?
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compensatory
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What will you observe on instrumental exam for delayed pharyngeal swallow?
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•Puree or liquids enter the valleculae and/or pyriform sinuses before the swallow is triggered (n/a to foods requiring mastication) •Penetration or aspiration before the swallow
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What will you maybe observe on a clinical exam for delayed pharyngeal swallow?
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•Elevation of thyroid notch is delayed (wide range of delays) •Clinical signs of aspiration (coughing) before or upon initiation of the swallow, as well as likely continued coughing after the swallow.
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What are some techniques/strategies which may be indicated for a delayed/absent pharygneal swallow?
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chin tuck modify bolus size modify liquid consistency subglottic swallow 3-second prep* sour bolus neurosensory stimulation thermal stim
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Why would a chin tuck be a rationale for a delayed swallow?
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may keep bolus higher up in pharynx until the swallow is triggered
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why would modify bolus size be a rationale for delayed swallow?
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smaller size may accumulate less before the swallow. A larger size may help tirgger a more prompt swallow
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why would supraglottic swallow be a rationale for delayed swallow?
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protects airway before the swallow and expels penetration after the swallow
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why would the 3 second prep be a rationale for a delayed swallow?
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get pt into a mental set to swallow. pt swallows on 3
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why would the sour bolus be a rationale for a delayed swallow?
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sour bolus may decrease delay
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why would neurosensory be a rationale for delayed swallow?
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suck and swallow in finger of glove filled with ice may elicit a swallow
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why would thermal stem be a rationale for delayed swallow?
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may elicit a swallow in pt with absent swallow. May even decrease delay, but no evidence one way or the other regarding efficiency
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What are the observations made on an instrumental exam for reduced base of tongue retraction?
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•Base of tongue does not make contact with posterior pharyngeal wall. •Residue in the valleculae and pyriform sinuses after the swallow
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What are the observations during a clinical exam for reduced base of tongue retraction?
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Observations during a clinical exam: •Overall weak swallow, with clinical signs of aspiration after the swallow. •Spontaneous multiple swallows that appear ineffective because has residue
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What are some techniques to do for reduced base of tongue retraction?
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chin tuck effortful swallow multiple swallows alternate liquids and solids exercises to increase BOT retraction
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What is the rationale for using a chin tuck for reduced base of tongue retraction?
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decrease distance between BOT to posterior pharyngeal wall
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Wha is the rationale for effortful swallow for reduced base of tongue retraction?
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more effort may facilitate increased BOT retraction
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What is the rationale for multiple swallows for reduced BOT retraction?
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May help to clear residue from vallecuale and pyriform sinuses with each swallow
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what is the rationale for alternate liquids and solids for reduced BOT retraction?
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One consistency may help to clear residue of the other consistency.
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What is the rationale for exercises to increase BOT retraction?
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Mendlesohn, yawning, /k,g/
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What do you observe during an instrumental exam for reduced velar elevation?
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•Nasal Regurgitation during the swallow -test material enters nasopharynx
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what do you observe during a clinical exam for reduced velar elevation?
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Observations during a clinical exam: •Test liquid dripping from nares •Test liquid seen on tissue when patient blows nose
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What are some techniques/strategies that may be indicated for poor velar elevation?
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chin up surgical management prosthetic management velopharyngeal exercises
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what is chin up for technique for poor velar elevation?
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gravity helps keep liquid from moving further into nasopharynx
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what is surgical management for poor velar elevation?
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palatal flap
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what is prosthetic management technique for poor velar elevation?
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palatal lift
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what is velopharyngeal exercises techniques for poor velar elevation?
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exercises involving blowing and producing stop consonants
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what are observations that would be seen on an instrumental exam for reduced epiglottis retroflexion?
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Observations on instrumental exam: •No epiglottis deflection •Residual material in the valleculae after the swallow •Test material flowing down lateral channels from valleculae and filling pyriform sinuses •Possible penetration or aspiration AFTER the swallow from the residue in the valleculae or pyriform sinuses
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what are observations on a clinical exam for reduced epiglottis retroflection?
