Treatment for Dysphagia Flashcards
Traditional Swallowing Treatments (3)
- Compensatory
- Rehabilitative
- Behavioral
Compensatory Strategies
- goal
- short term
- Goal: compensate for problem
- Short term adjustments to facilitate improved swallowing function while undergoing rehab or getting better
- Can alter bolus flow (rheology) (chin tuck)
- Alter physiology? perhaps
Rehabilitation
- goal
- Goal: To restore functional swallowing
- Systematic application of techniques
- Often challenges abilities to encourage learning and improvement
- Produce long-term improvement beyond the treatment period that generalizes to functional swallowing contexts.
- Evidence based exercises to rebuild muscle strength
Treatment (3)
- Must be evidence based.
- Or, must at least make sense based on your knowledge of the anatomy and physiology of the swallow.
- Treatment objectives must be specific to the physiological cause of the symptoms.
Focus of Swallow Therapy (treatment)
- 3 AREAS YOU WORK ON
- The focus of swallow therapy depends on which aspects of the swallow are disordered (is it these listed below)
a. muscular strength & range of motion (residue is often associated with strength issues)
b. timing
c. coordination of movement of the oropharyngeal structures
Compensatory Techniques
- Designed to compensate for lost function and/or mistiming.
- Control the flow of food and eliminate the patient’s symptoms without necessarily changing the physiology of the swallow (Logemann, 1988)
- Most often used by the patient during meals.***
Compensatory Techniques List (6)
- Changes in posture
- Bolus modifications
- Changes in timing and coordination
- Changes in food placement
- Changes in food presentation
- Changes in food consistency
Compensatory: Postural adjustments (chin down/chin tuck)
- Used with decreased oral or back of tongue control*****
- Orally, the patient gains more volitional control for propulsion of the bolus.
- Widens the valleculae in many patients to allow for collection of material without spill to the pyriform sinuses or into the trachea.
- Pushes epiglottis posteriorly, increasing airway (narrows the airway) protection by narrowing the distance from the epiglottis to the pharyngeal wall and the laryngeal entrance.
- When you don’t have good oral control, and food leaks,
- Try out on video swallow
Compensatory (Postural adjustments): What does chin down/chin tuck do (2 things)
- Slows the bolus
- Places the hyoid bone and the larynx in closer proximity, which likely closes the larynx faster.
Chin down vs. chin tuck (compensatory- postural adjustment)
- Chin down & chin tuck both result in consistent decreases in area of airway opening and distance between PPW/epiglottis
- Chin tuck increased airway protection greater than chin down or neutral position.
- 2 ways of doing it
a. Chin tuck- tightening (tucking it back)
b. Chin down- chin to chest
How far do you tuck?
- In normals, using manometry, there was a greater increase in UES peak pressure with a complete chin tuck vs. a partial chin tuck.
- the more you can tuck the better
* However - Has been shown to increase aspiration of those with dementia, Parkinson’s Disease and even healthy individuals.
- It must be tested in the VFSS prior to taking for granted that it is a useful technique with all patients.
Food for thought for compensatory strategies
- Prior to using ANY compensation or technique, it’s always a good idea to test it out during the VFSS. (but you don’t always have that option)
- How do you know that it will work with your patient if you haven’t tested it out????
Postural adjustments- Head Rotation (5)
- Assists those with unilateral pharyngeal paresis or paralysis***
- The patient should rotate his head all the way toward the damaged side.
- Narrows the pyriform sinus on that side
- Increases vocal fold closure
- Reduces resting tone in the cricopharyngeal muscle. (turning head you are opening the muscle, reducing tension)
- Turn head into weaker side- moves food and reduces residue (CVA pts?)
How far do you rotate for the head rotation?
- With normals, using manometry, UES peak pressures and opening duration were significantly increased for thin and puree consistencies with 90 degree rotation.
- With 45 degree rotation, pressures increased but not significantly.
- More rotation the better
With regards to pharyngeal clearance…
- Head Rotation
- Chin Tuck
- With head rotation, UES relaxation begins early which may help to clear residue.
- With chin tuck, there is delayed UES opening resulting in increased residue.
a. Pharyngeal constrictors have trouble with this
Compensatory Strategies
Postural Adjustments- head tilt
- Lateral
- Posterior
- Lateral: used with hemiparesis of the tongue and pharynx, tilt to the intact side for bolus direction.
- Posterior: rarely recommended but may be helpful with those with decreased ability to propel the bolus posteriorly to initiate swallow. Gravity assist.
- often used with cancer pts.
External Pressure to the Cheek
- Compensates for decreased muscle tone
- Decreases the amount of material falling into the weaker lateral sulcus
- Tactile cue reminds the patient to check the buccal pocket or lateral sulcus for material.
