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SPCH3206 > Dysphagia Therapy > Flashcards

Dysphagia Therapy Flashcards

1
Q

List why patient education is important, and some resources that could be used

A

Treatment begins with education
Family and patient
Patient needs to understand:
- What should be happening
- What’s not happening in their swallow
- Why this is an issue
-What they can do to help change this situation
Paper resources, diagrams, apps, YouTube

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2
Q

Define ‘compensation’

A

Immediate but likely transient effects

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3
Q

List 6 ways we can compensate

A
  1. posture
  2. delivery
  3. sensory technique
  4. bolus control and clearance
  5. bolus modifications
  6. other
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4
Q

Define rehabilitation, and list 2 ways in which we can rehabilitate

A

Permanent change to physiology

  1. Voluntary control/swallow manoeuvres
  2. Exercise/stimulation programs
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5
Q

List some examples of voluntary control/swallow manoeuvres (rehab)

A
  • controlled swallow
  • effortful swallow
  • supraglottic swallow
  • super supraglottic swallow
  • Mendleson’s manoeuvre
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6
Q

List some examples of exercise/stimulation programs (rehab)

A
  • Masako manoeuvre
  • shaker (head lift)
  • orofacial exercises
  • vocal adduction
  • breathing exercises
  • pharyngeal strengthening exercises
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7
Q

List some examples of postural (compensatory) approaches

A
  • chin tuck
  • head rotation
  • head tilt
  • side lying
  • neck extension
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8
Q

Explain the compensatory approach of posture

A

Adopting specific posture/s for each swallow:
- change pharyngeal dimensions
- redirect bolus flow
- most anatomically optimal position

All patients should be positioned to optimise swallowing:
- sit upright (at least 45 degrees)
- head looking front and centre
- slightly downward chin tuck
- remain upright post swallow trial

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9
Q

Explain rationale, instructions and population of chin tuck (postural compensatory approach)

A
  • moves epiglottis forward and narrows entrance to larynx
  • improved protective closure of larynx under base of tongue
  • reduces anterior-posterior dimensions of the pharynx, bringing base of tongue and posterior pharyngeal wall closer

Instruct the patient to tuck chin to chest and look at knees during swallow

Useful for populations with:
- delayed onset pharyngeal swallow in isolation
- reduced posterior movement of tongue
- premature spill

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10
Q

Explain rationale, instructions and population of head turn (postural compensatory approach)

A
  • Closes weaker pharyngeal side
  • directs bolus down stronger side
  • aids UES opening due to mechanical action

Instruct patient to keep their torso forward, turn head to weak side to full extent

Population:
- unilateral weakness

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11
Q

Explain rationale, instructions and population of head tilt (postural compensatory approach)

A
  • tilting head to stronger side may direct bolus down stronger side

Instruct patient to tilt head toward stronger, non damaged side during oral intake

Population:
- impaired oral motor control/residue
- unilateral pharyngeal weakness/residue
- asymmetric altered anatomy

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12
Q

Explain rationale, instructions and population of 60 degree angle/positioning (postural compensatory approach)

A
  • uses gravity to keep bolus on posterior wall of pharynx and away from open airway

Instruct patient to sit at 60 degree angle recline

Population:
- small residue due to poor UES opening
- must check prior to VFSS
- has good oral control

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13
Q

Explain rationale, instructions and population of head extension (postural compensatory approach)

A
  • uses gravity to move bolus into the pharynx
  • inhibits UES opening

Instruct patient: extend neck with back erect when preparing to transfer bolus out of the oral cavity into pharynx

Population:
- excellent cognition only!
- profound oral phase impairment who have good airway protection
- residue
- bolus transfer problems

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14
Q

Explain the differences between self-feed vs. fed (as a delivery technique)

Make mention also of i) rate of intake, and ii) oral intake methods

A

Being fed:
- necessary for some patients due to cognition, positioning, physical capacity
- ‘feeding assistant’ needs to be aware of size of mouthfuls, speed of presentation, ensuring mouth is clear before adding more
- can be difficult and add to feeding issues if not done well

