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Flashcards in Treatment for Dysphagia Deck (150):
1

Traditional Swallowing Treatments (3)

1. Compensatory

2. Rehabilitative

3. Behavioral

2

Compensatory Strategies

1. goal

2. short term

1. Goal: compensate for problem

2. Short term adjustments to facilitate improved swallowing function while undergoing rehab or getting better

3. Can alter bolus flow (rheology) (chin tuck)

4. Alter physiology? perhaps

3

Rehabilitation

1. goal

1. Goal: To restore functional swallowing

2. Systematic application of techniques

3. Often challenges abilities to encourage learning and improvement

4. Produce long-term improvement beyond the treatment period that generalizes to functional swallowing contexts.

- Evidence based exercises to rebuild muscle strength

4

Treatment (3)

1. Must be evidence based.

2. Or, must at least make sense based on your knowledge of the anatomy and physiology of the swallow.

3. Treatment objectives must be specific to the physiological cause of the symptoms.

5

Focus of Swallow Therapy (treatment)

- 3 AREAS YOU WORK ON

1. The focus of swallow therapy depends on which aspects of the swallow are disordered (is it these listed below)

a. muscular strength & range of motion (residue is often associated with strength issues)

b. timing

c. coordination of movement of the oropharyngeal structures

6

Compensatory Techniques

1. Designed to compensate for lost function and/or mistiming.

2. Control the flow of food and eliminate the patient’s symptoms without necessarily changing the physiology of the swallow (Logemann, 1988)

3. Most often used by the patient during meals.***

7

Compensatory Techniques List (6)

1. Changes in posture

2. Bolus modifications

3. Changes in timing and coordination

4. Changes in food placement

5. Changes in food presentation

6. Changes in food consistency

8

Compensatory: Postural adjustments (chin down/chin tuck)

1. Used with decreased oral or back of tongue control*****

2. Orally, the patient gains more volitional control for propulsion of the bolus.

3. Widens the valleculae in many patients to allow for collection of material without spill to the pyriform sinuses or into the trachea.

4. Pushes epiglottis posteriorly, increasing airway (narrows the airway) protection by narrowing the distance from the epiglottis to the pharyngeal wall and the laryngeal entrance.

- When you don’t have good oral control, and food leaks,

- Try out on video swallow

9

Compensatory (Postural adjustments): What does chin down/chin tuck do (2 things)

- Slows the bolus

- Places the hyoid bone and the larynx in closer proximity, which likely closes the larynx faster.

10

Chin down vs. chin tuck (compensatory- postural adjustment)

1. Chin down & chin tuck both result in consistent decreases in area of airway opening and distance between PPW/epiglottis

2. Chin tuck increased airway protection greater than chin down or neutral position.

- 2 ways of doing it

a. Chin tuck- tightening (tucking it back)

b. Chin down- chin to chest

11

How far do you tuck?

1. In normals, using manometry, there was a greater increase in UES peak pressure with a complete chin tuck vs. a partial chin tuck.

2. the more you can tuck the better

* However

3. Has been shown to increase aspiration of those with dementia, Parkinson’s Disease and even healthy individuals.

4. It must be tested in the VFSS prior to taking for granted that it is a useful technique with all patients.

12

Food for thought for compensatory strategies

1. Prior to using ANY compensation or technique, it’s always a good idea to test it out during the VFSS. (but you don’t always have that option)

2. How do you know that it will work with your patient if you haven’t tested it out????

13

Postural adjustments- Head Rotation (5)

1. Assists those with unilateral pharyngeal paresis or paralysis***

2. The patient should rotate his head all the way toward the damaged side.

3. Narrows the pyriform sinus on that side

4. Increases vocal fold closure

5. Reduces resting tone in the cricopharyngeal muscle. (turning head you are opening the muscle, reducing tension)

- Turn head into weaker side- moves food and reduces residue (CVA pts?)

14

How far do you rotate for the head rotation?

1. With normals, using manometry, UES peak pressures and opening duration were significantly increased for thin and puree consistencies with 90 degree rotation.

2. With 45 degree rotation, pressures increased but not significantly.

- More rotation the better

15

With regards to pharyngeal clearance…

1. Head Rotation

2. Chin Tuck

1. With head rotation, UES relaxation begins early which may help to clear residue.

2. With chin tuck, there is delayed UES opening resulting in increased residue.

a. Pharyngeal constrictors have trouble with this

16

Compensatory Strategies

Postural Adjustments- head tilt

1. Lateral

2. Posterior

1. Lateral: used with hemiparesis of the tongue and pharynx, tilt to the intact side for bolus direction.

2. Posterior: rarely recommended but may be helpful with those with decreased ability to propel the bolus posteriorly to initiate swallow. Gravity assist.

- often used with cancer pts.

17

External Pressure to the Cheek

1. Compensates for decreased muscle tone

2. Decreases the amount of material falling into the weaker lateral sulcus

3. Tactile cue reminds the patient to check the buccal pocket or lateral sulcus for material.

*** Weakness or loss of sensation

*** May need to do a finger sweep or lingual sweep

18

Labial and Chin Support

Place your finger under the chin or lower lip(or both) to help maintain closure of the mouth.