*** Weakness or loss of sensation
*** May need to do a finger sweep or lingual sweep
Labial and Chin Support
Place your finger under the chin or lower lip(or both) to help maintain closure of the mouth.
- Flaccid dysarthria
- You may need to support their mouth
Bolus Modifications:
Taste
- Sour Bolus
- Sour bolus can improve the onset of the oral and/or pharyngeal stages of the swallow.
- Taste stimuli increased the # of spontaneous swallows observed within 1 minute after initial swallow compared to water (Pelletier, 2002)
- Best response in patients without dementia
Bolus Modifications:
Taste
- Sweet and Salty
- Have been shown to positively change timing and lingual pressure.
a. Pts. with dementia like sweet boluses
Bolus Modifications
Temperature
- Use of a Cold Bolus
- Cold bolus also adds significant sensory input for increased speed of swallow initiation.
- Technique to use to improve timing and coordination of the swallow.
- Use ice and ice water in finger of glove, have patient suck on it, remove, ask patient to swallow (dry swallow).
- Swallowing sensors at the bottom of the anterior faucial pillars- gets a swallow doing, but it didn’t do much
However,
- Overall assessment of temperature effects have been mixed.
- Need more studies on hot temps
Chemesthesis
- A chemically stimulated sensation of irritation mediated by the trigeminal nerve that is elicited by such stimuli as carbonation. It is a somatosensory perception that adds to the flavor experience.
- For example, it is responsible for the perception of hotness from a chili pepper or coolness of menthol.
Chemesthesis
- Capsaicin
- Carbonation
- Capsaicin: increased hyoid movement, however this response decreased over time. Laryngeal penetration, oral-pharyngeal residue were decreased and the time to laryngeal closure was decreased (0.4 to .29 sec).
*** pepper speeds up swallow
- Carbonation (more sensory)– has been demonstrated to reduce laryngeal penetration and aspiration in some and may be equivalent to nectar thick liquids. (this must be independently tested in an objective way)
- The overall assessment of chemesthesis effects has been mixed.
Bolus Modification- Volume (hyolaryngeal movement)
- Arytenoid to epiglottis contact time increases with bolus volume. – larynx has to stay closed longer (so COPD, smaller amounts, more breathing breaks)
- Duration of hyoid elevation increases with a larger bolus
- Peak hyoid elevation increases with larger bolus.
Bolus Modification- Volume (bolus timing)
- Decreases swallow delay
- Decreases bolus flow through the oral and pharyngeal cavities.
- Pharyngeal delay time diminished in stroke patients with larger bolus.
- More UES opening with larger bolus
Compensatory Techniques: Changes in timing and coordination
- 3-second prep (“1, 2, 3, swallow”)- great for pts. Who have trouble initiating the swallow (good for PD pts.)
- Use of a metronome
- Suck-swallow- helps get the bolus to the middle of the tongue and prepare for the swallow)
- Anterior bolus hold- hold it in the front of the mouth and think about swallowing
Compensatory Techniques: Food Placement Options
5
- Place on stronger side
- Place in middle of tongue
- Place as far back on tongue as possible
- Only use spoon with liquids
- No straws
Compensatory Techniques: Food Presentation Options
- You may recommend different ways for food or liquid to be presented depending upon your goal. Spoon, cut-out cup (never have to tilt your head back), straw
- Alternate liquids and solids
- No liquids with meal
- Multiple swallows per each bolus (swallow 2 or 3 times with every bite)
- Single vs. multiple sips (single sip, drink and set the cup down)
- maybe alternate a solid and a liquid
Compensatory Techniques- Changes in food consistency
- Consistency/Viscosity Changes
- Decreased pharyngeal delay with more viscosity.
- Delayed oral and pharyngeal bolus transit.
- Increased pharyngeal peristaltic waves, UES opening and extrinsic laryngeal muscle activity.
- Heavier something is, slower it flows
- Esophagus does not work well with thin liquids (dependent on gravity)
Facilitation Techniques
- Designed to improve function – to change swallow physiology.
- May or may not be used during meals
- Might just do during treatment session or sessions and meals
Facilitation Techniques
3 types
- Oral-motor exercises
- Laryngeal elevation exercises (MBS shows larynx is not elevating)
- Exercises for increasing laryngeal closure
- Need to be careful with these
- We need to know physiology
Techniques- Compensation and facilitation
- Some techniques are both a compensation and a facilitation.
- -the technique can be used to compensate for lost function and can also improve function
Regarding Treatment-
- What is the goal?- 7 goals
**Know these
- Increase strength?
- Improve timing?
- Increase speed of movement?
- Increase endurance?
- Coordination?
