Competency Exam 1 Flashcards
What structures are needed for swallowing?
Tongue, soft palate, esophagus, hyoid bone, epiglottis, trachea, thyroid cartilage, vocal folds, pharyngoesophageal sphincter, cricoid cartilage
What are the phases of swallowing?
Preoral phase,oral preparatory phase, oral phase, pharyngeal phase, & esophageal phase
Describe the pre-oral phase of swallowing.
Cognitive and physical orientation to the eating activity occurs. Feeding takes place during the preoral phase, during which the client moves food or liquid to the mouth. This phase is primarily voluntary.
Describe the oral preparatory phase of swallowing.
A solid or liquid bolus is prepared by the structures of the oral cavity to be swallowed, which involves tasting, chewing, manipulation, and containment of the bolus in the mouth. This phase is also primarily voluntary.
Describe the oral phase of swallowing.
The bolus is propelled toward the pharynx by motion of the tongue against the hard and soft palates. Both voluntary and involuntary controls occur during the oral phases.
Describe the pharyngeal phase of swallowing.
The soft palate elevates to close off the nasopharynx. The larynx lifts and protracts, and the epiglottis moves posteriorly to cover the opening to the larynx, protecting it from the entry of the food or liquid bolus. The swallow response is initiated as the bolus is propelled through the pharynx during closure of the larynx and the opening of the upper esophageal sphincter (UES). This phase is primarily involuntary, although voluntary controls may alter its motions.
Describe the esophageal phase of swallowing.
The UES returns to its closed position to keep food from reentering the pharynx. The bolus travels through the esophagus, and the lower esophageal sphincter opens, allowing the bolus to pass into the stomach. This phase is involuntary, although body position changes may alter the movement of the bolus through the esophagus.
What are the screening tools for dysphagia?
Screening - process of determining whether a patient requires a full formal dysphagia evaluation. Can be done through a combo of oral report from caregivers and observation of the patient.
SCREENING TOOL
- Nutrition and Swallowing Screen (observational checklist)
- Burke Dysphagia Screening Test (Checklist)
- Northern Dysphagia Patient Check (Checklist)
- Gugging Swallowing Screen (Checklist)
- Massey Bedside Swallowing Screen (Checklist)
Describe the Burke Dysphagia Screening Test.
Format: Checklist
Standardization and Comments: Uses 3 oz.of water to screen; stroke patients; standardization protocol
Describe the Northern Dysphagia Patient Check.
Format: checklist
Standardization and Comments: Uses thin liquid of pudding texture and cookie; Standardized protocol
Describe the Gugging Swallowing Screen.
Format: checklist
Standardization and Comments: Standardized protocol; reliability and predictive and concurrent validity tested
Describe Massey Bedside Swallowing Screen.
Format: Checklist
Standardization and Comments: Content validity; predictive validity, and interrater reliability tested
Describe Dysphagia Assessment Components.
They commonly include information on cognitive status, including alertness and orientation; motor control, including posture and positioning and the ability to self-feed; oral and pharyngeal control without test foods; and oral and pharyngeal control during swallowing.
List the standardized dysphagia assessments.
- Dysphagia evaluation protocol
- MASA: Mann Assessment of Swallowing Ability
- Clinical Swallowing Examination
- Occupational Therapy Clinical Dysphagia Assessment
Describe the Dysphagia Evaluation Protocol
- standardized
- developed by occupational therapists in an acute care settings
- applicable to all dysphagia diagnoses
- has reliability and validity testing
- Is comprehensive
Describe the MASA: Mann Assessment of Swallowing Ability
- 24 pt scale
- quickly administered
- applicable for neurogenic dysphagia
- has reliability and validity testing
- is comprehensive
Describe Clinical Swallowing Examination
- uses a scoresheet form
- developed by a speech-language pathologist
- applicable for all dysphagia diagnosis
- does not have reliability and validity testing
- is comprehensive although does not include dysphagia history and demographic information collection
Describe the Occupational Therapy clinical Dysphagia Assessment.
- scoresheet form
- developed by occupational therapists
- applicable to all dysphagia diagnoses
- Does not have reliability or validity
- is Comprehensive
What are the instrumental evaluations for dysphagia?
MBS (modified barium swallow) - sometimes called the videofluoroscopy - the patient eats therapist-selected textures of food and fluid that have been combined with barium. Swallowing images are caputres on videotape or DVD. The study can then be viewed later, including frame-by-frame analysis if necessary, to not elements of swallow.