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Observations on clinical exam: •Multiple spontaneous swallows •Clinical signs of aspiration after the swallow •Patient reporting feeling solids or pill stuck in his throat and points to above the thyroid notch
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This strategy would reduce epiglottis deflection and facilitate epiglottis deflection especially if there is an osteophyte impeding deflection
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chin tuck
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This strategy may increase strength of swallow, improving epiglottis deflection. May help clear residue
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hard swallow
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This strategy is to facilitate clearing or reduce residue from the valleculae and pyriform sinuses which might be aspirated after the swallow when there is reduced epiglottis deflection
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multiple swallows
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This strategy: one may help clear residue of other. solids may facilitate epiglottis deflection
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alternate liquids and solids
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This strategy attempt to clear penetration or mild aspiration with cough and swallow for epiglottis deflection
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couch/throat clear and swallow
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this strategy is larger or smaller, more solid or more liquid may facilitate improved epiglottis deflection
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modify bolus size or consistency
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What do you see for reduced laryngeal elevation?
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•Penetration and/or aspiration DURING the swallow •Residual material in the valleculae and pyriform sinuses
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What techniques are used for reduced laryngeal elevation?
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-Supraglottic Swallow -Super-Supraglottic Swallow -Some base of tongue exercises can also facilitate laryngeal elevation -Chin tuck can sometimes facilitate a mild impairment because narrows laryngeal vestibule
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What happens in reduced pharyngeal wall contraction?
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•Residual material in the valleculae and pyriform sinuses, bilaterally or unilaterally. •Penetration and/or aspiration AFTER the swallow from residue
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what are some treatment strategies that might work for reduced pharyngeal wall contraction?
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-Head rotation toward weaker side -Effortful swallow -Multiple Swallows -Alternating liquids and solids
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What happens with reduced cricopharyngeal relaxation?
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•Residual seen in the pyriform sinuses only after the swallow •Backflow of material from the esophagus •Penetration and/or aspiration AFTER the swallow from the residue in the pyriform sinuses
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What are some treatment techniques for reduced UES relaxation?
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-Shaker Exercises -CP myotomy-CP to tight and cut to open it up a little -Dilation -BOTOX injection to the pharyngeal plexis branch of CN X (Vagus): Stop muscle from becoming so tense
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What happens in reduced esophageal transit?
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•Reflux of material back into the pharynx •Aspiration of refluxes material •Patient feels "something stuck" at the level of the thyroid notch.
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What are some treatment techniques for reduced esophageal transit?
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-Management is medical if severe -Alternate liquids and solids -Second swallows
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T/F: some treatments provide both compensation and faciliation?
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true i.e., effortful swallow
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T/F: Functional STGs can reflect compensation rather than faciliation
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true example: pt will compensate for decreased laryngeal elevation to reduce the amount of food remaining in the pyriform sinuses that is aspirated after the swallow pt will compensate for decreased laryngeal closure to eliminate aspiration after the swallow
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Is this facilitation or compensation or diet: treatment objective: increase lingual lateralization to R/L corners of mouth
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facilitation because its increases motion and strength
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Is this facilitation or compensation or diet: Treatment objective: pt will lateralize tongue against resistance from tongue blade
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Facilitation
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Is this facilitation, compensation, or diet: treatment objective: pt will place food on R side of oral cavity without cues
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compensation
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Is this facilitation, compensation, or diet: treatment objective: pt will take food that only a form a cohesive bolus
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Diet because changing the diet
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Sign: coughing after the swallow physiologic cause: poor base of tongue retraction treatment objective for compensation is what?
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chin tuck because narrows oropharynx
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Sign: coughing after the swallow physiologic cause: poor base of tongue retraction treatment objective for faciliation is what?
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mendholsons because improve range of motion of base of tongue
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Sign: coughing after the swallow physiologic cause: poor base of tongue retraction treatment objective for diet is what?
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Thin liquids because need more tongue retraction for thicker liquids
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what are questions to determine goals in dysphagia therapy?
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What is/are the dysphagic sign(s)? What is/are the physiologic cause(s)? What treatment techniques are indicated? What evidence do we have for the treatment technique?
