HC5 Treatment by SLP - compensation Flashcards
What is compensation? How can we compensate?
- compensation = adjustments to compensate for dysfunction
- possibilities:
−Bolus manipulation
−Posture
−Facilitative maneuvers
−Facilitative devices
Explain: bolus manipulation
- change bolus characteristics to compensate for
- timing/coordination
- constriction/function impairments of chambers or valves
- manipulation of:
- properties that maximize sensory feedback (temperature, taste, size, texture, placement of the bolus)
- properties that affect bolus deformability and/or bolus flow
How can we change the bolus characteristics in order to maximize the sensory feedback?
- temperature
- no significant effects on transit times or durations with chilled bolus
- temperature does affect esophageal function
- taste: irritating taste = sour
- pro: produces stronger muscle contractions, more dry swallows and decreasing aspiration and penetration, shorter pharyngeal transit
- contra: potentially noxious in the nasal and tracheal airways and lungs => better/safer to introduce it to the lips or anterior oral cavity to stimulate production of saliva
- size: larger bolus = more sensory feedback
- texture:
- carbonation of liquids => more texture
- shorter pharyngeal transit time, reduces aspiration and residue
- bolus placement:
- when unilateral sensory deficit -> place bolus onthe intact side
- mastication or manipulating the bolus briefly in the oral cavity facilitates swallow inititiation
How can we change the bolus characteristics that affect bolus deformability and flow?
- viscosity:
- affects the flow
- continuum from water (least) to e.g. hard candy (most)
- liquid -> thick liquid -> pureed -> soft solid,….
- bolus size:
- affects the flow in response to gravity or compression
- placement of the bolus at a particular site on the tongue or in the oropharynx => avoiding patients weaknesses, take advantage of the anatomic and motoric strenghts
How does viscosity affect the bolus flow?
•Thin liquids
»Easily deformed, moves fast as a reaction to gravity/compression
»Passes through narrow sites
»May be aspirated
•Thicker liquids
»Moves more slowly -> requires less agility and control (timing, coordination problems)
»Requires more strength of constriction, more mastication and salivary mixing
»Less likely to pass through narrow sites
»May obstruct the airway
How is the viscosity of the bolus standardized?
- by IDDSI (International Dysphagia Diet Standardisation Initiative)
- liquids: 0 -> 4
- solids: 3 -> 7
- communication tool for caregivers
How does the bolus size affect the bolus flow and deformability?
- increased bolus size -> earlier airway protection and increased pharyngeal and UES pressures
- larger bolus:
- Compensate for incomplete oral or pharyngeal constriction
- Decreases work per meal
- Risky with impaired laryngeal function
- small bolus:
- Increases swallows/work per meal
- Less reliant on laryngeal function
Why may postural compensations helpful in swallowing?
- redirecting bolus that improves swallowing efficiency
- and/or improving protection of the airway
Which position strategies may be helpful?
- tilting upper body laterally or posteriorly
- tilting the head
- positions that impact pharyngeal chamber shape & function
Explain: tilting the upper body. When is it indicated?
- helps the bolus move downwards, away from the airway
- degree of tilt will impact bolus transit time and the size of bolus tolerated
- !! cervical spine remains in neutral relation to the thoracic spine and shoulders !!
- indicated when:
- bolus transit and sequence of pharyngeal swallow gestures are discoordinated
- pharyngeal constriction is incomplete
- pharyngeal transit is prolonged
Explain: tilting the head
− Laterally:
- site of bolus entry into the pharynx is affected (not the course in the pharynx)
- Usefull:
»Unilateral impairment of lingual movement, sensation or anatomy
»Impairment of epiglottic inversion
− Anteriorly (capital flexion) = chin-tuck
- Purposeful initiation of pharyngeal transit
- Less oral residue will fall into the pharynx after the swallow
- Usefull when impairment of linguapalatal valve
−Posteriorly (capital extension)
- Facilitates oral transit (gravity)
- ! requires adequate laryngeal airway protection
- often combined with head flexion
Explain: positions that impact pharyngeal chamber shape & function
−Capital flexion:
•Alters oropharyngeal space & facilitates airway protection
−Capital extension:
- Narrows pharynx, closes valleculae, impact mobility of hyoid and larynx
- May be beneficial for patients with poor oral capabilities but good airway protection
−Capital rotation:
- Usefull with asymmetric constriction or UES opening
- E.g. turning head towards weak side à bolus can follow strong side
What’s the difference between a compensatory strategy and a facilitative maneuver?
