Dysphagia Treatments Part 1 Flashcards
Dysphagia Treatment Types (9):
1) Diet modification
2) Positional Strategies
3) Oral sensory Techniques
4) Maneuver
5) Exercise
6) Prosthetic*
7) Surgery*
8) Experimental
9) Other
Diet Modification (compensatory) may include modification to (6):
1) volume / Bolus volume (size)
2) viscosity / Bolus viscosity (consistency)
3) texture
4) temperature
5) Taste
6) Possible NPO diet - NG tube, G tube, PEG, J tube, etc.
Positional Changes Types(5):
1) posture (Sitting upright at 90°, Lying on side)
2) chin tuck
3) head rotation
4) head tilt
5) Head back
Oral sensory therapy types:
tactile/taste/thermal-tactile stimulation
Maneuver Types (4)
1) Supraglottic Swallow
2) Super-supraglottic Swallow
3) Mendelsohn Maneuver
4) Effortful Swallow
Exercise Types (3):
1) Shaker
2) Masako
3) Oral muscle strengthening
Prosthetic Types (2):
1) Palatal lift
2) obturator
Surgery Types (5):
1) CP myotomy –> for CP achalasia
2) Diverticulectomy –> for diverticulitis
3) Dilation –> for an esophageal stricture
4) Palatopexy –> surgery of the palate
5) VF medialization –> likely due to VF paralysis
Experimental Therapy Types (4):
1) Neuromuscular electrical stimulation-NMES: “VitalStim”
2) Deep pharyngeal neuromuscular stimulation-DPNS
3) myofascial release-MFR
4) Botox
Other Therapy Techniques (5):
1) multiple swallows
2) food presentation
3) liquid wash
4) adduction techniques
5) EMST
Compensatory Techniques vs. Therapy Techniques:
Compensatory Techniques –> (4)
1) UNDER CONTROL OF CAREGIVER
2) DO NOT Δ MOTOR CONTROL OF SWALLOW
3) DESIGNED TO ELIMINATE SYMPTOMS
4) THERAPEUTIC BECAUSE Δ TIMING OF SWALLOW
Compensatory vs. Therapy Techniques:
Therapy Techniques –> (3)
1) Δ SWALLOW ANATOMY/PHYSIOLOGY
2) DESIGNED TO ↑ROM, CONTROL, Coordination, STRENGTH
3) Categorized: DIRECT OR INDIRECT
Compensatory Techniques can include (5):
1) Diet Modification
2) Positional Strategies
3) Oral Sensory Techniques
4) Prosthetics
5) Other (multiple swallows, liquid wash)
Diet Modification should be use as a ______ (6)
- “Last resort”
- If other compensatory strategies or therapies fail
- If too cognitively impaired
- If a “building block”
- Neurom. control/strength
- ROM ex’s
- If not possible to rehabilitate them (except if they are end of life–>consider quality of life)
Longterm goal: to get back to a regular diet after treatment
Example of liquid thickener:
“Thick it”
Diet Consistencies:
Liquids
- Thin (water, tea, coffee, milkshake)
- Nectar (V8, nectar fruit juice)
- Honey (thickest liquid, honey)
Solids
- Pudding (thick puree)
- Puree (thin e.g. apple sauce)
- Mechanical soft (scrabbled eggs)
- Chopped (corned beef hash)
- Regular (cookies, crackers, etc.)
