Chapter 3 Flashcards
What is dysphagia a manifestation of what?
of another disease or disorder
What are the 2 basic divisions of the the nervous system?
upper motor neurons
lower motor nuerons
What is the basic foundation of upper motor neurons?
the central nervous system
What is the basic foundation of lower motor neurons?
the peripheral nervous system
Name 3 descriptive words used to describe MOTOR neurological disorders.
- spastic
- flaccid
- muscular weakness
Name 3 descriptive words used to describe SENSORY neurological disorders.
- taste
- smell
- consistency
Cortical/Subcortical =
Cognitive Function; initiation/inhibition
Brainstem =
Junction box / switch yard
Cerebellum =
Refinement
Spinal tract =
motor / sensory tract highway
Peripheral system =
exit the CNS
Muscle insertion =
Muscle action
Sensory initiation
Sensory uptake
What is subcortical function?
It is mainly giving directions and subconscious/sub-cortical fast unconscious reactions
What are the 2 areas of neurological swallowing disorders?
cortical and subcortical
Where is subcortical?
Anything beneath the cortex: thalamus, hypothalamus, brainstem, cerebellum. It is inside the orange peel.
Where is the cortical layer?
It is located on the outer layer of neural tissue and it surrounds the brain. It is the orange peel.
What are the 2 cortical function LOBES involved with swallow function?
frontal lobe
parietal lobe
What are the responsibilities of the frontal lobe during cortical functioning for swallowing?
MOTOR CONTROL
- intent
- initiation of movement
- coordination of movement
- movement of space and time
What are the responsibilities of the frontal lobe during cortical functioning for swallowing?
SENSORY
- Recognition
- Interpretation
Impairments due to cortical damage may vary for what 4 reasons?
- location of damage
- extent of damage
- type of damage (trauma vs. blunt force)
- unilateral vs. bilateral
What deficits should you consider when considering the swallowing effects of cortical damage?
- cognitive deficit
2. physical deficit
When you are assessing someone with cortical damage, what might assessment be “drawing the line” between?
Whether or not the patient gets to eat.
What are the 3 largest categories of neurological cortical disorders?
- stroke
- dementia
- traumatic brain injury
What is a stroke from cortical damage?
- A CVA that does not include the brainstem.
2. Anoxia damage.
What is dementia?
generalized neurologic degeneration
What is a traumatic brain injury?
- closed or open head injury
2. vascular, tissue, or neurologic damage
What do know about swallowing disorders if a hemisphere stroke occurs?
- swallowing disorders pertaining to left side/right side are not entirely defined.
What happens to swallowing if someone has a left hemisphere stroke?
oral apraxia
Define oral apraxia.
Voluntary movement disorder of sequence.
Inability to sequence motor movement voluntarily.
Since oral apraxia is a disorder of voluntary motor sequencing what should you remember for swallowing evaluations with these patients?
Patients do better feeding themselves. THIS DOES NOT MAKE SENSE. ASK SOMEONE ABOUT THIS.
What happens with swallowing during a right side hemisphere stroke?
- oral transit problems
- delay in pharyngeal swallow
- laryngeal elevation delayed
What happens to swallowing if a patient has multiple strokes?
- There is an overall multiplication of symptoms.
- More severe oral transit
- reduced laryngeal elevation/closure
- treatment is difficult
What is the overall recovery like for someone who had his/her first stroke?
- full oral intake recovery usually takes 3-4 weeks
2. most progress occurs within 3-4 weeks
Name 6 other factors that affect stroke patients recovery.
- comorbidities
- diabetes
- neuropathies
- prior CVA
- pulmonary disorders in PNEUMONIA
- medications
What are your goals as an SLP for a patient in stroke swallow treatment?
- ensure that they swallow their food SAFELY
- keep in mind that they have to MEET NUTRITION
(i.e. double swallow, thickened liquids)
NOTE: honey thickened liquids are not the answer for everyone
Don’t get stuck in a box during stroke swallow treatment. HOW should dysphagia treatment CHANGE over time?
Changes in:
- bolus volume
- bolus viscosity
- bolus taste (sour bolus)
What should treatment include for a head and neck patient?
- head and body positions
2. put your head down, turn your head to the side
- For most strokes that cause a delay in the pharyngeal swallow, what might be the most difficult for the patient to swallow?
- What might be the best to start off with?
- thin liquids might be the most difficult
- a puree might be the best to start of with (i.e. pudding bolus
OR - follow IMBSP protocol
List a few examples reasons for cortical damage dementia?
