Chapter 5, Class 5- Exam 2 Flashcards
More damage in_____ that effects swallowing than ______
UMN
LMN
• Functional Neuroanatomy
Table 5-1
- Cortical
- Subcortical
- Brainstem
- Cerebellum
- Peripheral Nerves
- Muscles and Sensory Receptors
• Cortical Functions
- Where is swallowing represented?
* fMRI studies show wide range of areas cortical, subcortical, brainstem involved
• Strokes
- Right versus left hemisphere
- Dysphagia in both right and left hemisphere CVAs
- Left side CVA greater incidence of oral dysphagia and right side CVA greater incidence of pharyngeal dysphagia
- Swallowing is bilaterally represented
- Cortical plasticity may occur over time
- Plasticity to retrain and reengage the neurological system to improve the swallow
- Treatment Considerations/Decisions
• Deficits after Hemispheric CVA
- Reduced initiation of saliva swallow
- Delayed triggering f pharyngeal swallow
- Poor co-ordination of oral movements in swallow
- Oral prep should be less than 10 seconds
- Oral transit should be less than 1 second
- Increased pharyngeal transit time
- Reduced pharyngeal constriction
- Aspiration
- Pharyngo-esophogeal segment dysfunction
- Impaired lower esophageal sphincter relations.
• Treatment Considerations, Dysphagia following CVA
(See Table 5-2, page 79)
Acute: 0-1 month
• Resolving dysphagia
• Malnutrition
Improving (1-6 months)
• Feeding routes established
• Malnutrition
Chronic (+ 6 months)
• Feeding Routes established
• Compensations
• Continue therapy?
• Dysphagia with Dementia
Symptoms/Swallowing deficits seen in patients with cognitive decline • Unexplained weight loss (more common) • Oral stage dysfunction (more common) • Could also have anticipatory issues • Pharyngeal stage dysfunction • Flash penetration, bolus in triangular space of VFs and coughed out • Combined oral & pharyngeal dysfunction • Minor aspiration • Feeding limitations • No appetite, don’t want to eat • Anticipatory stage problems
• Examples of swallowing and feeding deviations in mild-stage dementia
(See Box 5-4, page 81)
Swallowing deviations
• Slow oral movements
• Slow or delayed pharyngeal response
• Overall slow swallowing duration
Feeding deviations
• Increased self-feeding cues needed
• Direct assistance with utensil use and food preparation
• Imitation of feeding behavior from meal partner
• Dysphagia and TBI
- Ranges from 60%-90% with dysphagia
- Based on severity of trauma
- Glascow Coma Scale (GCS)
- Rancho Coma Scale (RLAS)
- Functional Independence Measure (FIM)
- Pneumonia is frequently seen
• Dysphagia in Subcortical Impairments
- Basal ganglia deficits
- Parkinson’s Disease (Page 86)
- Progressive Supranuclear Palsy
- Dysphagia Considerations (Box 5-5)
- Treatment Considerations in general
• Deficits in PD (See Table 5-3)
Oral stage: • Lingual tremor • Tongue pumping • Pumping food up and down, no A-P transport • Ramplike posture • Piecemeal deglutition • Velar tremor • Buccal retention
Pharyngeal State • Vallecular retention • Pyriform sinus retention • Impaired laryngeal elevation • Airway penetration • Aspiration • Phayrngo-esophageal segment dysfunction
• Dysphagia after Brainstem CVA
See Box 5-7, page 87
- Absent or delayed pharyngeal response
- Reduced hyolaryngeal elevation
- Reduced oro-pharyngeal constriction
- Reduced pharyngeal constriction
- Reduced laryngeal closure
- Reduced pharyngo-esophageal segment opening
- Brief swallow event
- Generalized in-coordination with breathing
• Lower Motor Neuron/Muscle Diseases
Amyotrophic lateral sclerosis (ALS) (Box 5-8 page 89) • Oral control of bolus • Peri-oral weakness • Lingual weakness • Reduced transport • Velar leak • Reduced tongue pump • Reduced pharyngeal contraction • Residue • Airway protection • Bradykinisia • Residue • Table 5-4—Swallowing interventions with ALS • Specifics on Boxes 5-8 and 5-9
• Ideopathic/Iatrogenic Disorders
- Vascular deficits (TIAs, mini-strokes)
- Advancing age
- Complex medical conditions
- Medication
- Progressive diseases
- Post surgical changes
- Resemble Neurogenic Dysphagia but no overt neurologic disease
• The role of Executive Function in Eating
- Anticipatory Stage
- Meal planning
- Portion judgment
- Appetite judgment
- Treatment Considerations: Dementia and dysphagia
* Focus on:
- QOL
- Dignity
- Comfort
• Treatment Considerations-Brainstem CVA
- Recover function over time
- Symptomatic and change over time
- May be more direct and aggressive
• The Cerebellum and Swallowing
- Adjacent to the brainstem
- Role in swallowing poorly understood
- Activation on functional imaging
- Volitional swallowing
- Ataxia,
- Intention tremor
- Hypotonia
• Dysphagia in ALS (Box 5-9)
Oral Stage: • Leakage • Mastication problems • Bolus formation • Bolus Transport • Residual pooling
Pharyngeal Stage • Nasopharyngeal regurgitation • Valleculae pooling • Pyriform sinus pooling • Airway spillage • Ineffective airway clearance • Shortness of breath
• Dysphagia Tx with ALS
- See Table 5-4, page 91
- Early Swallowing Problems
- Dietary Consistency Changes
- Results of Reduced Intake
- Salivary Problems
• Other Lower Motor Neuron Disorders with Dysphagic Symptoms
- Polyneuropathy- system diseases such as Diabetes, Guillain-Barre syndrome
- Myesthenia Gravis
- Polymyositis
- Scleroderma
- Systemic Lupus Erythematosus
- Muscular Dystrophy
2 hallmarks of dysphagia:
Two hallmarks of dysphagia:
- Delay in propulsion from mouth to stomach
- Misdirection of bolus – enters airway
Delay in propulsion:
What could be impaired neurologically?
What would it look like?
o Slow
What do you predict could be done therapeutically?
o Change consistency
o Oral-motor exercises
o Compensatory strategies to speech propulsion
o Children- oral motor strengthening and awareness
Aspiration
Langmore et al. 2008
Aspiration pneumonia
o 13-48% of nursing home infections
o Second most common cause of mortality 20-50%, some say 80%
