Lecture Slides (Pos. Changes / Manu., Tx, and Biofeedback) Flashcards
rationale behind postural changes and compensatory maneuvers
to improve airway protection; to improve oral and / or pharyngeal transit of food / liq
chin tuck
gravity facilitates reduced premature spillage; vallecular space widens to hold more food; improved BOT to PPW contact; decreased opening of the laryngeal additus / vestibule
head turn to left / to right
extrinsic pressure increases TVC closure; bolus passes through stronger side of pharynx; pulling cricoid further away from PPW reduces resting pressure of CP segment
when to use head turn
most often used when there is pyriform sinus and pharyngeal wall residue, particularly when residue collection is asymmetrical
what happens when you combine chin tuck and head turn
increased clearance and improved airway protection
effortful swallow
stronger tongue to palate contact and stronger BOT to PPW contact
how to supraglottic swallow
hold your breath prior to and during swallowing, then cough immediately after, then dry swallow; helps to protect against aspiration before the swallow (premature aspiration)
super supraglottic swallow
effortful swallow + supraglottic swallow
mendelson maneuver
prolong the duration of laryngeal elevation; results in increased duration / extent of laryngeal elevation and therefore increases duration / extent of CP opening
the “final decision,” based on beside eval, medical hx, and MBSS, includes:
NPO or PO (if PO, what kind of diet); aspiration precautions; compensatory postures / maneuvers; level of supervision needed during meals / feeding; whether or not to follow client; whether or not to repeat MBSS (and when); whether the pt is a candidate for dysphagia tx
final decision: NPO vs PO
assess occurrence of aspiration, how much, silent or not silent, effectiveness of cough; assess postures / maneuvers that help to reduce aspiration and / or improve swallowing
an MBSS report contains the following sections:
medical hx; diet hx; consistencies given during eval; oral stage observations; pharyngeal stage observations; aspiration type; impression statement; prognosis; diet / precautions / comp starts recommendations; tx and / or follow up goals
dysphagia tx is divided into
medical treatments and behavioral treatments
dysphagia medical treatments
includes prescription medications or invasive surgeries
dysphagia behavioral treatments
includes diet changes, postures / maneuvers, oral-facial exercises (relevant to swallowing), and stimulation-biofeedback
dysphagia behavioral treatments using food
indirect : without food :: direct : with food
oral phase treatment: bolus maintenance / lip seal; sx: drooling
tx: alternate puckering / spreading lips with and w/o resistance, opening mouth wide and then puckering slowly, pressing lips tightly together for a few seconds
oral phase treatment: bolus maintenance / control; sx: poor mastication / formation of bolus, maintenance of bolus, posterior bolus propulsion, premature spillage, oral residue
tx: to increase tongue strength, ROM, and coordination
oral phase treatment: bolus maintenance / control; tx: to increase tongue strength, ROM, and coordination
tongue lateralization with and w/o resistance; tongue tip elevation / deelevation into the anterior sulci / buccal sulci; use body of tongue to press a tongue depressor wrapped in gauze against the hard palate; manipulation of a button tied to a string throughout oral cavity
oral sensation tx
there is no definitive evidence of long term improvements in therapies directed at improving oral sensation
stimulation of the oral cavity with ___ may effect an improvement for the next swallow
sour, cold substance
if food tends to collect in one of the sulci, ___ can be used
external digital pressure: using your hands or fingers in the mouth to remove food