- Flaccid dysarthria

- You may need to support their mouth

19

Bolus Modifications:

Taste

1. Sour Bolus

1. Sour bolus can improve the onset of the oral and/or pharyngeal stages of the swallow.

2. Taste stimuli increased the # of spontaneous swallows observed within 1 minute after initial swallow compared to water (Pelletier, 2002)

3. Best response in patients without dementia

20

Bolus Modifications:

Taste

1. Sweet and Salty

1. Have been shown to positively change timing and lingual pressure.

a. Pts. with dementia like sweet boluses

21

Bolus Modifications

Temperature

1. Use of a Cold Bolus

1. Cold bolus also adds significant sensory input for increased speed of swallow initiation.

2. Technique to use to improve timing and coordination of the swallow.

3. Use ice and ice water in finger of glove, have patient suck on it, remove, ask patient to swallow (dry swallow).

- Swallowing sensors at the bottom of the anterior faucial pillars- gets a swallow doing, but it didn’t do much

However,

- Overall assessment of temperature effects have been mixed.

- Need more studies on hot temps

22

Chemesthesis

- A chemically stimulated sensation of irritation mediated by the trigeminal nerve that is elicited by such stimuli as carbonation. It is a somatosensory perception that adds to the flavor experience.

- For example, it is responsible for the perception of hotness from a chili pepper or coolness of menthol.

23

Chemesthesis

1. Capsaicin

2. Carbonation

1. Capsaicin: increased hyoid movement, however this response decreased over time. Laryngeal penetration, oral-pharyngeal residue were decreased and the time to laryngeal closure was decreased (0.4 to .29 sec).

*** pepper speeds up swallow

2. Carbonation (more sensory)– has been demonstrated to reduce laryngeal penetration and aspiration in some and may be equivalent to nectar thick liquids. (this must be independently tested in an objective way)

- The overall assessment of chemesthesis effects has been mixed.

24

Bolus Modification- Volume (hyolaryngeal movement)

1. Arytenoid to epiglottis contact time increases with bolus volume. – larynx has to stay closed longer (so COPD, smaller amounts, more breathing breaks)

2. Duration of hyoid elevation increases with a larger bolus

3. Peak hyoid elevation increases with larger bolus.

25

Bolus Modification- Volume (bolus timing)

1. Decreases swallow delay

2. Decreases bolus flow through the oral and pharyngeal cavities.

3. Pharyngeal delay time diminished in stroke patients with larger bolus.

4. More UES opening with larger bolus

26

Compensatory Techniques: Changes in timing and coordination

1. 3-second prep (“1, 2, 3, swallow”)- great for pts. Who have trouble initiating the swallow (good for PD pts.)

2. Use of a metronome

3. Suck-swallow- helps get the bolus to the middle of the tongue and prepare for the swallow)

4. Anterior bolus hold- hold it in the front of the mouth and think about swallowing

27

Compensatory Techniques: Food Placement Options
(5)

1. Place on stronger side

2. Place in middle of tongue

3. Place as far back on tongue as possible

4. Only use spoon with liquids

5. No straws

28

Compensatory Techniques: Food Presentation Options

1. You may recommend different ways for food or liquid to be presented depending upon your goal. Spoon, cut-out cup (never have to tilt your head back), straw

2. Alternate liquids and solids

3. No liquids with meal

4. Multiple swallows per each bolus (swallow 2 or 3 times with every bite)

5. Single vs. multiple sips (single sip, drink and set the cup down)

- maybe alternate a solid and a liquid

29

Compensatory Techniques- Changes in food consistency

1. Consistency/Viscosity Changes

1. Decreased pharyngeal delay with more viscosity.

2. Delayed oral and pharyngeal bolus transit.

3. Increased pharyngeal peristaltic waves, UES opening and extrinsic laryngeal muscle activity.

- Heavier something is, slower it flows

- Esophagus does not work well with thin liquids (dependent on gravity)

30

Facilitation Techniques

1. Designed to improve function – to change swallow physiology.

2. May or may not be used during meals

- Might just do during treatment session or sessions and meals

31

Facilitation Techniques

3 types

1. Oral-motor exercises

2. Laryngeal elevation exercises (MBS shows larynx is not elevating)

3. Exercises for increasing laryngeal closure

- Need to be careful with these

- We need to know physiology

32

Techniques- Compensation and facilitation

- Some techniques are both a compensation and a facilitation.

--the technique can be used to compensate for lost function and can also improve function

33

Regarding Treatment-

- What is the goal?- 7 goals

****Know these

1. Increase strength?

2. Improve timing?

3. Increase speed of movement?

4. Increase endurance?

5. Coordination?

6. Bolus clearance?

7. Some combination of the above?

- KNOW THIS

34

Oral-Motor Exercises (3)

1. Bolus maintenance (bolus is falling over tongue, out of the mouth, or into the lateral sulcus- need to keep it where it needs to be)

2. Bolus preparation/manipulation (pt. can’t do rotary chew so you need to do exercises)

3. Bolus propulsion and clearance (need to help increase strength

35

Bolus Maintenance

1. Labial control exercises (keep from spilling anteriorally

2. Lingual control exercises (keep in oral cavity, reduce premature spillage)

36

Bolus preparation/manipulation

Chewing exercises to control and manipulate the bolus

37

Bolus Propulsion and Clearance (7) techniques

KNOW THESE

1. Isometric lingual exercises (best)

2. BOT exercises

3. PPW exercises

4. Laryngeal elevation exercises

5. Exercises to increase laryngeal closure

6. Effortful swallow

7. LSVT (Lee Silverman Voice Therapy)

38

LSVT Research

1. Improvement in oral transit time and percentage of oral residue

2. Tongue rocking disappeared

3. Reduction in delay, improved tongue base retraction with reduction in amount of residue spilling from the valleculae.

--- Excellent therapy for swallow

* Therapy for PD

- Slow rushes of speech with hypokinetic dysarthria- need to make them loud (4 days, 4 weeks, 1 hour per session)

- Also improved swallowing, tongue rocking disappeared

*** works because we challenge the system

39

Regarding Exercise

1. Exercise efforts that do not force the neuromuscular system beyond the level of usual activity will not elicit adaptations.