Positional Changes (compensatory):
Sitting upright at 90°
Contributes to gravity to direct bolus down
Positional Changes (compensatory):
Lying on side
Eliminates gravitational effect on pharyngeal residue
Positional Changes (compensatory):
Chin tuck
chin to chest and swallow
1) Widens valleculae so it can hold more (to prevent penetration)
2) Narrows airway entrance & ↑ laryngeal elevation (bc of ↑ in pressure) & vf closure
3) Pushes tongue base backward toward pharyngeal wall
4) Puts epiglottis in a more protective position
Positional Changes (compensatory):
Head rotation
Used for asymmetry
To weaker side: closes off damaged side & directs bolus down stronger side
Positional Changes (compensatory):
Head tilt
Used for asymmetry
Works with gravity
To stronger side: directs bolus down stronger side (by gravity)
Positional Changes (compensatory):
Head back
Uses gravity to clear oral cavity
(similar to how some ppl take pills)
Not common but:
e.g. Useful for pts who had glossectomy (lost all or part of tongue)
Oral Sensory Descriptions (compensatory)
1) Downward pressure of spoon against tongue
2) Sour bolus (lemon juice)
3) Cold bolus
4) Bolus requiring chewing
5) Suck-swallow
* Measure by duration from command to swallow; oral transit time; pharyngeal delay time
Oral Sensory (compensatory):
Cold Bolus
Thermal-tactile stimulation
- Vertically rub anterior faucial arch 4-5 times with a cold laryngeal mirror or ice sticks
- Heightens oral awareness & triggers pharyngeal swallow
- used to address delayed pharyngeal
- widely used
Oral Sensory (compensatory):
Suck-swallow
1) Vertical tongue-jaw sucking with lips closed
2) Triggers pharyngeal swallow, draws saliva to back of mouth
* Not widely used
* Measure by duration from command to swallow; oral transit time; pharyngeal delay time
Prosthetics (compensatory): Reason for (2)
1) Congenital defects (disease, cleft lip/palate/mandible, bifid uvula)
2) Acquired defects (disease, trauma, burns)
Prosthetics (compensatory): What do they do
1) Improves speech intelligibility
2) improves oral prep/oral phase (↑ chewing, bolus formation & control, propulsive pressure, rate of swallow; ↓ tongue-palate distance)
Prosthetic (compensatory): Help With Dentition –> (3)
1) ↑ mastication
2) appearance
3) denture retention
Prosthetic (compensatory): Help with Palatal lowering (hard palate) –> (2)
1) ↓ volume of oral cavity
2) ↑ bolus transit & tongue-palate contact
Prosthetic (compensatory): Help with Soft Palate –> (4)
1) Restores contact b/n palate & posterior tongue to maintain bolus control & direct bolus
2) aid in mastication
3) avoid pharyngeal spillage (slow down transit)
4) avoid nasal regurgitation during swallow
Prosthetic (compensatory): Help with Lingual –> (4)
1) ↓ oral cavity size (↓ pooling)
2) ↑ tongue-soft palate contact (↑ bolus control)
3) ↑ eating
4) ↑ articulation & resonance
Therapy Techniques can include (4):
1) Maneuvers
2) Exercises
3) Other (EMST, adduction techniques)
4) Surgeries *
Maneuvers:
Effortful Swallow –> What does it do? (3)
1) Increases posterior tongue base mvmt/retraction &
2) Increase epiglottic mvmt &
3) ↓ pooling in valleculae
Maneuvers:
Effortful Swallow –> How to do it
1) Squeeze hard with all of your muscles
2) Swallow with “squeeze”
Maneuvers:
Supraglottic Swallow –> What does it do?
- Voluntary breath hold
- Closes vf’s BEFORE & during swallow (if having trouble with apneic period)
Maneuvers:
Super-supraglottic: What does it do?
- Effortful breath hold
- Tilts arytenoids forward, closing vf’s before & during swallow (quickens closure)
- hopefully quickening the pharyngeal phase back to 1sec
- false VF are coming together and are being used as a line of defense here (only time this happens)
- Valsalva maneuver: ↑ false vf closure & shortens swallow
Maneuvers:
Super-supraglottic: How do you do it?
1) Inhale & hold breath
2) Place bolus in position (at back of tongue)
3) Swallow while holding breath & “bear down”*
4) Cough after swallow before inhaling
5) Swallow again to clear material from cough
- Valsalva maneuver: ↑ false vf closure & shortens swallow
2 swallows, 1 cough
Maneuvers:
Supraglottic Swallow –> How do you do it?
1) Inhale & hold breath
2) Place bolus in position (at back of tongue)
3) Swallow while holding breath
4) Cough after swallow before inhaling
5) Swallow again to clear material expelled by cough
- More protective bc closing off VF before swallow and coughing to clear anything
- Can’t inhale again until done with 2nd swallowing after your cough
- only do if they have a strong cough
2 swallows, 1 cough
Maneuvers:
Mendelsohn –> What does it do? (3)
1) Prolonged laryngeal elevation opens &
2) prolongs UES to ↓ pyriform pooling
3) Normalizes/coordinates timing of pharyngeal swallow events
- good for pts w/CP dysfnc, pyriform pooling, and incoordination of swallow
- not good for pts w/decreased cognition
Maneuvers:
Mendelsohn –> How do you do it?
1) Push tongue hard up against roof of mouth
2) Several dry swallows while feeling thyroid lift
3) Hold thyroid up for several seconds
Exercises:
Shaker–> What does it do?