- alzheimer’s disease
- alcoholism
- cardiovascular disease
Dementia is a progressive deterioration of what?
cognitive abilities
What is negatively effected because of cortical damage dementia?
- memory
- judgement
- apraxia
What can be a 1st indication of dementia?
persistent weight loss
What reduces in the swallow as a result of dementia?
speed and coordination
What will a cortical damage dementia patient display?
- self-feeding problems
- motor deficits of apraxia and/or dysarthrua
- loss of appetite
- food avoidance
A dementia patient’s caregiver is a great source for what?
- a history of change and deterioration
What happens in the later stages of dementia?
oral agnosia
What is the goal in cortical change patients with dementia?
nutrition while keeping their swallow as safe as you can
What is swallowing treatment like in with dementia patients with oral agnosia (moderate to severe)?
DIETARY or perhaps BEHAVIORAL
- special foods (foods that the patient likes)
- enhanced flavoring
- consistency choice
- meal time supervision and cueing
- change swallow mechanics
- N-G or Peg tube for AUGMENTATION not conveneince
What usually happens when people with oral agnosia are given an N-G tube or a Peg Tube?
most people end up passing away within 3 months of this time
Describe treatment for mild dementia patients.
You can still work with indirect treatment.
Give them the long term statistics, no treatment at this stage.
Mainly behavioral.
Maybe you can do indirect rote treatment.
What do you need to keep in mind about goals during cortical dementia treatment?
goals of treatment are always dependent on the patient’s:
- advanced directives
- code status
- quality of life definition
What should you never ignore in a patient?
their DIGNITY
What are the 2 types of TBIs?
- closed
2. open head
Describe a closed head traumatic brain injury.
concussion and bruising of brain matter
skull and dura matter remain in tact
What is an open head TBI?
Injury from penetrating injuries
i.e. knives, bullets, bone fragments, fragments from explosions
What do we want to diffuse when someone gets a TBI?
neurologic deficits affecting several aspects of behavioral control
What is a contra coup brain injury?
brain bouncing against brain case
Severity of dysphagia is equal to severity of neurotrauma. What are different kinds of severity of neurotrauma?
contra coup brain injuy
twisting of brainstem
laryngeal fractures
What happens to the oral stage when someone has a TBI?
- reduced range of tongue motion and poor bolus control
- increase in oral defensiveness
- bite reflex
What happens to the pharyngeal phase when someone has a TBI?
delay in triggering pharyngeal swallow
absent pharyngeal swallow
reduced laryngeal elevation and closure
UES dysfunction
What do patients with TBI have on top of cognitive issues?
behavioral issues
impulsiveness
poor awareness
attention issues
Name 4 different types of TBI swallow treatment with examples of each.
Dietary: modification of diet
Behavioral: posture, maneuvers
Surgical: tube placement
Medical: medications to help their anxiety
What was Professor Foster’s words of wisdom?
- Always give your patients/families the specific goals of treatment for them to see the “light at the end of the tunnel.”
- Example: John needs to be able to move his food from the front to the back of his mouth within 10 seconds, then we can do an MBS.
- Be specific when educating patients and families. You owe it to patient’s and their families.
- explain the uncertainties and the probabilities of the journey
Where is the NTS (nucleus tract solitari) located?
- in the medulla oblongata which is clusters of nucleii (cell bodies) to regulate sensory and taste junction box
- it has a large amount of input and output for sensory/motor (including respiratory, gag)
List subcortical neurological disorders.
- subcortical strokes
- degenerative diseases
- subcortical lesions
Where do subcortical strokes take place?
damage to the thalamus and the cerebellum
damage to brainstem
What happens as a result of subcortical strokes?
- damage or infarcts in cerebellum/thalmus
- mild to profound delays of oral transit time
- mild to profound delays in pharyngeal swallow
- UES dysfunction
- takes 3-6 weeks to get better
Where do upper brainstem strokes take place?
- region of the pons
What happens as a result of an upper brainstem stroke?
- severely hypertonic
- absent pharyngeal swallow or severely delayed
- spastic pharyngeal wall or paralysis
- recovery poor…very slow
- delayed swallow is 15 seconds or over
Where does a lower brainstem stroke take place?
in the NTS is the medulla oblongata
NTS
nucleus tractus solitari
What cranial nerves are harmed during a lower brainstem stroke?
facial, glossopharyngeal, and vagus
What functions are harmed from a lower brainstem stroke?
information regarding taste, cough and gag reflexes
triggering, timing and sequence of swallow
difficulty triggering the pharyngeal swallow
absent pharyngeal swallow
delayed pharyngeal swallow
reduced laryngeal elevation
reduced UES opening
Where does an upper brainstem stroke take place?
between the midbrain and the pons
What is silent aspiration?
zero response to an aspiration event
Evidence shows that most patients with lower brainstem strokes start eating at how many weeks? Although, what is still affected?