2. By challenging the system beyond typical use, adaptations occur to accommodate the increased demand. (brain plasticity)

*** Challenge the system

40

Exercising and Swallowing

1. Swallowing is a submaximal muscular activity. (just using the amount of energy you need)

2. For strength to increase, demand must be continuously increased. This is called “progressive resistance.”

41

Lingual Strengthening

1. Isometric Exercises

- Isometric exercises have been shown to increase tongue strength and tongue bulk.

- IOPI- Iowa oral pressure indicator

- MOST- Madison oral strength trainer

- Isometric is the best tongue strengthening

42

IOPI- Iowa oral pressure indicator

1. Tells the pt. how strong they are pushing

2. Find out their max

3. Designed for research

4. Very expensive

5. Bulbs are single use

43

Madison Oral Strengthening Therapeutic Device- MOST

1. Developed by Joanne Robbins at University of Wisconsin-Madison

2. Less expensive and more “clinician friendly” than the IOPI, but same concept for progressive oral resistance training.

44

Lingual Strengthening Procedure

1. Record the pressure that is most consistently generated plus or minus 5%

2. “Push the bulb against the roof of your mouth as hard as you can”

3. To train swallowing pressure strength, set the target at 60% of maximum.

** build it up

4. Begin with a series of five or so consecutive trials with rests period in between.

5. Increase training load by no more than ~10% per week and avoid great boosts in volume or intensity.

45

Results from IOPI

1. Robbins demonstrated that 8 weeks of IOPI training resulted in:

a. Increase in maximal isometric pressure generation

b. Increased oral pressure during swallowing

c. Increased safety per penetration/aspiration scale.

2. She has also replicated this with her MOST device.

46

What if you don’t have an IOPI or a MOST?

- Lingual resistance exercises in all planes using a tongue depressor.

1. Use a tongue depressor and have the pt. push anteriorly 10 times

2. Do the same thing laterally

3. And have pt. push against the roof of their mouth as hard as they can, watch the neck and have them do it against the lower central incisors too.

47

Expiratory Muscle Strength Trainer (EMST)

1. Another progressive, load-bearing strength training device.

2. One way, spring-loaded pressure release valve that the patient blows into.

3. Release set at 60 – 80% of maximal expiratory pressure.

4. Adjusted throughout program to incorporate a progressive load.

* Want to build up expiratory muscles because without good respiration, you cannot swallow well

48

EMST benefits

1. Improves the expiratory breathing muscles.

2. Also, increases activity of suprahyoid muscles. (which raises the larynx)

3. Results in improved expiratory driving pressures for cough.

4. Can also be used as an IMST (inspiratory muscle strength trainer)

49

Contraindications for EMST

1. Pregnancy

2. Untreated hypertension

3. Recent stroke

4. Cardiac abnormalities

5. Asthma, emphysema or COPD

6. Hx of collapsed lung

7. Head/neck surgery

8. Untreated GERD

9. Symptoms of heartburn….consult your MD

50

EMST Method (8)

1. Instruct the patient to take a very deep breath

2. Position the device in mouth with a tight seal, pinch off nose

3. Have pt blow forcibly into the device until the valve pops open

4. Help the pt learn to identify the feel and sound of the valve opening

5. After every trial, ask questions about any discomfort or light-headedness especially in the beginning

6. Once the proper resistance has been established, begin multiple reps

7. Expect inconsistency

8. Check constantly for correct lip seal

51

Frequency/Duration of EMST

1. Minimum of 25 reps per day

2. Five days per week

3. For five (preferably many more) weeks

- Building exercise principles

52

Laryngeal elevation exercises

1. High pitched “ee” – will also see pharyngeal wall movement

2. Pitch glides

3. Effortful pitch glides

4. Mendelsohn Maneuver – “squeeze” at the height of the swallow to keep the larynx up high in the neck- exercise and compensation (meal and exercise)- want them to raise their larynx and hold it

a. Change pitch, it raises the larynx

b. Add effort or tension as you move up the scale

c. In the height of the swallow hold your larynx up

53

Base of tongue exercises (5)

1. Lingual isometrics – best (residue at the valleculae)

2. Yawn: “pull your tongue back during a yawn and hold for a second”

3. Gargle: “pull your tongue back during a gargle and hold for a second”

4. Eel, Earl, Ale (hold them)

5. Forceful repetition of “k” words (exagg. Car, cat, cake)

54

Masako Maneuver (tongue hold)

1. Designed to increase the forward movement of the posterior pharyngeal wall to meet the base of the tongue.

2. Ask the patient to protrude the tongue and hold it between his teeth while he swallows.

3. Done with saliva swallows,

4. NOT with food.

- The more the tongue is protruded the better

5. Evidence with both tongue resection cancer patients and with normal pts.

6. Increased PPW anterior bulging at mid and inferior levels of second cervical vertebra

7. More bulging with greater tongue resection

8. Suggested that PPW could compensate

55

Masako Maneuver (what it does)

