question

Knowing WHAT to treat is important, it requires the SLP to do what?

answer

-Identify signs of oral, pharyngeal and esophageal dysphagia -Understand the UNDERLYING PHYSIOLOGY that is the likely cause of the sign.

question

What happens if you don't have knowledge of the underlying physiology?

answer

-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

question

Knowing WHY to treat requires the SLP to understand what?

answer

the functional improvement that is sought Example: we've increased tongue control with exercises but the patient is still NPO = NO GOOD

question

Knowing HOW to treat requires the SLP to understand what?

answer

-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.

question

Knowing how LONG to treat requires understanding of what?

answer

-Etiology -Prognosis -Outcomes data -NOMS has been around for 10 years (National outcome measures)

question

What is the short term goal based on?

answer

based on physiology that determines what is wrong or impaired which will then determine functional short term goals Physiology ; Functional Short Term Goals

question

Once you have the functional short term goals then you can identify what?

answer

treatment objectives

question

How do we observe a SIGN?

answer

on either the clinical swallow study or during an instrumental examination like MBS

question

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?

answer

Oral Prep

question

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?

answer

Pharyngeal phase

question

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?

answer

Oral Transit

question

T/F: short term goals cannot be written from the SIGNs observed

answer

FALSE! they can be written fro the signs observed. Get the sign then make it into a short term goal

question

Why are short term goals not FUNCTIONAL?

answer

Because it doesn't man anything to the non-SLP e.g., insurance

question

If the sign is poor oral transit-can't move bolus to back of mouth. What would the short term goal be?

answer

Pt will improve oral transit ability

question

If the SIGN is the pt has residue in the valleculae. what would the short term goal be?

answer

Pt will reduce residue in the vallecualae

question

If the SIGN is the pt loses food from the front of the mouth. What would the short term goal be?

answer

Pt will decrease loss of food from front of mouth

question

functional Short term goals are written in terms that who can understand?

answer

Payers, consumers and other health professionals so everyone understand improving the pt's health and safety

question

T/F: functional short term goals should address WHY the skill needs improvement.

answer

true

question

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?

answer

pt will improve ability to move food back of mouth TO REDUCE ORAL RESIDUE THAT MIGHT FALL INTO THE AIRWAY

question

If the short term goal is to decrease residue in the valleculae what would the functional short term goal be?

answer

decrease residue in the valleculae THAT MIGHT FALL INTO THE AIRWAY AFTER THE SWALLOW

question

If the short term goals is pt will reduce anterior loss of food what would the functional short term goal be?

answer

pt will reduce anterior loss of food SO THAT MORE FOOD WOULD BE CONSUMED

question

Attending to physiology helps determine what?

answer

WHAT to treat

question

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?

answer

reduced pharyngeal wall movement or reduced CP opening

question

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?

answer

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

question

What are the treatment objectives?

answer

smaller, more measurable steps used to achieve the functional short term goal.

question

How should treatment objectives be chosen?

answer

Should be chosen based on the physiologic cause of the sign/symptom

question

what are the types of treatment objectives?

answer

-Compensatory -Facilitation or therapeutic -Diet

question

What are compensatory treatment objectives?

answer

Designed to compensate for, not improve the lost function. (Can't fix but work around ex: dysarthria)

question

Compensatory treatment objectives are most often used when?

answer

During meals

question

what are the types/components of compensatory treatment objectives?

answer

• Postural changes • Increased sensory input • Food placement • Food presentation

question

What are common compensatory techniques?

answer

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

question

What is the chin tuck?

answer

The patient puts their chin to the chest before the swallow and maintains this position until the swallow is completed.

question

when do you use a chin tuck? what does it do?

answer

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)

question

what is the rationale for the chin tuck?

answer

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

question

What is a read rotation?

answer

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)

question

what is the head tilt?

answer

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.

question

What is laying on side or side lying?

answer

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

question

What is multiple swallows technique?

answer

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)

question

What are alternating liquids and solids technique?

answer

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

question

What is the rationale for alternating liquids and solids?

answer

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

question

What is the supraglottic swallow technique?

answer

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

question

What is the supra-superglottic swallow technique? What does it help with?

answer

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.

question

What is the effortful swallow technique? what does it help with?

answer

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.

question

What is the Mendelsohn Maneuver technique? What is theory? Is it successful?

answer

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

question

What is the modify volume and speed of food presentation technique?