Self-feeding:
- can assist orientation and awareness
- facilitate improved oral stage

Rate of intake:
- assists poor oral control
- need to be fed if impulsive
- can slow down rate with smaller spoon, smaller cup or putting down in between bites

Oral intake:
- cup
- straw
- syringe
- fork vs. spoon

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15
Q

List some examples of sensory techniques (compensatory)

A
  • thermotactile stimulation/orofacial brushing/icing
  • cold, carbonated, sour bolus
  • manipulating texture of bolus
  • manipulating size of bolus
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16
Q

Explain rationale, instructions and population of using thermotactile stimulation/orofacial brushing/icing (sensory compensatory technique)

A
  • enhances sensory awareness
  • bolus awareness
  • helps trigger swallow
  • speed up total duration of swallow
  • reduce hypersensitivity

Instruction:
- SLP uses small ice-cold mirror/cold metal spoon to repeatedly stroke and stimulate the facial muscles and oral structures/base of anterior faucal arch

Population:
- delayed swallow trigger
- saliva management issues
- non-oral
- need to increase sensory awareness
- hypersensitive/gagging/bite reflex

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17
Q

Explain rationale, instructions and population of using cold, carbonated or sour bolus (sensory compensatory technique)

A
  • enhances sensory awareness
  • trigger swallow
  • speed up total swallow duration

Instruction:
- introduce cold/carbonated/sour bolus every few swallows

Population:
- slow oral transit
- delayed swallow trigger

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18
Q

Explain rationale, instructions and population of manipulating bolus texture (sensory compensatory technique)

A
  • enhances sensory awareness
  • trigger swallow
  • speed up total swallow duration

Instruction:
- heighten texture of bolus

Population:
- slow oral transit
- delayed swallow trigger

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19
Q

Explain rationale, instructions and population of manipulating size of bolus (sensory compensatory technique)

A
  • altering volume in mouth
  • increased sensory feedback
  • reduced size assists in ability to control bolus

Instruction:
- work out optimal bolus size
- ensure patient control of bolus

Population:
- slow oral transit
- delayed swallow trigger
- reduced oral sensation (larger bolus)
- reduced oral control (smaller bolus)

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20
Q

List some examples of bolus control and clearance techniques

A
  • pharyngeal expectoration
  • lingual sweep
  • double swallow
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21
Q

Provide a rationale and instruction for using pharyngeal expectoration

A
  • clearing out oropharynx residue post swallow
  • actively remove pharyngeal residue

Instruction:
- bring up secretions from back of throat
- truck drivers spit
- in time swallow secretions

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22
Q

Provide a rationale and instruction for using throat clear

A
  • clears larynx and hypopharynx of residue post swallow
  • exhaled air + construction assist to clear residue

Instruction:
- clear throat
- model

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23
Q

Provide a rationale and instruction for using cough

A
  • clears lung of aspiration and laryngeal airway
  • after penetrations
  • forceful exhalation removes residue from lung

Instruction:
- strong cough
- *model)

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24
Q

Describe how to do;
a) lingual sweep
b) second swallow
c) cyclic ingestion

A

a) use tongue (or finger) to clear residue from buccal, sublingual, intra-oral regions
b) after each swallow, patient has a dry swallow to clear residue
c) liquid bolus follows solid bolus to facilitate pharyngeal residue (1:1 ratio)

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25
Q

List some helpful strategies to implement a) during and b) after the meal (bolus control and clearance techniques)

A

a) During:
- discourage laughing and talking while eating
- go slowly
- give small mouthfuls
- check for residue between mouthfuls
- make sure each mouthful has been swallowed before giving next

b) After:
- ensure all residue is clear
- keep upright for 20-30 minutes

26
Q

List some examples of bolus modifications

A
  • consistency
  • altering the viscosity and cohesion properties of the bolus to facilitate bolus control
27
Q

Why use thickened fluids as a bolus modification compensatory technique?