1. Do NOT use with food as this impairs some of the natural movements of swallowing (inhibits tongue base retraction).

2. Increases pharyngeal residue

3. Shortens duration of airway closure

4. Increases pharyngeal delay time

*** ONLY USE AS A STRENGTHENING EXERCISE NOT A COMPENSATION WITH FOOD

56

Laryngeal Adduction

1. Same techniques as used in voice therapy.

- (pushing, pulling, hard glottal attack)

2. Valsalva maneuver (breath hold or effortful breath hold)

3. Supraglottic swallow
(reduces laryngeal aspiration)

57

Decreased closure of the airway

1. Super supraglottic swallow

- (reduces laryngeal penetration)

58

Supraglottic Swallow Procedure

Designed to close the airway at the level of the TVC (true vocal cords)
1. Take a breath

2. Let a little out

3. Hold your breath tightly (gets pharyngeal closure)

4. Swallow

5. Cough

6. Swallow again

a. Used with reduced or late vocal cord closure; delayed pharyngeal swallow

b. Voluntary breath hold usually closes vocal folds before and during swallow.

*** Closes off the airway

59

Super-supraglottic swallow procedure

1. Take a breath

2. Let a little out

3. Hold your breath as tightly as possible. (bear down)

4. Swallow, squeezing as hard as you can.

5. Cough

6. Swallow again

60

Caution: supraglottic and super-supraglottic techniques

- SG and SSG were found in one study to be contraindicated in stroke or CAD patients due to the high likelihood of abnormal cardiac findings (supraventricular tachycardia, premature atrial and ventricular contractions) – in as many of 86% of their patients.

- don’t do it with cardiac pts.

61

Shaker Exercise

1. An isotonic/isometric neck exercise

2. Sustained & repetitive head-raising performed by the patient

3. An augmentation method for Dysphagia Therapy

a. Great research, great evidence

b. Lay pt. on the ground and have them do head sit ups

62

Goals of Shaker Exercise (5)

1. Increase deglutitive UES opening

2. Strengthen UES opening muscles

3. Increase anterior excursion of the larynx

4. Decrease hypopharyngeal intrabolus pressure

5. Decrease pharyngeal outflow resistance

63

Performing the Shaker Exercise

1. Perform the sustained head lifts followed by the repetitive head lifts.

2. Do the total regime 5 TIMES a day for 6 weeks.

3. Need to have good cognition, no trach or cervical spine issues

- Can put a towel rolled under the chin

64

Sustained Head LIft

1. Lay in a supine position, NO pillow under head

2. Patient instructed to lift head and look at toes

3. Shoulders remain flat on surface

4. Hold (sustain) this position 1 full minute, interrupted by 1 minute rest periods.

5. Perform 3 times

65

“Repetitive” Head Lift

1. Lay in a supine position, NO pillow under head

2. Patient instructed to lift head up to look at toes and then back down (like a “sit up” with the neck)

3. Shoulders remain flat on surface

4. Perform 30 consecutive repetitions; rest 1 minute

5. Repeat 3 times until 90 “sit ups” have been completed

66

Cautions with Shaker

1. Fatigue

2. Neck pain/discomfort; resolved spontaneously within 1 week during research conditions

3. Do NOT pull the chin to the chest -- puts pressure on C-spine

- Can do this in seated position using a towel roll or rubber ball as the resistance.

67

Exercise- building strength

- How do you know how many exercises to do?

- How do you know how many repetitions to do?

- There is very little evidence based medicine with regards to oropharyngeal musculature

- Data from the PT literature with regard to skeletal muscles.

68

If strength & endurance is the goal:

1. 8-12 repetitions per set of exercise proved most effective

2. 6-8 repetition sets elicited greater outcomes for generating strength with greater power

69

How might this translate to swallowing therapy?

1. Fatigue toward the end of the meal?

a. Try strength training with 8 – 12 repetition sets.

2. Generally weak swallow?

a. Try sets of 6-8 repetitions with high load demand. Use a tongue depressor, need to know how much your pt. can tolerate

70

Task specificity is important in training.

1. The training task must resemble the end goal as much as possible.

2. In swallowing, this may be difficult.

3. May need to start with general strength training, then progress to functional tasks.

- Try to make the task as much like swallowing as possible

71

Participating in strength training tasks may:

1. Build a foundation of force producing capacity

2. Increase functional reserve (how much gas you have in your tank, as you age your functional reserve is reduced)

3. Prime the neuromuscular system for activity

72

In therapy we are hoping for:

1. Transference

2. Where you engage in isolated exercise drills to fine tune specific components of movement in order to improve overall performance.

73

Adapting exercise principles to swallow rehab

1. Simply swallowing food, liquid or saliva is not an activity that can provide the degree of load that is necessary to force adaptations in the neuromuscular system to increase strength. (maybe but maybe not….MDTP)

2. Remember, swallowing is a sub-maximal task.

74

Compensatory and Facilitation techniques- Thermal- Tactile Application

1. Improves oral sensory awareness prior to a swallow

2. Hypothesis: Alerts the CNS, which lowers the threshold of the swallow centers


- Laryngeal mirror dipped in ice and placed on the anterior faucial pillars


*** Does not change motor control of swallow

*** Does change timing of oral onset and pharyngeal delay times

- Candidates for treatment should show radiographically defined delay on at least 2 consecutive swallows.

