dysphagia Flashcards
dysphagia in stroke is located in what 3 areas of brain
In cases of stroke, dysphagia is traditionally associated with brainstem lesions or bilateral cortical damage, unilateral hemispheric lesions
swallowing occurs in what two phases? - unlateral hemispheric lesions
Swallowing occurs in voluntary (oral) and involuntary (pharyngeal) phases, hence, damage to voluntary and involuntary components of neurological function can affect dysphagia after a stroke
how does swallowing use bi-hemispheric components of neurological function?
left hemisphere was more associated with the voluntary oral phase of swallowing, whereas the right hemisphere was more associated with the reflexive (involuntary) pharyngeal phase and aspiration as a complication.
oral phase swallowing dysfunction has difficulty with doing what? and what brain track lesions?
-interrupt voluntary control of mastication and bolus transport
-corticospinal and corticobulbar tracts
Pharyngeal dysfunction involves relatively large brain areas called?
corona radiate
neural pathways involved in activation of the motor system are asymmetrically organized in humans. The right hemisphere plays a dominant role in activating? The left hemisphere mainly activates?
right- both ipsilateral and contralateral motor neurons
L- ipsilateral motor neurons.
https://www.youtube.com/watch?v=MhI4ZHLA7xg
define dysphagia
“dysfunction in any stage or process of eating. It includes any
difficulty in the passage of food, liquid, or medicine, during any stage of
swallowing that impairs the client’s ability to swallow independently or safely.”
how is Swallowing is an essential activity of daily
living:
the inability to swallow negatively affects nutrition, overall health, and quality of life.
diagnosis with dysphagia
cva- cebrebovasuclar accident, parkinson’s, elderly institutionalized patients
EAT-10 eating assessment tool questions is used as what kind of tool and it’s purpose, what score means more assessment needed?
quick screening tool for subjective symptoms
initial dysphagia severity and monitor the treatment response
3 or more areas an issue to undergo further assessment
MISA McGill- 4 areas it assesses?
positioning, self feeding skills, oral motor skills, texture management
What are the therapy treatment options (3)
management / compensation
rehabilitation
or both
reasons for Compensatory treatment? why is it commonly used by clinicians? What should be considered?
- Accommodates or compensates for underlying
swallowing disorder - “Works” when used – disorder still exists when not
used - Commonly used by clinicians:
– Can improve safety/nutrition to allow intake
– In populations where rehabilitation may not be
feasible - Consider if this is the only approach
reasons for Rehabilitation approach?
- Used to improve swallowing function
- Improve skill, alter underlying
pathophysiology - Principles of plasticity:
– Muscle
– Behavioural
– Neural
10 principals of nuro plasticity
-use it or loose it
-Use It and Improve It
-plasticity is experience specific
-repetition matters
-intensity matters
-time matters (pairing compensatory strategies with
those that access neural adaptation early in recovery)
-transference
-interference
-age
-salience matters (movement is purposeful and related to the behavior being trained)
define the use it or lose it neuro plasticity prinicpal and how does it relate to dysphagia?
-if a neural substrate is not biologically active, its function can degrade
-Following brain injury further cortical loss can occur without training, as the movements formerly represented in the lesioned zone do not reappear in adjacent cortical regions
-Failure to drive specific brain function through training can lead to further degradation of a function
-disuse of the swallowing mechanism may diminish its cortical representation and poses a threat to functional recovery in the long term
is asperation alleviated by tube feeding? (aspiration pneumonia)
it is now recognized that aspiration is not alleviated by tube feeding
Use it or Lose it - nero plasticity - rehabilitation goal and method for oropharyngeal dysphagia life threatening aspirations and reasoning?
hypothesized that they should be offered systematic swallowing drills but without using a bolus.
The goal would be to improve their swallowing skill, albeit only on dry or saliva swallows. Intuitively, such activity — if it emphasizes multiple repetitions of more immediate, stronger swallows — will help preserve cortical and subcortical representations and make the patient’s return to oral nutrition easier and faster.
define behavioural plasticity
behavioral plasticity, operationally defined as apparent change in task performance without clear evidence of associated neural systems alteration(s)
Use it and Improve it extends the Use it and lose it prinicpal, define the theory. What two systems are we trying to connect ultimately?
-with increased biological activity, future functioning is enhanced, especially if that activity involves skill training or what could be called target practice
-important: use a function with increasing competence, whether that competence is measured as efficiency or accuracy.
-simply swallowing will not necessarily improve swallowing by a person with dysphagia
trying to connect: discover which of these methods, in which patients, has maximum effects on both behavioral and neural plasticity.
give example/ explain how connecting a trained motor gain can trigger a nero response?
training with strenthening of oral motor accuracy seems to trigger the pharyngeal swallow which is a different pathway - neuro
training in other abilities can lead to an enhancement of function and the underlying neural mechanisms involved in that behavior
A testable hypothesis is when a normalized motor pattern accompanies a stronger oral phase; the volitional oral events are recognized more readily and therefore trigger the pharyngeal swallow response more efficiently. Such events may be a function of neural plastic adaptation.
repetition matters (neuro plasticity)- consistent practice allows 2 improvements
intensity has two affects?
-From a clinical perspective, findings suggest a source of evidence to support the need for consistent practice to acquire and maintain an improved swallow.
-there is a threshold of intensity required to elicit neural changes and also the possibility of excitotoxicity with too great a level of stimulation: training long does not necessarily imply training hard.
evidence suggests: that low-intensity treatment is unlikely to support maximum behavioral or neural plasticity.
Salience - nero plasticity
how does this apply to learning?