A
  • slows down rate of bolus
  • increases cohesion of bolus
  • may reduce aspiration but not always
  • can be harder for some patients
28
Q

Why use modified consistency of foods as a compensatory technique? Make mention of some important considerations

A
  • reduces amount of effort to chew and process bolus
  • good for patients with reduced ability or fatigue issues
  • increases cohesion of bolus/parts that may enter airway before swallow

Consider:
- effort of chewing
- transitional food/foods that change over time (i.e. icecream)
- mixed texture (i.e. cereal)
- stringy texture
- floppy texture
- small/hard

29
Q

Define IDDSI

A

International Dysphagia Diet Standardisations Initiative

  • standardised terminology and definitions to describe texture modified foods and thickened liquids
  • has 8 levels (0-7) identified by numbers, text labels and colour codes
30
Q

What is the ‘common zone’ of food and liquid descriptors in the IDDSI figure?

A

Pureed -> 4 -> extremely thick
Liquidised -> 3 -> moderately thick

31
Q

Number the drink and food classifications from IDDSI

A
  1. thin
  2. slightly thick
  3. mildly thick
  4. moderately thick (liquidised)
  5. extremely thick (pureed)
  6. minced and moist
  7. soft and bite-sized
  8. easy to chew, and regular
32
Q

What is a) the description and b) physiological rationale of a ‘thin fluid’ as classified in IDDSI?

A

a) Description - 0
- flows like water
- fast flow
- can drink through any type of teat/nipple or straw appropriate for age and skills

b) Physiological rationale
- functional ability to safely manage liquids of all types

33
Q

What is a) the description and b) physiological rationale of a ‘slightly thick fluid’ as classified in IDDSI?

A

a) Description: 1
- thicker than water
- more effort to drink than liquid
- flows through straw, syringe, nipple (medium flow teat)
- similar thickness of most AR infant formulas

Physiological rationale:
- often used in paediatric population to reduce speed of flow
- adult population when drinks flow too fast to be controlled safely

34
Q

What is a) the description and b) physiological rationale of a ‘mildly thick fluid’ as classified in IDDSI?

A

a) Description - 2
- flows off a spoon
- sippable, pours quickly off spoon but slower than drinks
- mild effort required through straw

Physiological rationale:
- flow at slower rate
- suitable if tongue control is slightly reduced

34
Q

What is a) the description and b) physiological rationale of a ‘moderately thick fluid’ as classified in IDDSI?

A

a) Description - 3
- can be drunk from cup
- moderate effort through straw
- will not retain shape
- can be eaten with a spoon
- no chewing required, can be swallowed directly
- no lumps or fibres

Physiological rationale:
- insufficient tongue control
- allows more time for oral control
- needs tongue propulsion
- use if pain on swallow

34
Q

What is a) the description and b) physiological rationale of a ‘liquidised food’ as classified in IDDSI?

A

a) Description - 3
- can be drunk from cup
- moderate effort through straw
- will not retain shape
- too thick for straw
- can be eaten with spoon
- no chewing required, can be swallowed directly
- no lumps or fibres

Physiological rationale:
- insufficient tongue control
- allows more time for oral control
- needs tongue propulsion
- use if pain on swallow

35
Q

What is a) the description and b) physiological rationale of a ‘extremely thick fluid/food’ as classified in IDDSI?

A

a) Description - 4
- usually eaten with spoon or fork
- cannot be had in a cup
- too thick for straw
- no chewing required
- can be piped or layered and retain shape
- not sticky or lumpy
- liquid must not separate from solid

Physiological rationale:
- reduced tongue control
- moderate propulsion
- no biting or chewing
- use when pain on swallow or chewing
- use with dental issues

36
Q

What is a) the description and b) physiological rationale of a ‘pureed food’ as classified in IDDSI?

A

a) Description - 4
- usually eaten with spoon or fork
- cannot be had in a cup
- too thick for straw
- no chewing required
- can be piped or layered and retain shape
- not sticky or lumpy
- liquid must not separate from solid

Physiological rationale:
- reduced tongue control
- moderate propulsion
- no biting or chewing
- use when pain on swallow or chewing
- use with dental issues

37
Q

What is a) the description and b) physiological rationale of a ‘minced and moist food’ as classified in IDDSI?