FEES - an endoscopic swallowing evaluation. A small flexible fiberoptic endoscope is passes through one of the patient’s nares through the nasopharynx to the level of the valleculae. Easily done at the patient’s bedside and may be particularly useful in the intensive care unit setting
Blue Dye Testing - used to assess for aspiration in clients with tracheostomy or during FEES. Dye is given to the patient either mixed with food or by itself. IF the patient has a tracheostomy, tracheal secretions are observed for blue food color; during FEES a blue tinge is observed below the level of the vocal cords
What interventions are used with dysphagia?
Typical interventions include positioning and mobility, oral care, and self-feeding, and they may have great impact on the patient’s ability to manage safe oral intake over the course of an initial intervention session.
Describe the positioning and mobility intervention for dysphagia.
- stable trunk position with core and extremity symmetry can optimize the client’s swallowing
- eating in a chair is best, and it encourages arousal when the patient is drowsy
- seated in an upright chair or wheelchair with legs supported on the floor and arms on the table
Describe oral care for dysphagia intervention.
(good oral care has been shown to reduce pneumonia rates because the same organisms that colonize the oral cavity can enter the airway and cause pneumonia in the lungs)
- provides important sensory and motor stimulation for the client in preparation for a meal or the feeding-trial portion of the dysphagia assessment
- remove and clean dentures and partial plates -use of mouthwash and toothpaste
Describe the self-feeding in dysphagia intervention.
likely improves the quality of the swallow and of course, reinforces independent self-care goals
- there are several strategies to encourage self-feeding for different challengesm A
What strategies are used to encourage self-feeding for someone who is disoriented or distracted to activity?
- remove distractions (visual and auditory) from environment; turn off TV
- Present one food container at a time
- Provide verbal cues to orient the client as needed during eating
What strategies are used to encourage self-feeding for someone who has unilateral neglect or visual field cut?
- present one food container at a time, and cue the client to observe it as needed
- provide an anchor (a colorful piece of paper at the side of the plate)
What strategies are used to encourage self-feeding for someone who has low vision?
- use clock method to describe location of food on the plate
- present a limited number of food containers at one time
- Use a dark tray or placemat and a light-colored plate
What strategies are used to encourage self-feeding for someone who has a lack of appetite?
- present favorite or preferred foods
- discontinue pump feedings 1 - 2 hours before meals or snacks
- limit portion size so as not to overwhelm patients with large amounts of food on the tray
What strategies are used to encourage self-feeding for someone who has difficulty bringing food to mouth?
- provide adapted eating tools: utensil, plate guards lidded cups, universal cuffs
- provide finger foods to start
What strategies are used to encourage self-feeding for someone who has difficulty using dominant arm to eat?
- use hand-over hand guiding techniques
- provide splints, overhead slings, or mobile arm supports as needed
- If motion is absent, retrain self-feeding with non-dominant arm
List the modified swallowing techniques used for direct intervention in dysphagia.
- Chin Tuck
- Supragottic swallow
- Mendelsohn maneuver
- Effortful swallow
- Neck rotation
Describe the chin tuck technique for dysphagia.
Movement Required: Capital flexion
Effect: Chin tuck narrows the entrance to the larynx, reducing the chance of food or fluid falling into the airway; chin tuck has been shown to reduce aspiration of thin liquids.
Describe the Supraglottic swallow technique used in dysphagia intervention.
Movement required: Breath hold, swallow, maintaining swallow, cough,then reswallow
Effect: Supraglottic swallow causes a prompt upper esophageal sphincter opening, prolongs the pharyngeal swallow, and helps to close off the larynx. Any bolus that drips into the airway is coughed up above the vocal cords and can be reswallowed.
Describe the Mendelsohn maneuver used in dysphagia intervention.
Movement Required: Push the tongue up into the hard palate and maintain laryngeal elevation during the swallow
Effect: Increases extent and duration of laryngeal elevation, which increases duration and width of cicopharyngeus opening, allowing easier bolus passage
Describe the Effortful Swallow technique used in dysphagia intervention.
Movement Required: Contract the throat muscles hard while swallowing
Effect: Moves the base of the tongue posteriorly, thus helping to clear food material from the valleculae during swallow. Also, it further elevates the hyoid bone and reduces oral residue during the swallow and increases pressure in the pharynx during the swallow.