posterior bolus propulsion; sx: tongue pumping with premature spillage
tx: instruct pt to consciously try and reduce pumping action and initiate a hard, deliberate post tongue movement; straw use; sEMG biofeedback
straw usage is not a ___, it’s a ___
treatment; compensation
straw usage
places the bolus more posteriorly into the oral cavity and circumvents the tongue behaviors
what do you do if straw usage (placing the bolus more posteriorly) causes even more premature spillage
stop using straws
delayed pharyngeal swallow; sx: pooling of food / lie into hypo pharynx before the swallow
tx: presenting cold-sour boluses (more sensory input, less delay), stroking faucial arches with cold laryngeal mirrors (subsequent swallows less delayed)
delayed pharyngeal swallow tx:
chin tuck widens the vallecular space; allows more food / liquid to be held safely until swallow is triggered
tx of pharyngeal phase characterized by vellecular residue
dx: BOT weakness; tx: effortful swallow, chin tuck, masako maneuver (holding tongue tip gently between front teeth while swallowing)
tx of pharyngeal phase characterized by weak pharyngeal contraction; sx: PPW residue and pyriform sinus residue
tx: effortful swallow, masako maneuver (strengthens superior constrictor), sEMG biofeedback, head turn to the weak side
if there’s a lot of residue in the valeculae, it is likely a ___ issue
BOT
if residue is dispersed in the pharynx and pharyngeal wall, it is likely a ___ issue
pharyngeal constrictor
masako maneuver may strengthen ___
superior constriction
what is the downside of FEES
we don’t see the oral stage; we don’t see the swallow (only see what’s immediately before and after the swallow)
___ is not a treatment
biofeedback: it is a way of showing someone their performance (a more enhanced feedback to the pt); compare to effortful swallow, which is an actual treatment
a form of advanced feedback; is not a diagnostic tool
biofeedback
tx of pharyngeal phase characterized by laryngeal penetration / aspiration
tx: chin tuck, effortful swallow, repeat dry swallow, head turn posture, thermal-gustatory or thermal-tactilestim during meals, supraglottic and super supraglottic swallow
tx of cricopharyngeal dysfunction
tx: botox injections, surgical anatomy, head turn (may help to pull UES open), exercises to increase laryngeal elevation when poor UES opening is due to poor elevation (for example, shaker exercise which works out the suprahyoid muscle)
regarding diet, as patients show improvement in either direct or indirect tx, the clinician should determine ___
when to re-assess and / or advance the patient’s diet (for example, NPO, PO, thick liquids, are solids, etc.)
according to Robbins, “the best exercise for swallowing is ___”
swallowing
interdisciplinary treatment of dysphagia
MD has ultimate responsibility; SLP is the dysphagia team lead; OTs usually covers pediatric swallowing and hand to mouth issues; radiologists help perform MBSS with the SLP
the technique of making unconscious or involuntary bodily processes perceptible to the senses in order to manipulate them by conscious mental control
biofeedback
according to AAPB, biofeedback tx includes:
non-harmful treatments; uses scientific instruments to measure physiological feedback; leads to self-regulation (and is the learned skill / primary goal of biofeedback); tx always includes a therapist, pt, and monitoring instruments
biofeedback applications in speech pathology
stuttering, voice, dysarthria, aphasia, dysphagia
biofeedback modalities in dysphagia rehab (Huckabee)
fluoroscopy; endoscopy; auscultation (the clunking sound of the normal swallow); sEMG (shown on a line - the where the peak = the pt’s activated swallow)
what are the pros of fiberoptic endoscopic examination of swallowing (FEES)?