75

How to Measure Effectiveness (Thermal-Tactile Application)

1. Oral stage initiation time

2. Oral transit time

3. Pharyngeal delay time

4. Reduction in stage transition duration

76

Thermal Stimulation

1. Method

2. Evidence

1. Thermal stimulation Method

1. used with swallow initiation delay

2. use a double 00 laryngeal mirror dipped in
ice

3. rub up and down 5 times on one anterior faucial arch

4. instruct patient to swallow

2. Research does not suggest any carry-over effect.

- This is where the compensations come in

77

Deep pharyngeal neuromuscular stimulation (DPNS)

1. No research that says this works but it is still used

2. A systematized therapeutic program which stimulates “directly” the pharyngeal musculature.

- indirect- mendelhson, laryngeal elevation

78

DPNS concentrates on 3 reflex sites.
- They are:

1. Tongue base and bitter taste buds for improving the tongue base retraction reflex.

2. Soft palate musculature for improving the palatal reflex and velopharyngeal closure

3. Superior and medial pharyngeal constrictor musculature to improve the pharyngeal constrictor reflex.

Base of tongue, posterior pharyngeal wall, and velum

- Gagging indicates that pts. Are regaining sensory function

- Frozen lemon swaps

79

DPNS - hypothesis

- In stimulating these three sites, thermal stimulation elicits strong reflexes which in turn activates muscle group contractions which then strengthens the pharyngeal and lingual musculature.

80

Benefits to be observed quickly by the patient during DPNS

1. improved redirective/reflexive cough

2. improved phlegm/saliva management

3. improved vocal quality

4. generalized sensation that pharyngeal muscles are “stronger” or “feel better”

- Gagging indicates stimulation

- Have the pt. eat right after swallow is initiated

- Use it as a treatment

81

1. Equipment Required for DPNS

2. Evidence for DPNS

1. Frozen probes are used to stimulate the
afferent sensory tracts of specific oral and pharyngeal reflexes.

2. There is no published research to demonstrate effectiveness.

82

Techniques with research backing it up

- Supraglottic swallow

- Super supraglottic swallow

83

Effortful Swallow

1. Designed to get more movement of the base of the tongue and to help push the food through the pharynx.

2. More recently has been found to also assist peristalsis of the esophagus.

- Swallow like you are swallowing a golf ball (use with weakness) also been shown to improve peristalsis in the esophagus


84

Effortful Swallow- Directions

- Put your tongue up against the roof of your mouth, squeeze all of your mouth and throat muscles as hard as possible as you swallow.

- With normals, the effortful swallow elicited significantly earlier onset of pharyngeal pressures and greater total pressure event durations compared to non-effortful swallows.

(pts. need to use this every time)

85

Showa Maneuver

- Patients are instructed to: “take a deep breath, hold your breath tightly, keep your tongue contacting the roof of your mouth as tightly as you can and keep squeezing your throat.”

- By using this maneuver, orifices at the levels of the laryngeal entrance and vocal folds are “remarkably” narrowed.

86

Mendelsohn maneuver- what it does

1. Used with reduced laryngeal movement or a dis-coordinated swallow.

2. Laryngeal movement opens the UES, prolonging laryngeal elevation prolongs UES opening.

3. Normalizes timing of pharyngeal swallow events.

- Holding the larynx up for an extended period of time

87

Mendelsohn Maneuver- Method

Designed to keep the larynx at its highest point during the swallow.

1. Swallow with your fingers lightly on
your larynx.

2. When the larynx is at its highest point, hold it up by pushing your tongue hard against the roof of your mouth and keeping it there.

3. Hold the larynx lift for _____ seconds.

88

Surface Electromyography (sEMG)

1. Often with swallow treatment, we’re asking patients to execute complex tasks that are hard to measure.

2. sEMG is a record of electrical activity from a muscle or group of muscles.

3. It is a visible representation of a motor response with hopes that the patient can enhance their volitional control over a generally automatic process.

Provides biofeedback for the pts.

- X axis is strength

- Y axis is time

- You want them to internalize the strength they need to (picks up muscular activity)

4. Biofeedback, which is immediate and objective

5. Surface electrodes are placed below the chin.

6. Allows you to see the amount and the duration of submental muscle activity.

89

sEMG

1. Pick up activity from laryngeal elevators

2. Lingual Musculature

1. Mylohyoid

2. Anterior belly of the digastric

3. Stylohyoid


2. Genio-glossus

90

Good Populations for sEMG

1. Cortical CVA

2. Disuse atrophy

3. Oral/pharyngeal CA

4. Neurodegenerative disorders

5. Patients with good cognition

- Pair with tongue strengthening or the mendhleson to show them how to do it

91

sEMG treatment may focus on

1. Muscle relaxation & inhibition

2. Coordination & patterning of muscle response (Mendelsohn, Masako, effortful swallow)

- train a motor response

3. Strength of contraction is measured in microvolts (vertical axis)

4. Timing of contraction (horizontal axis)

5. This program encourages more active participation of the patient in the treatment process.

92

Treatment progress with sEMG

1. Change in peak amplitude during the swallow

2. Count the # of times the patient exceeds the set threshold

3. Sustain contraction for a period or maintain period of relaxation

Done in microvolts, do they fatigue over time?