A

a) Description - 5
- can be eaten with spoon, fork or chopsticks
- can be scooped into shape
- soft and moist - no separate thin liquid
- small lumps visible
- lumps can be squashed with tongue

Physiological rationale:
- biting not required
- tongue force can separate texture
- more propulsion required
- use when pain/fatigue on chewing
- use with dental issue

38
Q

What is a) the description and b) physiological rationale of a ‘easy to chew food’ as classified in IDDSI?

A

a) Description - 7
- normal, everyday foods or soft-tender textures
- developmentally and age appropriate
- any method may be used to eat these foods
- sample size not restricted
- may include dual consistency that is safe at level 0, if not - increase
- does not include: crumbly bits, pips, seeds, husks, bones, etc.

Physiological rationale:
- requires ability to soft bite foods, chew, orally process foods for ling enough to form cohesive bolus that is swallow ready
- does not require teeth
- use for difficulty chewing
- could be risk of choking hazard
- progression food
- person must have supervision

39
Q

What is a) the description and b) physiological rationale of a ‘regular food’ as classified in IDDSI?

A

a) Description - 7 - NO RESTRICTION
- range of sizes
- can include tough, fibrous, stringy, dry, crispy
- can include seeds, pips, husks, bones
- can include dual consistency

Physiological rationale:
- ability to bite hard or soft foods long enough that they form a cohesive bolus that is swallow ready
- can chew all foods without fatiguing
- can remove bone or gristle from mouth cannot be swallowed safely

40
Q
A
40
Q

List some ways to determine fluid and food consistency

A

Fluid:
- IDDSI Flow Test
Food:
- Fork Drip Test
- Spoon Tilt Test
- Fork Pressure Test and Spoon Pressure Test
- (Chopstick Test and Finger Test)
- Transitional Food Texture Assessment

41
Q

What are some ongoing issues surrounding fluids?

A
  • intake amount
  • illness/medical state
  • dysphagia + dependence on feeding
  • lack of choice, issues with taste, etc.
42
Q

What are some ongoing issues surrounding foods?

A

Appeal - unappetising, bland, palatability, mouth-feel
Emotional reaction: cruel, restricted choice

  • portion size/finger food
  • using smaller bite-sized meal portions to encourage patients
  • encourage intake and maintain nutrition
43
Q

What are the rehabilitation swallow (direct or indirect) and non swallow activities?

A

Swallow: Direct – involving the use / manipulation of food to reinforce appropriate behaviours and motor control

Swallow: Indirect – work indirectly on the swallowing mechanism without using food, but can use saliva swallows. Can be used for all patients but particularly useful for those patients unsafe on any oral intake

Non-swallow: e.g. oromotor exercises, strengthening, improving ROM, enhancing respiratory support/cough strength

44
Q

Provide a rationale, instruction and the appropriate population for the effortful swallow technique (direct swallowing)

A

Designed to increase posterior motion of the tongue base during the pharyngeal swallow and thereby improve bolus clearance from valleculae, facilitates greater oral and pharyngeal pressures

Instruct:
As you swallow, squeeze hard with all your muscles (should get increased lingual effort) Sometimes helps with imagery/visualisation – “swallowing an elephant”, “a whole apple” etc….

Population:
- problems with base of tongue and bolus clearance

45
Q

Provide a rationale, instruction and the appropriate population for the controlled swallow technique (direct swallowing)

A

Provides conscious control of bolus in mouth and then volitional airway protection and conscious initiation of the swallow

Instruction:
- First, teach the patient to control bolus in mouth.
- Then train commencing swallow at will/on command.
- Then combine: bolus control, at beginning of posterior propulsion…then SWALLOW!