- Head lift exercise
- Increases UES opening & decreases hypopharyngeal intrabolus pressure
- good for CP dysfunction (if decreased CP opening)
Exercises:
Shaker –> How do you do it? (usually do a modified version of this)
1) Lay flat on your back on the floor or a bed
2) Without lifting your shoulders, hold your head off the floor & look at your feet for 1 minute
3) Relax your head back down for a 1 minute break
4) Repeat sequence 2 more times
5) Raise your head 30 more times & look at your toes (don’t sustain these head lifts)
6) Repeat entire exercise 3 times per day
* just aiming at the CP opening
Exercises:
Masako –> What does it do? (3)
- Anterior posturing of the tongue
- Strengthens pharyngeal constrictors
- Done only with dry swallows
(not safe to do with a bolus) - strengthens mostly the superior pharyngeal constrictors, not so much the middle and inferior constrictors
- number depends on pt. Maybe start with 5-10
Exercises:
Oral motor
1) ROM
2) Resistance
3) Bolus maintenance:prep/manipulation/propulsion
Exercises:
Oral Motor –>Bolus maintenance: prep/manipulation/prolulsion (3)
1) Lip seal (obicularis oris)
2) Jaw strengthening
3) Tongue strengthening (elevation/retraction/protrusion/lateral)
*widely used for oral dysphagias
Experimental Therapies:
Deep Pharyngeal Neuromuscular Stimulation (DPNS) (4)
1) Designed to treat neuromuscular weakness or incoordination
2) Frozen lemon ice stick applied to 9 sites in mouth & throat
- Bitter taste buds (tongue base/back)
- Soft palate
- Superior & medial pharyngeal constrictors
3) Designed to activate muscles
4) Repeated application attempts to strengthen neurom. signals & increase m. strength
Experimental Therapies:
Neuromuscular Electrical Stimulation
“VitalStim” “E-Swallow” “Ampcare” “Guardian”
NMES) (2
1) Surface electrodes applied over swallowing muscles
2) Stimulation attempts to facilitate motor mvmt (via neurom. transmissions) and strengthen muscles for swallow
* SLPs don’t know how to do electrical stimulation
Experimental Therapies:
Myofascial Release (3)
1) Manual technique
2) Palpation with joint and soft tissue mobilization/ release of lips, tongue, face, jaw, neck
3) Attempts to loosen tight muscles & fascial adhesions, improve area circulation
Fascials are all connected where muscles are not. Tight fascials in one area can affect/cause problems in another area.
Experimental Therapies:
Botox (2)
1) Motility disorders
2) CP hypertonicity/dysfunction/achalasia (if the CP won’t relax, if it is spastic)
3) Temporary
Other Therapy Strategies:
Food Presentation (feeding)
1) Tray positioning
2) “head on” feeding - important when someone else is feeding pt
3) adaptable utensils (thick, loop, etc. handles)
4) speed
Other Therapy Strategies:
Multiple Swallows
to clear
Other Therapy Strategies:
Solid followed by liquid
liquid wash
to clear
Other Therapy Strategies:
Adduction techniques (↑ laryngeal adduction) (5)
1) Cough
2) Throat clear
3) LSVT/increased loudness
4) Hard glottal attack
5) Sustained phonation
Other Therapy Strategies:
Expiratory Muscle Strength Training (EMST) (2)
1) ↑ cough strength
2) resp. coordination
3) ↑ VP closure
CP myotomy (surgery)
–> for CP achalasia
CP is cut
Good:
muscle no longer tonic
stuff can get through
Bad:
no longer elastic
no longer keeps air out
no longer keeps out back flow
Another option = Botox
Dilation (surgery)
–> for a stricture in the esophagus
- done under “twilight”
- Common in pt who had ration and/or with reflux
- can be done when you get an upper endoscopy
VF medialization (surgery)
–> likely due to VF paralysis
2 Types:
Augmentation (quick fix-injection)
Thyroplasty (permanent-silicone implant))
Good side effect of LSVT:
Better articulationI
Why is “Ampcare” - NMES better than all other NMES?
BC dr. c learned about it.
only has 1 channel with 2 electrodes on the suprahyoids
Small electrodes
What’s up with “Guardian” NMES?
website sucks
no efficacy data
VitalStim + NMES and Dr. C’s dissertation:
e-stim on normal swallowers with different bolus sizes, intensity levels
swallowing muscles are type 2: fast, small twitch muscles that don’t have good endurance
Dr. C applied electrodes to thyrohyoids and other outside muscles
Found an increase of penetration when VitalStim was on
Found no difference between hyoid movement at 100% level and 75% level