To be aware of things that are more important or striking to that person
neural plasticity is best induced when the movement is purposeful and related to the behavior being trained
Learning has been shown to be as related to the behavioral importance of the stimulus as it is to the frequency of occurrence, so a stimulus that is relevant to the organism
Age matters - neural plasticity
Younger nervous systems are more responsive to training and adaptive neural plasticity than older ones - neural plasticity does occur over the lifespan, although outcomes are demonstrated to decrease with age
define interference in neuro plasticity, the result, and an example.
Interference refers to “the ability of plasticity within a given neural circuitry to
impede the induction of new, or expression of existing, plasticity within that same circuitry”
The result is that learning or skill acquisition or reacquisition may be hampered.
example: literature suggesting that compensatory activities such as using the unimpaired limb following damage to a limb on the other side of the body may cause nervous system changes; in fact, such changes impede recovery in the affected limb and may impact subsequent rehabilitation of the impaired function
The oropharyngeal swallow has been represented as a complex function comprised of how many physiologic components?
14 physiologic components
The primary role of swallowing rehabilitation is?
swallowing requires coordinated activity of both?
-to effect change (improved strength, duration, and timing of movement)
-requires the coordinated activity of neural mechanisms distributed across both cranial and spinal nerve systems
The neural networks are referred to as central pattern generators (CPGs) in relation to dysphagia? how is the network organized and what does it allow?
-Similar to breathing, chewing, and walking, interneurons have been identified in the brain stem that can generate a basic swallowing pattern in the absence of ascending (sensory) or descending (cortical) inputs.
-flexibly organized neural networks
-allows coordinated activity within the swallowing system but also the cross-system coordination with respiratory and laryngeal systems
Interventions - Sensory: what aspects can be modified? two areas change sensory imput?
All aspects of oropharyngeal swallowing have been found to be modifiable with varying sensory input.
-Bolus characteristics
-stimulation of structures with thermal, tactile, gustatory, and electrical stimulation
Interventions- Bolus: name 5 sensory changes regarding bolus
volume, viscosity, thermal, taste, tactile
Several aspects of oral and pharyngeal swallowing are altered with bolus volume, including: (6)
-timing and extent of structural movement,
-duration of laryngeal vestibule closure,
-anterior and superior hyo-laryngeal movement,
-upper esophageal sphincter(UES)opening,
-base of tongue to posterior pharyngeal wall approximation,
-respiration cessation during swallowing
Compensatory interventions are used in the treatment of dysphagia to compensate for? .They include? These treatment techniques exploit? The majority of these techniques seek to? in this way compensatory interventions are ______ with anticipated ______ effect.
When used alone what is not expected to occur?
-structural and physiologic deficits
-alterations in diet consistency or positioning
-retained abilities
-alter the circumstances of the swallow instead of the swallow patterns themselves
-behavioral / temporary
-not believed to modify neural plastic underpinnings as a treatment outcome
Motor exercises accomplished during swallows are used to?
Their use is predicated on the assumption that changes in what 3 things?
In response to specific exercises that increase: what 3 things?
What pathway are motor exercises using?
-reduce the deficiencies within the swallow pattern itself
-muscle strength, range of motion, and coordination
-the effort, duration, and force of muscle patterns.
-musculo-spinal pathways
This “motor with swallow” category of techniques centers on the principles of _______________ neural plasticity
what 3 areas of neuro plasticity support this?
what is the goal?
this may result in the preservation of ______ and the maintenance of allocated ________ representation
-experience-dependent neural plasticity
-Use It or Lose It, Use It and Improve It, and Repetition Matters.
-goal of increasing the success of the swallow itself
synapses
cortical
The “motor without swallow” includes exercises to?
Non-swallowing exercising of the oral, pharyngeal, laryngeal, and re-spiratory (i.e., swallowing) musculature holds a great deal of promise in treating individuals with severe dysphagia, why?
-improve range of motion and strengthening (lingual, velar, pharyngeal, laryngeal [non-speech and speech], and respiratory)
-allows patients to progress through a training regimen safely without limitations that may be imposed if the swallowing of boluses is necessary for functional gain
-
“motor without swallow”
evidence exists that some of the swallowing musculature has a propensity for increasing?
and this translates into?
Behavioral plasticity of swallowing has been demonstrated from three different non-swallowing exercising techniques:
muscle strength/tone with non-swallow exercising
improved function (behavioural plasticity)
lingual exercising, head lifting, and LSVT ( LVST = Lee Silverman Voice Treatment)
Lingual Exercise showed an increase in what? it is a _____strengthening exercise.
as a result, improvement in swallowing pressures of what occured? some showed improvement in _______ aswell.
non-swallowing
lingual strength increased
on liquid boluses occurred
speech
head lifting exercise
head-lifting exercises and experienced increased what physically? (Shaker et al., 1997). In addition
improved swallowing function was reported, with de-creased? and an ability to return to?
laryngeal anterior excursion and cross-sectional opening of the UES
post swallow aspiration
various levels of oral intake
InParkinson’s patients observed that 3 things decreased following completion of 1 month of LSVT?
what does LSVT stand for?
oral transit time, pharyngeal transit time, and vallecular residue
LVST = Lee Silverman Voice Treatment
motor exercises without swallow have been shown to increase? 3 things
range of motion and strength in those muscles used for swallowing, to improve the swallow itself, and to demonstrate associated behavioral plasticity.
compensatory treatment is a quick-fix, these immediately executable interventions have 3 notable negative things?
(e.g., postural adjustment)
ex postural adjustment
appear to have no long-lasting effects,
must be implemented for each swallow,
and may diminish the pleasure associated with dining
nero plasticity - what questions should the clinician ask to improve the clinician’s ability to effect significant and long-lasting improvement?
who to treat,
at what intensity,
how many repetitions,
when to initiate interventions in the course of the disease