view structures in real time; visualize bolus residue post swallow; observe postural compensatory techniques; facilitates vocal adduction and airway protection training (supraglottic swallow); facilitates training of velopharyngeal closure
describe vital stim
sends an electrical current to help stimulate muscles involved in swallowing
describe sEMG
surface electromyography; measures effort and strength of a swallow; electrical activity is easily influenced (oils, shaven / unshaven hair); simply measures electrical activity
the basis of EMG signal ___
concerns the activity of the muscle motor units located under or near the electrodes
describe motor unit
found inside a muscle; the motor neuron, its axon, and the muscle fiber innervated by the neuron; smallest functional unit of a muscle
sEMG biofeedback provides ___
real time visual representation of the swallow (making involuntary function a conscious deliberate process); objective tx expectations, goal delineation, and measurement; accelerated tx process; framework pt driven tx
Adams’ (1971) closed loop theory of motor learning
closed loop type of learning in which accuracy and repetition are important for refinement of a skill
what sEMG doesn’t tell us
what the pharynx is doing; when to proceed with PO intake; when to re-evaluate (diagnostics); when the pt is aspirating
___ is NOT a diagnostic tool
sEMG
current approach to rehab (Huckabee)
muscle function recovers by addressing muscle weakness; three categories: flaccidity or hypofuntion, spasticity or hyper function, muscle dyscoordination or apraxia
sEMG treatment (Huckabee)
prep the skin and place electrodes correctly; pt population (cortical-brainstem infarct, cancers, atrophy pts, CP); use caution with pts with unstable cardiac conditions; transient dysphonia is not uncommon; discourage biting / teeth-grinding
sEMG treatment protocol (Huckabee)
education; relaxation; patterning of a motor response; muscle recruitment
describe tracheostomy
surgical opening in the anterior neck into the trachea; purpose: bypass airway obstruction, long-term easy access to the airway for mechanical ventilation and / or pulmonary toilet
effects of trach tubes on swallowing
if cuff is inflated, may compress the esophagus; MAY decrease laryngeal elevation; MAY result in a decrease in sensitivity of the cough reflex
describe ethics
the study of human conduct-character focusing on decisions and actions that are right / wrong, good / bad, better / worse
compare ethical principals
autonomy : the right to decide for oneself about one’s own life :: beneficence : actions done for the benefit of others and actions that produce good :: nonmaleficence : actions that avoid harm or evil
describe virtue
a habitual disposition to act well; a habit under the guidance of reason
briefly describe informed consent
the right to consent and the right to refuse
components of informed consent
adequate disclosure of info; capacity of the pt to understand the information and make an informed decision; voluntary choice without coercion; appreciation of consequences of the choice made
describe legal competence
the law’s presumption that all adults are competent to decide for themselves what will be done with their person or property; competence to: stand trail, manage property, for medical decision making; this is determined by a court
describe decision-making capacity
of comprehension; of choices; of consequences
how decisions are made for people without decision making capacity
let others decide; substituted judgement (what would the pt want); best interest (what is best for the ct)
describe advance directives
a document enabling people to express their wishes about their health care that will tell others how to care for them and / or make decisions for them if they are unable to; two types: the living will, the durable power of attorney
potential benefits of feeding tubes
increased: life span, recovery, return to useful functioning, resistance to infection; improved: QOL, psychological and physiological state, healing of skin and wounds
overall burdens of feeding tubes
cannot be absorbed from the gut; does not abstate failure to thrive; physical pain; underlying condition is hopeless; uncomfortable; prolongs dying; spiritual-emotional pain and suffering; indignity; emotional and financial burden on family
describe palliative care
improving the QOL of pts and families facing the problems associated with life-threatening illnesses; enrollment in hospice is not required
SLP role for NPO and PO
NPO : secretion management, oral care, small PO feeds for oral gratification :: PO : intervention by increasing activity and participation and not restoration of function
describe blue dye swallowing test
only for pts with tracheostomy tubes; takes place of a typical clinical / bedside eval; administer food / liq after feeding water with blue veg dye, then suction
blue dye swallowing test procedures
start with 1 tsp water with blue veg dye, administer food / liq, then suction; if there are any signs of aspiration / penetration you must suction; if no aspiration / penetration, suction after 2 - 3 tsp to rule out silent aspiration; suction 10 - 15 min after completing the eval to clear out the cuff
blue dye swallowing test: if the pt passes the formal exam and is made PO, ___
their food is often tinged blue for a few days to verify safety
advantages of FEES
observe structure; able to see pts bedside; no radiation; biofeedback; test sensation using the scope; pts more tolerant of FEES
disadvantages of FEES
no oral phase assessment, no observation during the pharyngeal swallow (because of squeezing)
disadvantages of MBSS
radiation; you have to move the pt from their room