93

Electrical Stimulation

1. VitalStim

2. Biber approach

***Very controverstial

94

FDA approved uses of NMES

- NMES (Neuromuscular Electrical Stimulation)

1. Muscle re-education (relevant for swallowing)

2. Prevent/retard disuse atrophy (relevant for swallowing )

3. Relax muscle spasm

4. Increase local blood circulation

5. Prevent DVT when applied post-surgically to calf muscles

6. Maintain or increase ROM (relevant for swallowing

95

For swallow

1. Standard muscle re-education for small muscle groups

2. To prevent or retard disuse atrophy of the suprahyoid musculature due to inactive periods (NPO)- we cause atrophy when we make pts

96

NMES- Stimulation Parameters

1. Waveform

2. Pulse frequency

3. Pulse width

4. Amplitude

5. Ramping

6. Duty cycle

97

What is NMES

1. Noninvasive modality that directly stimulates the peripheral nervous system to evoke an action potential via surface electrodes.

2. Effects depend on the depth of the electrical field. It stimulates muscles closest to the skin first.

3. To stimulate deep muscles, must stimulate more superficial ones at same time

- Attach electrodes to the neck- to get to the muscles that elevate the larynx

- To get to deep muscles, you need to turn the electricity up

98

NMES:

1. Superior electrode

1. Stimulates the muscles closest to the surface first, Platysma and Anterior Belly of the Digastric

99

NMES:

1. Superior Electrode- Submental area

1. Platysma

2. Anterior Belly of the Digastric

- opens jaw

3. Mylohyoid

- Raises the hyoid

4. Geniohyoid

- pulls hyoid anteriorly

100

NMES:
Inferior Electrode Laryngeal Area

1. Platysma

- under skin and fat

2. Sternohyoid and Omohyoid

3. Thyrohyoid

**several placements

***will need to shave neck to put electrodes on

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NMES:

1. Inferior Electrode Throat Area

1. Platysma

2. Sternohyoid

- pulls hyoid down

3. Omohyoid

- pulls hyoid laterally

4. Thyrohyoid

- Raises larynx

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NMES

1. Mechanism of Action

1. A pulsed current penetrates the skin and reaches the target muscle groups

2. The motor neuron is depolarized and produces a mild contraction

3. This in turn facilitates muscle function: swallow.

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Vital Stim in Healthy Volunteers

1. Lowered the hyoid bone in the neck during stim

2. All positions except submental alone lowered the hyoid

3. Submental position did not raise the hyoid or the larynx

4. Submental stimulation was too weak to overcome the sternohyoid effects on hyoid position

5. Reduced hyo-laryngeal elevation during swallowing in healthy volunteers

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Evidence for VitalStim

- Bulow(2008), RCT, No significant difference between two groups (traditional therapy vs therapy with Vital Stim)

- Kiger(2006), No significant difference in the amount of improvement between the traditional and Vital stim groups in the pharyngeal phase.

- Shaw(2007) retrospective, phone interviews. Results – greater change in less severe patients. (those who were already able to consume some consistency safely)

- Park (2009), healthy volunteers, motor vs. sensory groups. The amount of hyoid elevation increased only in the experimental group immediately after treatment but was lost 2 weeks later.

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Sub-mental approach

1. Humbert study – submental not effective

2. Safi study (in preparation) – the hyoid moved up but not the larynx, opening the laryngeal vestibule instead of closing it.

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Clinical implications of NMES

1. Sensory stimulation may aid all patients in swallowing by serving as a facilitory input to the central nervous system

2. Motor stimulation may serve as a resistive therapy in patients who can already raise the hyo-laryngeal complex by making them augment volitional elevation

3. BUT…. (could be strengthening if normal swallow, due to resistance from hyoid moving down)

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In patients without elevation

- Hyoid depression may put patients at further risk as it opens the vestibule in patients who cannot overcome depression by volitional elevation

- Sessions should last an hour

- Improvement could be due to practice

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NMES (controverstial treatment)

- Non-invasive

- Low levels of current may provide sensory facilitation

- High levels lower the hyoid, providing resistance to movement

- Could put some at risk

- Consider early in recovery in less severe patients.

--- Base of tongue issues or residue issues don’t do estem

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FDA warnings about stimulation

Stimulation should not:

- Be applied over the neck or mouth

- Be applied over swollen, infected or inflamed areas

- Applied over or in proximity to cancerous lesions

- Be used with cardiac demand pacemakers

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Concept of Mass Practice

1. McNeill Dysphagia Therapy Program (MDTP)

1. MDTP is a systematic, exercise-based therapy framework for the treatment of dysphagia.

2. Uses simple techniques focused on swallowing as exercise.

3. Organizes these techniques into a hierarchy of events that progressively advance the patient toward more “normal” eating behavior.

- It is mass practice

- Places normal eating in a hierarchy

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MDTP

- Includes “home work” based on patient progress that facilitates return to a more normal eating routine.

- Incorporates specific criteria for starting, advancing, or “regressing” an individual patient’s progress.

