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9633 Swallowing > L10: Management - Therapeutic Strategies > Flashcards

L10: Management - Therapeutic Strategies Flashcards

(45 cards)

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1
Q

dysphagia rehab is an attempt to

indirect vs direct?

A

improve the swallow

direct = involves use of food/drink

indirect = involves use of saliva, but no food or drink - if pt is NPO, need physicians order to initiate direct therapy

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2
Q

dysphagia rehab is aimed at improving

A

bolus formation and oral transport

airway protection

inc pressure on bolus thru pharynx

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3
Q

behavioural therapies are reco when

A

strength, edurance, and/or mobility of swallowing structures are dimished

probes indicate that swallowing may be facilitated/made safe by deficit-directed exercise (otherwise consider compensatory strategies)

initiation or timing of bolus transit could be improved

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4
Q

behavioural therapies include (4)

A

exercise protocols

vol maneuvers (therapeutic intent)

sensory facilitation

muscle and nerve stimulation

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5
Q

behavioural therapies regardless of strategy, applied w a motor learning mindset, meaning we should consider:

A

type, timing, freq of feedback (biofeedback)

instructions and models being provided

practice conds and structure

error processing questions

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6
Q

exercise phys states that

consider… (3)

A

efforts need to push muscular sys beyond the usual level of activity to induce change

intensity
specificity
transference

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7
Q

intensity =

A

amount of resistive load, vol, duration

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8
Q

specificity =

A

how closely does the exercise tasks correspond w the targeted outcome

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9
Q

transference =

A

cross-training and nonspecific strength training (ex. LSVT)

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10
Q

Exercise protocols are directed toward

including…. (7)

A

improving the effectiveness of the valves and chambers

oral transport (tongue strip)
VP closure
laryngeal vestibule closure
vF (glottal) closure
UES opening
TB retraction
pharyngeal strip wave

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11
Q

labial exercise are to ______and include ____ and ___

A

improve lip closure

ROM exercises

strength exercises

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12
Q

lip ROM exercises include

A

stretching of lips (retraction) in /i/ position

puckering lips tightly

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13
Q

lip strengthening exercises include

evidence?

A

bringing lips together, holding tightly for specified length of time

may also intro an object to be held bw the lips (i.e. tongue depressors, sheet of paper)

some evidence to suggest that these inc lip strength but no evidence of impact on swallow phys

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14
Q

oral control and ROM exercises are used to improve

A

lateralization of tongue during chewing

elevation of tongue to palate

cupping of the bolus

anterior-posterior movement

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15
Q

oral tongue exercises include ____ movements, examples such as…

A

elevate, protrude, retract, lateral extension

hold for 1 sec, and release

repeat series 5-10 times in one session, 5-10 times per day

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16
Q

exercises to improve bolus control includes (3)

A

begin w large object –> pt manipulates one end while clinician holds other end (tehthered gauze) - begin by moving side to side etc imitating mastication

transition to smaller object

transition to bolus –> start w cohesive consistency - paste approx 1/3 tsp, move it around w/o loosing material, inc size of bolus and change consistency

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17
Q

bolus transport exercises may be used to improve….

for example…

A

anterior-posterior movement

ex. long, narrow roll of gauze - tongue pushes upward and backward along length of gauze squeezing out liquid - amount of liquid depends on integrity of pharyngeal swallow- thickness of gauze can be reduced as ROM improves

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18
Q

tongue strengthening exercise to improve pressure on tail of bolus (reduce oral residue), may include…. (2)

A

pushing against tongue depressor- elevate, protrude, lateral extension (hold for 1 sec, release)

newer techniques involved pushing against intraoral sensor to allow for biofeedback (re- effort) - evidence of inc lingual pressures in non-swallow and swallow tasks

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19
Q

what are the 5 ways to target tongue base?

Study These Flashcards
A

retract tongue (pull back)

(pretend to) gargle

(pretend to) yawn

effortful swallow

tongue-hold maneuver (masako maneuver)

20
Q

masako maneuver is aimed at …

3 steps

Study These Flashcards
A

inc posterior motion of the base of the tongue and pharyngeal constrictor action

1= stick out your tongue and hold it gently bw your lips or teeth
2= holding your tongue in this position, try to swallow your saliva
3= after your swallow, relax

as an exercise = repeat step 1-3x10

21
Q

shaker exercise is designed…
targets….

steps?

Study These Flashcards
A

to improve HLE and UES opening

targets suprahyoid muscles (like mendelsohn manuever)

steps:
-series of sustained head raising and rep head raisings
- lie flat on floor or bed
- raise head high and forward, observe toes, w/o raising shoulders off floor/bed

22
Q

shaker exercise evidence…
alternatives?

Study These Flashcards
A

evidence of effect but no LT data

chin tuck against resistance and jaw lowering against resistance may similar outcomes but easier to implement

23
Q

falsetto (pitch raise) designed to target

Study These Flashcards
A

suprahyoid musculature and pharyngeal shortening muscles

24
Q

mandibular stretch is designed to

3 steps?