answer

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)

question

What are the facilitation/therapeutic treatment objectives designed to do?

answer

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

question

What are the different types of facilitation/therapeutic techniques?

answer

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

question

What does the Shaker exercises improve?

answer

improves cricopharyngeal functioning when there is a CP bar

question

What is Thermal-tactile stimulation?

answer

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!

question

What is McNeil Dysphagia treatment program?

answer

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*

question

What is expiratory muscle strength training?

answer

pt blows into a part and turn to increase resistance. improve expiratory muscles then Improve persons efficiency to protect airway.

question

What is vital stem?

answer

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)

question

What is sEMG?

answer

surface electromyography- measures muscle recruitment in microvolts (Measuring not giving a pulse. See how many microvolts to put out a swallow.)

question

What is the IOPI?

answer

-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

question

What is MOST or swallow strong?

answer

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))

question

What are the different exercises that can be done?

answer

labial exercises lingual exercises mendelsohn maneuver ecercises masako maneuver oral bulbar exercises shaker exercises

question

what is a labial exercise?

answer

oo and /i/

question

what are the different types of lingual exercises?

answer

resistance exercises (stick tongue out) IOPI MOST

question

What is the Mask Maneuver? What does it increase?

answer

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

question

what does the Oral Bulbar exercises help with?

answer

velopharygneal closure (blow a kleenex)

question

What is the best exercise for swallowing?***

answer

*is to swallow and should be included in the treatment objective *use of surface EMG is helpful for biofeedback

question

What are the diet treatment objectives?

answer

Involves diet changes in texture or temperature to help compensate for lost function

question

when do you modify food or liquid consistency?

answer

when other treatment and strategies are not feasible

question

what are the different types of liquids?

answer

thin, smh-thick (nectar), and thick (honey)

question

what are the different types of foods?

answer

puree ground mechanical soft regular consistancies

question

if there is a problem in the oral prep phase for labial seal what is the treatment?

answer

labial exercises

question

in oral prep: if there is a problem with mandibular strength and range of motion what are is the treatment?

answer

terabyte exercises (break contraction so can open mouth if have trismus (cant open mouth) for pt with TMJ

question

Oral Transit: if there is a problem with lingual control what is the treatment?

answer

sucking exercises

question

Oral transit: pt puts their head back. what type of treatment is this?

answer

compensatory

question

What will you observe on instrumental exam for delayed pharyngeal swallow?

answer

•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

question

What will you maybe observe on a clinical exam for delayed pharyngeal swallow?

answer

•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.

question

What are some techniques/strategies which may be indicated for a delayed/absent pharygneal swallow?

answer

chin tuck modify bolus size modify liquid consistency subglottic swallow 3-second prep* sour bolus neurosensory stimulation thermal stim

question

Why would a chin tuck be a rationale for a delayed swallow?

answer

may keep bolus higher up in pharynx until the swallow is triggered

question

why would modify bolus size be a rationale for delayed swallow?

answer

smaller size may accumulate less before the swallow. A larger size may help tirgger a more prompt swallow

question

why would supraglottic swallow be a rationale for delayed swallow?

answer

protects airway before the swallow and expels penetration after the swallow

question

why would the 3 second prep be a rationale for a delayed swallow?

answer

get pt into a mental set to swallow. pt swallows on 3

question

why would the sour bolus be a rationale for a delayed swallow?

answer

sour bolus may decrease delay

question

why would neurosensory be a rationale for delayed swallow?

answer

suck and swallow in finger of glove filled with ice may elicit a swallow

question

why would thermal stem be a rationale for delayed swallow?

answer

may elicit a swallow in pt with absent swallow. May even decrease delay, but no evidence one way or the other regarding efficiency

question

What are the observations made on an instrumental exam for reduced base of tongue retraction?

answer

•Base of tongue does not make contact with posterior pharyngeal wall. •Residue in the valleculae and pyriform sinuses after the swallow

question

What are the observations during a clinical exam for reduced base of tongue retraction?

answer

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

question

What are some techniques to do for reduced base of tongue retraction?

answer

chin tuck effortful swallow multiple swallows alternate liquids and solids exercises to increase BOT retraction

question

What is the rationale for using a chin tuck for reduced base of tongue retraction?

answer

decrease distance between BOT to posterior pharyngeal wall

question

Wha is the rationale for effortful swallow for reduced base of tongue retraction?

answer

more effort may facilitate increased BOT retraction

question

What is the rationale for multiple swallows for reduced BOT retraction?