Population:
- any issues with bolus containment and initiation of swallow

46
Q

Provide a rationale, instruction and the appropriate population for the supraglottic swallow technique (direct swallowing)

A

Provides conscious, volitional airway protection (closes the airway at the true vocal folds before and during the swallow consciously)

Instruction:
Take a breath and hold it (nb) while swallowing bolus (Voluntary breath hold). Post swallow expel air forcefully with cough prior to inhalation

Population:
- inadequate airway protection particularly silent aspiration (e.g. delayed pharyngeal swallow; swallow-respiration coordination probs)

47
Q

Provide a rationale, instruction and the appropriate population for the super supraglottic swallow technique (direct swallowing)

A

Designed to close the airway entrance (not just true folds) before and during the swallow (different from supraglottic is the effort…). The bearing down helps to tilt arytenoids forward, close false vocal folds and true vocal folds

Instruction:
- Take a deep breath and hold it firmly/bear down while swallowing the bolus.
- After the swallow exhale forcefully or cough.
- To teach, break task into units: Hold breath while bearing down (3,5, 10 sec) then relax; hold breath while bearing down then exhale forcefully; hold breath while bearing down, swallow, exhale forcefully

Population:
- problems with airway protection (as for supraglottic swallow)

48
Q

Provide a rationale, instruction and the appropriate population for the Mendelsohn Maneuver swallow technique (direct swallowing)

A

Designed to increase the extent and duration of laryngeal elevation and thereby increase duration and width of cricopharyngeal opening

Instruction:
- Requires the most training / education……… “When you swallow feel larynx lift.
- This time when you swallow, try to keep larynx “UP” for several seconds before you let it relax”.
- To teach, break task into units: Become familiar with movement of larynx when swallowing. Then, try to hold larynx “up” for a few seconds during dry swallows. Then try bolus swallows. *****HARD to teach – need augmentative feedback often to assist eg., SEMG

Population:
- problems with airway protection and poor cricopharyngeal opening

49
Q

What are the indirect swallowing and non-swallowing exercises?

A

Not “swallowing” but working on the muscles / structures involved in swallowing. Building up the functional capacity:- agility, strength and endurance.

  • Shaker or “Head lift”
  • Opening jaw against resistance (emerging evidence…)
  • Masako technique
  • Dry gargle

Non-swallowing:
- Oromotor therapy tasks

50
Q

Provide a rationale, instruction and the appropriate population for the shaker/head lift technique (indirect swallowing)

A

The head lifting/tilting action helps to strengthen the suprahyoid muscles including the geniohyoid, thyrohyoid, and digastric muscles. Targets stronger floor of mouth & improved anterior hyoid movement which enhances cricopharyngeal opening

Instruction:
- Original exercise: done lying down & lifting head up to on chest
- Can be done in modified positions (sitting upright using hand under chin or thumbs to jawbone, soft ball under chin……)
- Involves isometric & isokinetic exercises
- Isometric: three consecutive head lifts held for 60 seconds, with a 60-second rest period between each.
- Isokinetic: 30 consecutive head lifts (without holding). Keep velocity of lifts constant; slower velocity produces greater strength gains

Population:
- Addressing poor anterior hyoid movement and resultant poor UES opening

51
Q

Provide a rationale, instruction and the appropriate population for the opening jaw against resistance technique (indirect swallowing)

A

Different protocols are being suggested in some papers…..some use resistance bands
(eg elastic Therabands) wrapped around head and under jaw – increasing the effort required to open the jaw.
- Other place a product (pillow, ball, Therabite device) under the jaw and the person has to open the jaw against this resistance

Instruction:
- Protocols vary
- Patients open their jaw maximally and maintain the position for 10 s; then, they rested for 10 s.
- This is repeated for 20 min, 3 days per week for 6-8 weeks

Population:
- Improving strength of the suprahyoid muscles and help tongue pressures (evidence to date largely in healthy subjects…)

52
Q

Provide a rationale, instruction and the appropriate population for the Masako technique (indirect swallowing)

A

Limiting movement of the tongue forces increased posterior pharyngeal wall activity during swallow

Instruction:
-Gently hold tongue tip between front teeth then do a dry swallow.
- For those with dentures/no teeth - hold tongue anteriorly with a swab to “immobilize” it.
- Remember to allow saliva to return between trials / allow small sips of fluids