Study These Flashcards
A

improve HLE and/or jaw ROM

1= tilt your head back and open your mouth as wide as you can - hold this position for 5 seconds
2= while holding your head back, stick your jaw forward
3= still w your head back, move your jaw upward toward your nose and try to close your lips, you should feel a stretch along the front of your neck, hold this for 5 sec

repeat as an exercise 1-3, 10 times

25
how can you exercise airway entrance (3)
breathing holding, bearing down, rapid hard glottal attacks (may damage VQ)
26
how can you exercise vocal adduction (4)
produce clear voice while bearing down, hard glottal attack lifting, pushing w voicing, hard glottal attacks falsetto exercise EMST
27
pharyngocise =
high intensity swallowing therapy + diet modification battery of exercises (may include therabite) 4 exercises - 10 reps over 4 cycles, each 10 min duration (~45min therapy) twice daily for duration of chemo (up to 6wk)
28
RCT vs standard care vs sham exercise as preventative therapy during chemo found....
RCT ....maintenance of muscle comp, less deterioration on MASA, more maintenance of oral feeding/fewer G tubes, trend toward better FOIS, less decline in mouth opening, less decline in salivation/taste/smell
29
what are thw two types of resp muscle strength training (RMST)?
Inspiratory muscle ST (IMST) - to improve ventilation expiratory muscle ST (EMST) - to improve pressure (and control of expiratory flow)
30
describe EMST results in? shown to?
dev as a restorative therapy for use in pts w PD (asp pneumonia is leading cause of death) inc force of contraction of submental musculature, resulting in improved HLAE has been shown to improve penetration-asp scale scres after swallowing phys and cough variables
31
what does EMST use?
calibrated one-way spring loaded valce to mechanically overload the exp and submental muscles physiologic load on targeted muscles can be inc or dec by varying the device setting 5 sets of 5 reps 5 days out of 7
32
resp-swallow coordination is important for involves...
safe and efficient swallowing spatial swallowing kinematics pressure gen w/i the pharynx and eso
33
normal resp-swallow pattern ... disease resp-swallow pattern...
normal = apnea of ~1 sec, EX-SW-EX, Swallow initiated at mid-lung vol range of TV disease = longer apnea, IN-SW or SW-IN, swallow initiated at end of exp level of TV (ex. COPD, CVA, neuromuscular disease, tracheostomy tubes, HNC)
34
RST treatment paradigm = technology = evidence =
skilled based exercisses vs strength based exercises (target a skill rather than motor strength) = train accurate consistent R-S coordination can use technology or not - visualiing airflow and resp activity may inc accuracy and relaibility; may help facilitate biofeedback training evidence of improved R-Sw coordination, BOT retraction, LVC, pharyngeal residue, P/A in pts w HNC
35
McNeill dysphagia therapy protocol = evidence =
systemic exercise based therapy program for the treatment of dys in adults values specificity over transference - swallowing is the exercise also values: vol (freq) and intensity (resistive load) work on form, then vol, then intensity modest evidence of inc diet levels, improved swallow safety, and efficiency
36
electrical stimulation 2 main ways and then 4 sub types
neuromuscular electrical stimulation (NMES) applied to the muscles = transcutaneous electrical stimulation (TES) and intramuscular electrical stimulation neuromodulation = transcranial magnetic stimulation (tCMS) or transcranial direct current (tDCS) - may be paired w peripheral stimulation or other swallowing therapies
37
TES = type of TES= evidence =
surface (indirect) electrical stimulation applied to the submental region (above hyoid) vitalstim incorporates both submental and infrahyoid stim = purpose is to stimulate muscles involved in hyoid elevation (anterior suprahyoid muscles) and laryngeal elevation (thyrohyoid) evidence = poorly controlled studies to date, at best a small pos effect of NMES on swallowing, consider as an adjunct to other therapy (wont improve swallowing on their own but may facilitate greater/faster response to traditional therapy techniques)
38
neuromodulation: paired associative stimulation aka phagenyx = evidence =
neurostimulation of motor cortex associated w target muscles ....TMS of pharyngeal motor cortex - in stroke the undamaged cortex is stimulated peripheral stimulation of the target muscles (ex. pharyngeal constrictors) evidence =induces functional change in swallowing - penetration-asp score; timing measures (oral transit time, pharyngeal response time, pharyngeal transit time)
39
when should we re-assess?
when change in function is reasonable and anticipated (ex. muscle change requires min 4-6wks) when pt reports marked improvement when there is a decline in medical or cog status, or further surgical intervention when pt reports worsening of symps, decline in meeting nutritional needs, or recurrent APs
40
even when the treatment involves eating, therapy occurs... maintenance programs have..
outside of mealtime a diff focus than rehab, prolonging function
41
considerations for acute care
time pressure = pts need to be discharged get a full physiological ax completed and dev a therapy plan
42
LTC considerations
ax options are restricted (mobile units?) qs to guide care: - is there a reasonable chance for improvement? - what other behavioural issues could be impacting swallowing? (ex. fatigue, general attentiveness, attention span, awareness of food etc)
43
home considerations
lack of access to instrumental ax use therapy plan dev in acute care = no diff if implemented by SLP, caregiver pt if it is dev using physiological ax
44
school considerations
lack of access to instrumental ax start w indirect therapy (i.e. no food/liquid) until access to instrumental ax
45
strategies that lead to LT improvements in swallowing are ____ in nature; techniques dev based on the principles of ____ have the greatest potential
therapeutic neuroplasticity

9633 Swallowing (11 decks)

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