answer

May help to clear residue from vallecuale and pyriform sinuses with each swallow

question

what is the rationale for alternate liquids and solids for reduced BOT retraction?

answer

One consistency may help to clear residue of the other consistency.

question

What is the rationale for exercises to increase BOT retraction?

answer

Mendlesohn, yawning, /k,g/

question

What do you observe during an instrumental exam for reduced velar elevation?

answer

•Nasal Regurgitation during the swallow -test material enters nasopharynx

question

what do you observe during a clinical exam for reduced velar elevation?

answer

Observations during a clinical exam: •Test liquid dripping from nares •Test liquid seen on tissue when patient blows nose

question

What are some techniques/strategies that may be indicated for poor velar elevation?

answer

chin up surgical management prosthetic management velopharyngeal exercises

question

what is chin up for technique for poor velar elevation?

answer

gravity helps keep liquid from moving further into nasopharynx

question

what is surgical management for poor velar elevation?

answer

palatal flap

question

what is prosthetic management technique for poor velar elevation?

answer

palatal lift

question

what is velopharyngeal exercises techniques for poor velar elevation?

answer

exercises involving blowing and producing stop consonants

question

what are observations that would be seen on an instrumental exam for reduced epiglottis retroflexion?

answer

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

question

what are observations on a clinical exam for reduced epiglottis retroflection?

answer

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

question

This strategy would reduce epiglottis deflection and facilitate epiglottis deflection especially if there is an osteophyte impeding deflection

answer

chin tuck

question

This strategy may increase strength of swallow, improving epiglottis deflection. May help clear residue

answer

hard swallow

question

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

answer

multiple swallows

question

This strategy: one may help clear residue of other. solids may facilitate epiglottis deflection

answer

alternate liquids and solids

question

This strategy attempt to clear penetration or mild aspiration with cough and swallow for epiglottis deflection

answer

couch/throat clear and swallow

question

this strategy is larger or smaller, more solid or more liquid may facilitate improved epiglottis deflection

answer

modify bolus size or consistency

question

What do you see for reduced laryngeal elevation?

answer

•Penetration and/or aspiration DURING the swallow •Residual material in the valleculae and pyriform sinuses

question

What techniques are used for reduced laryngeal elevation?

answer

-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

question

What happens in reduced pharyngeal wall contraction?

answer

•Residual material in the valleculae and pyriform sinuses, bilaterally or unilaterally. •Penetration and/or aspiration AFTER the swallow from residue

question

what are some treatment strategies that might work for reduced pharyngeal wall contraction?

answer

-Head rotation toward weaker side -Effortful swallow -Multiple Swallows -Alternating liquids and solids

question

What happens with reduced cricopharyngeal relaxation?

answer

•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

question

What are some treatment techniques for reduced UES relaxation?

answer

-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

question

What happens in reduced esophageal transit?

answer

•Reflux of material back into the pharynx •Aspiration of refluxes material •Patient feels "something stuck" at the level of the thyroid notch.

question

What are some treatment techniques for reduced esophageal transit?

answer

-Management is medical if severe -Alternate liquids and solids -Second swallows

question

T/F: some treatments provide both compensation and faciliation?

answer

true i.e., effortful swallow

question

T/F: Functional STGs can reflect compensation rather than faciliation

answer

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

question

Is this facilitation or compensation or diet: treatment objective: increase lingual lateralization to R/L corners of mouth

answer

facilitation because its increases motion and strength

question

Is this facilitation or compensation or diet: Treatment objective: pt will lateralize tongue against resistance from tongue blade

answer

Facilitation

question

Is this facilitation, compensation, or diet: treatment objective: pt will place food on R side of oral cavity without cues

answer

compensation

question

Is this facilitation, compensation, or diet: treatment objective: pt will take food that only a form a cohesive bolus

answer

Diet because changing the diet

question

Sign: coughing after the swallow physiologic cause: poor base of tongue retraction treatment objective for compensation is what?

answer

chin tuck because narrows oropharynx

question

Sign: coughing after the swallow physiologic cause: poor base of tongue retraction treatment objective for faciliation is what?

answer

mendholsons because improve range of motion of base of tongue

question

Sign: coughing after the swallow physiologic cause: poor base of tongue retraction treatment objective for diet is what?

answer

Thin liquids because need more tongue retraction for thicker liquids

question

what are questions to determine goals in dysphagia therapy?

answer

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?

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