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Exercise-based (MDTP)

1. MDTP is based on principles of exercise physiology and rehabilitation:

a. Frequency

b. Intensity

c. Speed & coordination

d. Varying planes of movement

2. Progressively introduced as the patient advances.

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Philosophy of the treatment (MDTP)

1. Challenge the swallowing system (resistance)

2. Normalize the swallowing behaviors

3. Based upon principles of motor learning and muscle development (resistance and loading)

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The Food Hierarchy (MDTP)

- 11 Step hierarchy of food/liquid that is sequenced to “exercise” the swallowing mechanism based on speed/coordination and progressive resistance

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15 Sessions of MDTP

1. Nothing “magic” about 15 sessions

2. Can d/c therapy if patient “finishes” the food hierarchy or continue beyond 15 sessions if needed

3. Sessions 1 and 2 are for “accommodation”
Terminate once reach FOIS Level 6

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Components of MDTP

1. Real time monitoring of performance. Daily performance “index” (#swallows = amount of practice= intensity)

2. Outcome assessment and documentation

3. Adjunctive modalities may be used to enhance clinical improvement (NMES, sEMG)

4. May be combined with compensatory strategies and swallow maneuvers.

5. These are “faded” as the patient progresses.

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MDTP is NOT:

A single swallowing technique, compensation or maneuver. It is a systematic framework to facilitate appropriate clinical decisions using common and simple therapeutic techniques.




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Differences from previous swallowing treatment: MDTP

1. Progressive resistance-mass practice platform

2. Intensive – multiple swallowing attempts, carefully monitored (>80-100 per session)

3. Removes all “crutches” – eg spitting cups, tissues, liquid washes.

4. Focuses on loading the task requirements

5. Pushes the patient

6. ?? Brain plasticity???

Purpose of mass practice is that you want to change brain plasticity

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MDTP Program

1. Complete session = 1 hr working

2. Begin the next session the following day starting at last complete successful level

3. Re-evaluate after 15 sessions.

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MDTP was developed based on evidence

1. Specific to the functional task at hand

2. Frequent to promote sensorimotor learning (daily)

3. Intense to exercise target muscle groups (1 hour of therapy, mass practice, push patient)

4. Uses progressive resistance to build strength & coordination (food hierarchy)

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Evidence that MDTP works?

1. MDTP with adjunctive NMES produced positive results in chronic, treatment refractory adult patients

2. MDTP alone also produced these positive results in similar patients

3. Change was noted in clinical, functional and physiological measures

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Exercise Principles

1. Exercise causes muscle hypertrophy

2. Stretch also induces fiber growth

3. Immobility does the reverse! Causes fiber atrophy

4. The longer the immobility the greater the tissue atrophy.

- NPO really affects pts.

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Disuse Atrophy

1. Muscle will start to change within 4 hours of un-weighting

2. Slow twitch (I) are more susceptible to atrophy compared to fast fibers (II)

3. A muscle not exercised may decrease to less than half its usual size within a few months.

- In acute care you may use ice instead of water for the FWP (ice also has the cold stimulation)

- If you don’t use a muscle for 4 hours, it atrophies

- Swallowing muscles have slow twitch and fast fibers

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2 types of muscle fibers

1. slow-twitch

2. fast-twitch

1. resist fatigue

2. fast fatigue

- Most muscles are a mixture of I & II

- Muscles of the neck (swallow) are predominantly HYBRIDS (more II than I)

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Why do we care?

1. Fiber type influences the # of movements/repetitions a muscle can do

2. Fiber type influences the efficiency of response to exercise - as well as the outcome of exercise

- i.e. how you put together a treatment package of exercises!!- this is important !!!

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Muscle change with disuse (6)

1. Fatty infiltration

2. Muscle mass reduction

3. Loss of proteins

4. Reduction in contractile tension & range

5. Increased fatigability

6. Micro vascular change (capillary loss)

*** Need to exercise

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Re-training of muscles

1. Reactivation of muscles results in muscle gain

2. More pronounced in muscles not previously weakened

3. If performed in the presence of caloric deprivation, cannibalism can occur

4. Exercising atrophic muscle can cause damage.

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So- what do we do for retraining muscles

1. Voluntary movement always recruits type I fibers first, then type II

2. Type II (fast but little resistance to fatigue)

3. Type I (slow but resistant to fatigue)

4. Overload activities build strength (type II, short reps – heavy)

5. Light activities and more repetitions build endurance

In the past...

- Traditional swallowing treatments were aimed at the right goal, but delivery did not achieve the level required to change muscle function!

-10 exercises is not going to load the muscle, we have to do overload and mass practice, give them a log, have them practice at home

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Exercise principles

1. Normal swallowing strengthens and reaffirms functional movement patterns through contraction against resistance

2. Short term overload principle

3. Repeated many times to reinforce CNS patterning

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Components of Exercise (7)

1. Progressing (intensity/duration) of the exercise

2. Intensity - the effort used during the exercise

3. Need overload and progressive resistance

4. There must be specificity – movement pattern mirrors desired activity

5. Variety principle – train in all planes of motion

6. Recovery principle – pacing is important to overcome fatigue

7. Maintenance principle

-- We have to do things that make sense for the swallow

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Traditional swallowing treatments

Many exercises are aimed at the right goal….but does the delivery achieve the level required to change muscle function ??

-Need to up the level to change muscle function

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Top techniques reported in survey:

1. OME – stretching primarily (tongue in, tongue out, works well with CA pts. But doesn’t improve muscle strength)

2. Mendelsohn’s maneuver – might provide strength, dependent on # of trials and timing of repetitions

3. Effortful swallow – provides endurance activity and dependent on bolus, may provide strength. (easy to do)

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Where are we???

- Muscles are plastic and highly responsive

- Swallowing uses a muscular system

- Force and duration are important issues in re-training

- Short periods of activity under loaded conditions have significant impact.