Population:
- Impaired BOT to PPW contact

53
Q

Provide a rationale, instruction and the appropriate population for the dry gargle technique (indirect swallowing)

A

Action causes increased adduction of pharyngeal walls

Instruction:
- NOT phonation–use dry pharyngeal huff/hiss

Population:
Improving pharyngeal wall contraction

54
Q

Explain the non-swallow (Oro-motor) therapy tasks

A

Improved jaw strength and ROM:
- Jaw closing/ opening against resistance eg use of a theraband held under jaw to open against resistance
- Active chewing (if unable to safely swallow chew on substances wrapped in gauze on a string
- Reduced jaw opening: Therabite (see photo) used to passively stretch the jaw
Buccal Tension:
- Ooo-ee exercise

Lip closure:
- ROM
- Closure against resistance

Improve Lingual manipulation:
- Control of solid bolus (gauze on string) movement, moving end of piece of liquorice held by clinician, a lifesaver on string

Improve Tongue strength:
- Push tongue against tongue depressor or resistance device (eg., IOPI device pictured)
- Working on improving endurance and bolus control/propulsion/clearance
- Practice Maximum effort compressions, then max lingual effort in dry swallows

Laryngeal therapy tasks:

Laryngeal Adduction exercises
- Closing true vocal folds – same as for vocal fold palsy:- bearing down, pushing, pulling (against base of chair, using a theraband)
- Closing laryngeal airway – more effortful to involve arytenoid movement

Laryngeal elevation exercises:
- Pitch range / pitch glides:- slide up scale to high pitch and back down to low
- Component of Mendelsohn – elevate and hold laryngeal elevation

Velopharyngeal elevation / closure
- Speech drills targeting nasal/non-nasal sounds to exercise velar elevation and closure of nasal cavity
- Some have trialled doing speech drills whist using Continuous Positive Airway Pressure (CPAP). So the airflow creates a form of resistance to elevate the palate against.
- Some evidence for efficacy for treating hypernasality…minimal evidence for swallowing

Respiratory Training:
- Traditionally…With physios – respiratory trainers (inhalation!). EMST is EXPIRATORY…. Improved respiratory capacity and swallow
- Now…EMST 150 Emerging evidence base
- Tx (5 d/wk; 25 breaths/day; for 4-5 wks) Strengthening of expiratory muscles
- Enhanced max exp pressures, expiratory force – improved cough Increases Suprahyoid Muscle Activity

55
Q

Why is biofeedback important in therapy and what ways can we provide biofeedback?

A
  • enhances learning

Main means of biofeedback are:
- tactile
- visual (VFSS, FEES, SEMG)

56
Q

What does biofeedback look like during FEES?

A
  • capacity to module swallow behaviour with real-time feedback
  • direct visualisation, allowing live modification of behaviour
  • no issue with radiation: can trial multiple consistencies
57
Q

What does biofeedback look like during SEMG?

A
  • records muscle activity under the surface electrode
  • provides patients with feedback on strength and nature of movement
  • usually position electrode sub-mentally to record lingual/base of tongue or on natural neck for laryngeal elevation
  • ‘gross’ information as usually recording multiple muscle activity
  • feedback for non-swallow and swallow manoeuvres
  • strength and skill based training
58
Q

What are some other rehabilitation techniques?

A
  • Oral cares
  • Oral pain management
  • Prosthetic devices
  • Botox
  • Dilations
  • Saliva production
  • Flavour enhancers, after chemosenses of food or increase chewing action
59
Q

What are the emergency procedures to be aware of?

A

Aspiration:
- encourage coughing
- keep patient upright
- if concerned it was a large amount, inform medical staff and nursing and ensure patient is monitored for next day
- possibly also advise physio if involved with patient
- if the patient has a tracheostomy - nursing will suction and remove aspirated contents

Choking:
- brings medical and nursing assistance
- first aid training (alternate back slaps with lateral chest thrusts)

SPCH3206 (12 decks)

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