Describe the Neck Rotation technique used in dysphagia intervention.
Movement Required: Turning the head to the weaker or hemiparetic side during the swallow as far as range of motion and comfort will allow.
Effect: Rotation closes off the side of the pharynx to which the head is turned.
What is the OT role in dysphagia intervention?
screening, evaluating, assessing, indirect and direct intervention
What are the typical swallowing problems found in dysphagia?
coughing while eating, wet vocal quality complaints of pain with swallowing, throat clearing, effortful swallowing, drooling, residual food in the oral cavity, and weight loss
What are the different health systems?
Acute Medical Care system (hospitals) Post-Acute Care System (Long Term Care & Ambulatory Care)
What is the progression from one health system to another?
Acute care occurs at the beginning of the continuum; which is to the say, at the beginning of the course of illness. A pattern of heath care in which a patient is treated for a brief but severe episode of illness, for the sequelae of an accident or other trauma, or during recovery from surgery. Acute care is usually given in a hospital by specialized personal using complex and sophisticated technical equipment and materials and it may involve intensive or emergency care. This pattern of care is often necessary for only a short time, unlike chronic care.
Ambulatory Care (subcategory of acute care)- outpatient and no overnight stay required
Long-term care - the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. The care may be provided in environments ranging from institutions to private homes.
What areas does an OT evaluate and what assessments he/she may choose?
Evaluation is usually on cognitive (KELS) and physiological performance factors such as strength (MMT), ROM (goniometer), balance (Berg balance, functional reach, single leg stance, Romberg, & Timed up and Go), mobility (Barthel index & FIM), cardiopulmonary functions, and ability to participate in BADLs (Barthel Index & FIM).
Define evaluation.
An evaluation is focused on finding out what the client wants and needs to do, determining what the client can do and has done and identifying those factors that act as supports or barriers to health and participation. The evaluation consists of the occupational profile and analysis of occupational performance. The occupational profile includes information about the client and the client’s needs, problems and concerns about performance in areas of occupation. The analysis of occupational performance focuses on collecting and interpreting information using assessment tools designed to observe, measure, and inquire about factors that support or hinder occupational performance
Describe the FIM.
Functional Independence Measure - uses a 7 point ordinal scale to evaluate occupational performance for 18 items (13 motor and 5 cognitive) in the areas of self-care, sphincter control, transfers, locomotion, communication, and social cognition. Basic measure of severity of disability, not impairment
Describe the Barthel Index.
Evaluates 10 activities: feeding, bathing, grooming, dressing, bowel and bladder control, toilet use,transfers between chair and bed, mobility, and stair climbing. A score of 60 seems to be the transitioning point from dependency to assisted independence.
Describe the Functional Reach Test
A visual assessment determining how far the client can reach safely without losing balance. Level yardstick at height of acromion. Position client next to,but not touching, the yardstck. Instruct client to lift arm forward to 90 degrees of shoulder flexion and make a fist. Have client reach as far forward as possible without taking a step. measure distance of movement from 3rd metacarpal. (<15.2 cm = increased fall risk)
Describe Single Leg Stance Time.
Test to determine fall risk of the client. Instruct client to attempt to stand on one foot while standing upright. Knees must be maintained apart during test. Time standing balance for a maximum of 30 seconds. (<10 sec = increased fall risk)
Describe the Vestibular and Visual Aspects of Balance (Romberg Test).
Test to determine impaired balance. Test client under 4 conditions of standing balance. Instruct client to stand with feet together and hands resting on hips. Time trial for a maximum of 30 second. (<30 seconds = impaired balance)
Describe the Timed Up and Go Test.
Determines the level of mobility of the client. Position client sitting in a chair. Instruct client to rise, momentarily stand stil, walk toward a destination point 10’away, turn around, return to chair, and sit down. Time the entire sequence for a score.
< 10 sec = high mobility
10-19 sec = typical mobility
20-29 sec = slower mobility
30+ sec = diminished mobility
Describe the Berg Balance Test.
14 item detailed test to determine the mobility of the client
0-20= w/c bound
21-40 = walking with assistance
41-56 = independent
Describe the OTPF process from screening to outcomes.