*More inactivity you have, the weaker you get (need to do something)

- MDTP folks report that current treatments do not take this into account

- Which may help explain poor outcomes from treatment.

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Treatment programs that meet exercise principles:

1. Shaker

2. Lingual resistance (against tongue depressor, IOPI or Most.

3. LSVT

- Yes, but not totally!

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MDTP development strived to:

1. Follow the principles of exercise

2. Include generalization activities to the real life activity of feeding

3. Be able to measure accurately and monitor accurately the outcome

4. Be non-reversible

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To monitor outcome – used FOIS

Functional Oral Intake Scale:

1. Nothing by mouth (NPO)

2. Tube dependent with minimal attempts of food or liquid.

3. Tube dependent with consistent intake of liquid or food

4. Total oral diet of a single consistency

5. Total oral diet with multiple consistencies but requiring special preparation or compensations.

6. Total oral diet with multiple consistencies without special preparation, but with specific food limitation.

7. Total oral diet with no restriction.

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FITT principle

1. Frequency

2. Intensity

3. Time

4. Type

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General Guidelines for FITT

1. Appropriate seating (90 degree angle)

2. Small amounts

3. Slowly

4. No straws*****

5. Upright during and for 30 minutes following a meal (they could have a slow esophagus)

6. Head slightly flexed (almost looking down)

7. Environment quiet and non-distracting

8. Cognition effects (compliance, readiness)

- You need to have pt. attend to their meal

- Go after PT

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Other Considerations

1. Alertness and energy level of the patient

2. The emotional reaction to food (puree food looks more appealing now, try to put a positive spin on it)

3. Restraint and judgment (pts. With left hemiparesis, lack judgment)

4. Memory and sequencing skills (if they can’t sequence they will not be able to do the supraglottic swallow)

5. Focus and attention span

- It is important for people to be able to feed themselves for quality of life and aspiration pneumonia increases when pts. Need to be feed.

- Eating starts when we look at the food, anticipate the food, saliva, bring the food to out mouth

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Consider Desired Outcome 1

- Improve oral transit time

- Increase lingual tone

- Increase efficiency of PO intake

- Ensure optimum nutrition

- Minimize risk for pneumonia

- Provide patient/family education

- Oral management of medication

-- Get pt. to be able to efficiently eat

--- If someone is taking more than 15 mins to eat they are going to give up

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Consider Desired Outcome 2

1. Decrease hospital length of stay

2. Eliminate deaths from aspiration pneumonia

3. Reduce cost, increase profit

4. Maintain weight

5. Improve quality of life

6. Eat favorite food

7. Drink favorite flavor

Nutrition is the building block, if you don’t have good nutrition you won’t get well.

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Criteria for exercise

-The patient must be alert and cooperative enough to participate in at least 15 minutes of structured therapy.

- For mass practice to take place, this needs to be much longer (45 – 60).

- The patient must be able to learn and memorize the exercise program, or be able to read written instructions, or have a family member or caregiver who will assist them in completing the exercises several times a day.

-The patient must be able to demonstrate progress during the treatment program(i.e., show increased oral-motor function, exhibit improvement on a repeat videoswallow, etc.)

- If pt. does not progress it is called maintenance therapy

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Documentation

- Demonstrate functional outcomes

- Document “significant” progress

- Document skilled services- we need to document that are skills are necessary for the pt.

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Key words/phrases

1. Safety

2. Promote recovery and insure medical safety

3. Prior level of function- independently eating all consistencies

4. Skilled level of care

5. Reasonable and necessary

6. Requires the skills of a therapist

7. Decrease medical complications- pt. will not need PEG or PEJ

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Words and phrases to avoid

1. Inability to follow directions

2. Refuses to participate

3. Maintenance therapy (contradiction)

4. Poor rehab potential

5. Chronic/long-term condition

6. Drill- no

7. Monitoring- no sounds like maintenance activity

If any of these words/phrases accurately describes what is happening with your patient, the patient is most likely not a good candidate for treatment.

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Possibilities for the future…

1. Christy Ludlow information

2. Laryngeal pacer

3. Swallow expansion device

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Christy Ludlow research

- Using hook-wire electrodes, determined that the best muscles to stimulate to aid UES opening:

1. Geniohyoid

2. Thyrohyoid

3. Hyoglossus

4. mylohyoid

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NIH research

1. 10 chronic patients, experimental & control groups, randomized

2. 6 with implant, 4 with vibro-tactile device
Implant patients – biggest change in saliva control, QOL- quality of life

3. Even the control group improved

4. Why would vibro-tactile (control) group improve?

5. Sensory input may improve swallowing via increasing swallow frequency.

6. Mass practice in both groups every day.
So, why did these chronic patients improve? Sensory input? Motor input? Motor plus sensory? (60 times per hour)

7. Or was it purely because of the mass practice?

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Laryngeal pacer

- Implanted stimulator attached to the RLN

- Closes the glottis on demand for patients who aspirate

- “Locks” the airway

- Stimulate the recurrent laryngeal nerve which closes the airway

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Swallow expansion device

- Pulls the cricoid forward to open the UES.

- Titanium implant with an external magnetism device.

- UES can be opened 3 times greater than normal.

- UES isn’t opening- need to get cricopharyngeus open

- The reason the epiglottis doesn’t deflect is because the larynx does not elevate and if the arytenoids don’t meet the epiglottis