Strategy can to some extent be imposed on the swallower by a feeder; a maneuver requires:
- active participation
- good muscular kinesthetic
- good proprioceptive sense
- good movement control
- ability to understand, learn and apply the strategy
What are facilitative maneuvers?
Physiologic postures or gestures that improve swallowing efficiency or safety:
- effortful swallow
- supraglottic maneuver
- super supraglottic maneuvers
- Mendelsohn maneuver
- mandibular advancement or “jaw thrust”
Explain: effortful swallow
= increased effort, appropriate for patients with weak pharyngeal constriction
−“swallow as hard as you can, squeezing all your swallow muscles harder”
−Or “after you swallow, swallow once (or twice) more”
- reduced depth of penetration into the larynx, but no prevention
What’s the result of increased effort in normal subjects?
Increased durations of
- hyoid displacement
- PES opening
- laryngeal vestibule closures
Which maneuvers develop improved airway protection? How? For who?
- supraglottic maneuver
- super supraglottic maneuver
–> by voluntarily initiating airway closure before oral transit begins nad voluntarily reopen the airway after the swallow, releasing the breath audibly to blow any residual off the folds
–> for patients with delayed airway closure or whose supraglottic or glottic closure is incomplete
What is the Mendelsohn maneuver?
- goal: elevation of the larynx for a longer period => increase displacement and duration of hyoid movement => prolonged UES opening
- indications on videofluoroscopy (because no clinical assessment possible):
- slowed transit of bolus through pharynx and UES
- incomplete UES opening
- teaching is difficult: patient needs to identify maximal hyoid/larynx elevation and then prolongue this position during swallow
Explain the jaw thrust
= mandibular advancement
- indication: limited UES opening but good control of oral structures
- facilitates increased opening of UES
- jut the jaw forward at the same time swallow is initiated
Why would you use facilitative devices? What do they do? Give some examples
- they modify the delivery of the bolus into the swallowing tract
- or change the shape of the tract
- in a manner that positively impacts swallowing efficiency and/or safety
- e.g. syringe and catheter: allows placement and delivery of the bolus to particular areas, bypassing certain impaired structures
- e.g. modified spoons, different sizes and shapes of cups and bowls: may allow management of food previously prohibited
There are some other tools an SLP can use in treatment, which ones?
- biofeedback
- external stimulation
- prosthesis
- selective stimulation
- apps
Explain: biofeedback
Visual feedback:
− flexible fiberoptic nasopharyngoscope: gives info about vocal fold adduction, pharyngeal constriction,…
− Computerized displays of respiratory and nasal airflow activity: focus on coordination of respiration and swallowing
− Computer-assisted EMG biofeedback systems with surface electrodes: presence and amplitude of electrical activity of muscles close to the electrode
- IOPI can be used to develop tongue strength or endurance (normative data) and to strengthen specific tongue sites
- Thera-Bite: feedback regarding range of mandibular opening
What are the limitations of:
- EMG?
- IOPI?
- Thera-Bite?
- EMG:
- cannot target a particular muscle;
- increased effort in muscle does not signal a successful movement
- IOPI:
- only oral cavity
- some patients not at all sites in the oral cavity
- glossectomy
- Thera-Bite: no fb regarding strength or effort
Explain: external stimulation
− Transcutaneous electrical stimulation:
- Continuously or during swallow attempts
- Various frequency-intensity-duration patterns
− Muscle stimulation: more invasive but more potential, electrode placement into musles
−Neural stimulation: rTMS and tDCS
- Cortical stimulation technique
- Assuming intact brainstem and peripheral structures
- Combination with other techniques
Explain: prosthesis
= Devices that modify the shape of the swallowing tract and has a positive impact on swallowing efficiency and/or safety:
−Palatal prothesis:
- Reshaping oral cavity, e.g. with restricted lingual mass or motility
- Improvement of tongue-to-palate contact
−Palatal lift / obturator: closing velopharyngeal port, e.g. with nasal regurgitation because of structural or neuromuscular impairment of the vp port
−Mandibular prosthesis: in case of glossectomy
Explain: selective stimulation
= improved initiation and timing of swallowing events
- orientation, alerting the patient to the task: by reduction of distractions (noise, light,…), naming the patient, verbal cuing, instruction, visuel cues/demonstration
- sensory cueing by taste, smell, pacing the bolus (also heighten alertness)
- direct stimulation of oral-pharyngeal structures: tactile, electrical stim., thermal stim., chemical stim., cognitive stim.