Evaluation: 1) Occupational profile - The intial step in the evaluation process that provides an understanding of the client’s occupational history and experiences, patterns of daily living, interest, values, and needs. The client’s problems and concerns about performing occupations and daily life activities are identified, and the client’s priorities are determined. 2) Analysis of occupational performance - The step in the evaluation process during which the client’s assets, problems r potential problems are more specifically patterns, context or contexts, activity demands, and client factors are all considered, but only selected aspects may be specifically assessed. Targeted outcomes are identified.
Intervention: 1) Intervention plan - A plan that will guide actions taken and that is developed in collaboration with the client. It is based on selected theories, frames of reference and evidence. Outcomes to be targeted are confirmed. 2) Intervention implementation - ongoing actions taken to influence and support improved client performance. Interventions are directed at identified outcomes. Client’s response is monitored and documented. 3) Intervention review - A review of the implementation plan and process as well as its progress toward targeted outcomes
Outcomes: outcomes - determination of success in reaching desired targeted outcomes. Outcome assessment information is used to plan future actions with the client and to evaluate the service program (i.e., program evaluation)
What does a rating of 7 mean on the FIM?
Complete Independence (timely, safe)
What does a rating of 6 mean on the FIM?
Modified Independence (device)
What does a rating of 5 mean on the FIM?
Modified dependence - supervision (cuing) or set-up (open containers, apply device) then client performs
What does a rating of 4 mean on the FIM?
Modified dependence - minimal assistance (client performs 75 %)
What does a rating of 3 mean on the FIM?
Modified dependence - moderate assistance (client performs 50% or more)
What does a rating of 2 mean on the FIM?
Complete Dependence - Maximal assistance (client performs 25% or more)
What does a rating of 1 mean on the FIM?
Complete Dependence - Total assistance (client performs less than 25%)
What does a rating of 0 mean on the FIM?
Complete Dependence - activity does not occur
What safety concerns are there in balance and mobility?
- Gait belt
- Endurance Weight bearing status
- Footwear
- Guarding from therapist
- Environment: spills, throw rugs, floor surface
- Use caution standing for the first time
Describe how you guard a patient.
- Stand behind and slightly to one side (toward weak or affected side)
- Keep one hand on gait belt
- Grasp belt with palm up Keep other hand on client shoulder
Do not:
- Hold their arm or hand
- Hold onto their clothing
Describe the difference between dynamic and static balance. how is it graded?
Sitting Balance : Static - writing notes in class; dynamic: reaching around the post to pass handouts
Standing Balance: Static: washing hands at the sink; dynamic: unloading the dishwasher supported vs unsupported
Grading:
- good - able to assume and maintain balance in different situations; able to weightshift independently;
- fair - can assume and maintain balance but impaired when challenged;
- poor: unable to assume or maintain balance
Specify sitting, standing, dynamic, static, supported, unsupported
Name the balance assessments mentioned in class.
- Resistance Test
- Functional Reach Test
- Single Leg Stance
- Romberg
- Timed Up and Go
Describe the Resistance Test for Balance assessment.
Equipment: none
Procedure:
- Give client a slight push at the shoulder level
- Perform in sitting and standing
- Observe reactions, ability to maintain balance
- May need a spotter
Scoring: good, fair, poor
What needs to be considered before doing a transfer?
- Strength & ROM
- sitting & standing balance
- Motor control
- Cognitive status
How do you prepare for a transfer?
- Decide on type of transfer
- Explain procedure to the client and instruct them on their role
- Apply safety belt
- Organize environment -lock brakes, lower bed, drop handrails, etc
- Get help if needed
What are the proper body mechanics for a therapist doing a transfer?
- Stay close to client
- Face them directly
- bend knees and widen stance
- keep a neutral spine
- ask for help if needed
- use leverage!
What types of transfers are there? Please describe each.
Stand pivot - used for those able to come to standing and pivot on one or both feet
Squat pivot - used for those unable to initiate or maintain standing
Transfer Board
Dependent transfers
- two person lift
- mechanical lift
What are the levels of weightbearing?
NWB - non-weightbearing
TTWB- toe-touch weightbearing - 10-15% body weight; “walking on eggshells”
PWB - partial weightbearing - 30-50% body weight; “favoring” limb
WBAT - weightbearing as tolerated - between partial and full
FWB: Full weightbearing - 75% to 100%; distributing weight evenly
What is the rationale behind testing ROM?
- Determine how movement limitations impact occupational performance
- determine need for adaptive equipment
- Identify limitations in joint movement
- Establish baseline
- Prevent deformities
What are the precautions and contraindications for testing ROM?