3 weeks
the pharyngeal swallow is still affected
How long does it take for patients with lower brainstem stoke to start eating if they don’t start eating by 3 weeks?
4-6 months
What kind of intervention should be on hold in patients with lower brainstem strokes?
any type of surgical intervention AKA
crycopharyngeal myotomy should be on hold
What are the 2 largest categories for neurological sub-cortical disorders?
parkinsons and ALS
Describe the sub-cortical degenerative disease known as Parkinson’s disorder.
It is an upper motor neuron disorder of resting and voluntary movement
It happens because of a depletion of dopamine which results in impaired function of basil ganglia function
What is the basil ganglia responsible for?
- quality of movement
- regulate tone, tension
- initiation of movement
- presence of extra movement dystonias
What happens as a result of parkinson’s?
- impairment in execution of voluntary movement
- resting tremor (even tongue, palate, bradykinesia, rigidity)
- mask expression, dysarthria, body posture, gait are all affected
- “pill roll”
- cogwheel rigidity or cogwheeling
- medical management medications and deep lobe stimulation
What happens to the swallow as a result of Parkinsons?
- poor oropharyngeal control = poor bolus control
- random tongue movement
3 tongue pumping/lingual rolling - weak swallow reflex
- drooling = increased risk of silent aspiration
- incoordination of swallow and respiration
- swallow as progressive as disease
What kind of treatment do you give for swallowing in patients with Parkinsons?
Dietary treatment: ?
Behavioral: eat small portions, small and frequent meals
Adaptive equipment: ?
How do you treat swallowing in early Parkinson’s? Moderate? Severe?
Early: exercises
Moderate: sensory changes/input
Severe: counseling on nutrition/maximizing nutrition and quality of life
What is the better liquid option for people with Parkinsons?
Nectar is better for people with parkinson’s instead of honey thickened liquids. They can’t clear the residue with a thickener.
Do we base treatment off of coughs?
No we base treatment off of what muscle is dysfunctional
If you suspect a problem a problem in the throat what assessment do you need to administer?
FEEs do not prescribe a thickened liquid for anyone without a diagnostic test
Name an lower motor neuron disease that has a negative impact on swallowing.
ALS; amyotrophic lateral sclerosis; Lou Gehrig’s disease
What is ALS?
A lower motor neuron disorder.
It is a condition that usually begins with oral stage and progresses downward.
Respiratory failure occurs.
There is a loss of neuromuscular control excursion.
What kind of dietary modifications are made in patients with ALS?
change viscosities to thin them out
What kind of treatment are ALS generally treated with?
dietary modifications and behavior modifications
What kinds of treatment is not given for patients with ALS?
NOT active exercise because of muscles becoming easily fatigued.
Why would you get an MBS and a FEEs?
Because you can’t capture 2,000 swallows in a meal.
What happens to a swallow as a result of ALS?
decrease in pressure of tongue decrease in labial closure reduces laryngeal elevation reduced tongue base movement reduced pharyngeal wall contraction the pressure pump is gone increased difficulty with thicker viscosities
What disease is a distant relative of ALS (another lower motor neuron disease)?
myasthenia gravis
What is myasthenia gravis?
an inflammatory muscle disease/connective tissue disease
Name 3 other inflammatory muscle diseases/connective tissue diseases.
- polyneuropathy
- scleroderma
- lupus
What happens to the swallow with lower motor neuron disorders?
they don’t start having problems until the end of the meal because of fatigue.
Name 2 other kinds of neurological subcortical regions?
brainstem lesions
cerebellar lesions
What is the junction box?
the NTS (the main control center of swallowing) the following will happen
What happens if there is a brainstem lesion or tumor on the NTS?
swallow is uncoordinated and weak
What happens to swallow if there is a cerebellar lesion?
Little or not any affect on the swallow ataxia intentional tumor hypotonic impairs swallow coordination
What is idopathic/iatrogenic dysphagia?
dysphagia caused by medications especially psychotrophic meds
Why do psych meds cause dysphagia?
meant to slow down the brain and calm over years and years of using them it can slow down the muscles for the swallow.