- Sensory loss
- pain
- pain medications or muscle relaxants
- inflammation
- infection
- severe osteoporosis
- prolonged immobilization
- hemophilia
Describe ROM Assessment: Palpation.
Purpose
- find bony landmarks for goniometric measurement
diagnosis
- detect variations from normal anatomy, discover unusual masses or bumps, assess muscle tone, locate tenderness, compare bilaterally
Refer as appropriate
What preparations should be made before assessing ROM?
Know the anatomy of the area before you begin
Position the person comfortably
May need to expose skin
- privacy
- warmth
- security
Education
Describe the ROM Assessment: End Feel.
End feel: normal resistance to further movment
- Hard: abrupt, hard stop to movement when bone contacts bone (elbow extension)
- Soft: when two body surface come together a soft compression of tissue is felt (passive knee flexion)
- Firm: firm or springy sensation that has some give when muscle is stretched (ankle dorsiflexion)
Describe the general procedure for measuring ROM.
- Position client comfortably
- Explain procedure
- Uncover joint (or at least remove layers)
- Palpate bony landmarks
- Move part through PROM
- joint mobility
- end feel pain
- Stabilize proximal joints
- Measure and record starting position
- Move joint
- Reposition goniometer, measure and record end position
- Rest joint
What is the rationale behind muscle strength testing?
- Determine how muscle weakness impacts occupational performance
- determine need for adaptive equipment
- Understand patterns of weakness or identify specific muscle involvement
- Establish baseline
- Prevent deformities from imbalance
What methods are there for testing muscle strength?
MMT - evaluation of strength and function of individual muscles and/or muscle groups;
break test of maximum voluntary contraction
Dynamometer
Pinch Gauge
Observation of functional tasks
What are the precautions/contraindications for MMT?
- Sensory loss
- Pain
- Pain medications or muscle relaxants
- Inflammation or infection
- Dislocation or unhealed fracture
- Osteoporosis
- Abdominal surgery or hernia
- Cardiovascular disease
What are the muscle grades for MMT and their meaning?
- 0 0 : no muscle contraction seen or felt
- 1 T : contraction seen or felt, but no movement
- 2- P-: Part moves through less than full ROM with gravity eliminated
- 2 P : Part moves through complete ROM with gravity eliminated, no resistance
- 2+ P+: Part moves through full ROM with gravity eliminated and minimal resistance
- 3- F- : Part moves through less than full ROM against gravity
- 3 F : Part moves through full ROM against gravity, no resistance
- 3+ F+ : Part moves through full ROM against gravity with minimal resistance
- 4 G : Part moves though full ROM against gravity with moderate resistance
- 5 N : Part moves through full ROM against gravity with maximum resistance
What is the procedure for grip and pinch assessment?
Grasp
seated shoulder adducted
elbow at 90 degrees
forearm/wrist neutral
set dynamometer at 2nd position
demonstrate
2-3 min rest between trials
average 3 trials
3 types of pinch
- tip
- lateral
- palmar/3 jaw chuck
seated
average of 3 trials
What are the dysfunctions in muscle tone caused by UMN?
abnormal reflexes, abnormal timing of muscle activation, muscle paresis, hypertonicity, clonus
What are the dysfunctions in muscle tone associated with LMNs?
loss of reflexes ‘
muscle atrophy
flaccidity
What is flaccidity?
absence of tone, DTRs, & active movement
What is hypotonicity?
Abnormally low resistance to passive stretch usually no decrease in PROM
Where does hypotonicity/flaccidity occur?
cerebellar & LMN disorders
Termorarily following an acute UMN lesion (CVA and SCI) flacid initially (shock phase) then switches to hypertonicity
What is hypertonicity?
Increased muscle tone abnormally strong resistance to passive stretch
Two types: spastic rigid
Where does hypertonicity usually occur?
UMN lesions
Some basal ganglia disorders
What is hypertonicity associated with?
synergistic patterns: fixed movement patterns
primitive reflexes
associated reactins
abnormal increase in tone when there is an activity that requires excessive effort of the unaffected limbs
If a client has limitations in an AROM Scan but no limitations in PROM what does that imply?
The client has issues with muscle weakness.
If a client has limitations in an AROM scan and limitations in a PROM scan what does this imply?
There could be something obstructing the joint like a bony structure or tight muscle ligaments.