- Bolus clearance?
- Some combination of the above?
- KNOW THIS
Oral-Motor Exercises (3)
- Bolus maintenance (bolus is falling over tongue, out of the mouth, or into the lateral sulcus- need to keep it where it needs to be)
- Bolus preparation/manipulation (pt. can’t do rotary chew so you need to do exercises)
- Bolus propulsion and clearance (need to help increase strength
Bolus Maintenance
- Labial control exercises (keep from spilling anteriorally
- Lingual control exercises (keep in oral cavity, reduce premature spillage)
Bolus preparation/manipulation
Chewing exercises to control and manipulate the bolus
Bolus Propulsion and Clearance (7) techniques
KNOW THESE
- Isometric lingual exercises (best)
- BOT exercises
- PPW exercises
- Laryngeal elevation exercises
- Exercises to increase laryngeal closure
- Effortful swallow
- LSVT (Lee Silverman Voice Therapy)
LSVT Research
- Improvement in oral transit time and percentage of oral residue
- Tongue rocking disappeared
- Reduction in delay, improved tongue base retraction with reduction in amount of residue spilling from the valleculae.
— Excellent therapy for swallow
- Therapy for PD
- Slow rushes of speech with hypokinetic dysarthria- need to make them loud (4 days, 4 weeks, 1 hour per session)
- Also improved swallowing, tongue rocking disappeared
*** works because we challenge the system
Regarding Exercise
- Exercise efforts that do not force the neuromuscular system beyond the level of usual activity will not elicit adaptations.
- By challenging the system beyond typical use, adaptations occur to accommodate the increased demand. (brain plasticity)
*** Challenge the system
Exercising and Swallowing
- Swallowing is a submaximal muscular activity. (just using the amount of energy you need)
- For strength to increase, demand must be continuously increased. This is called “progressive resistance.”
Lingual Strengthening
- Isometric Exercises
- Isometric exercises have been shown to increase tongue strength and tongue bulk.
- IOPI- Iowa oral pressure indicator
- MOST- Madison oral strength trainer
- Isometric is the best tongue strengthening
IOPI- Iowa oral pressure indicator
- Tells the pt. how strong they are pushing
- Find out their max
- Designed for research
- Very expensive
- Bulbs are single use
Madison Oral Strengthening Therapeutic Device- MOST
- Developed by Joanne Robbins at University of Wisconsin-Madison
- Less expensive and more “clinician friendly” than the IOPI, but same concept for progressive oral resistance training.
Lingual Strengthening Procedure
- Record the pressure that is most consistently generated plus or minus 5%
- “Push the bulb against the roof of your mouth as hard as you can”
- To train swallowing pressure strength, set the target at 60% of maximum.
** build it up
- Begin with a series of five or so consecutive trials with rests period in between.
- Increase training load by no more than ~10% per week and avoid great boosts in volume or intensity.
Results from IOPI
- Robbins demonstrated that 8 weeks of IOPI training resulted in:
a. Increase in maximal isometric pressure generation
b. Increased oral pressure during swallowing
c. Increased safety per penetration/aspiration scale. - She has also replicated this with her MOST device.
What if you don’t have an IOPI or a MOST?
- Lingual resistance exercises in all planes using a tongue depressor.
1. Use a tongue depressor and have the pt. push anteriorly 10 times
2. Do the same thing laterally
3. And have pt. push against the roof of their mouth as hard as they can, watch the neck and have them do it against the lower central incisors too.
Expiratory Muscle Strength Trainer (EMST)
- Another progressive, load-bearing strength training device.
- One way, spring-loaded pressure release valve that the patient blows into.
- Release set at 60 – 80% of maximal expiratory pressure.
- Adjusted throughout program to incorporate a progressive load.
* Want to build up expiratory muscles because without good respiration, you cannot swallow well
EMST benefits
- Improves the expiratory breathing muscles.
- Also, increases activity of suprahyoid muscles. (which raises the larynx)
- Results in improved expiratory driving pressures for cough.
- Can also be used as an IMST (inspiratory muscle strength trainer)
Contraindications for EMST
- Pregnancy
- Untreated hypertension
- Recent stroke
- Cardiac abnormalities
- Asthma, emphysema or COPD
- Hx of collapsed lung
- Head/neck surgery
- Untreated GERD
- Symptoms of heartburn….consult your MD
EMST Method (8)
- Instruct the patient to take a very deep breath
- Position the device in mouth with a tight seal, pinch off nose
- Have pt blow forcibly into the device until the valve pops open
- Help the pt learn to identify the feel and sound of the valve opening
- After every trial, ask questions about any discomfort or light-headedness especially in the beginning
- Once the proper resistance has been established, begin multiple reps
- Expect inconsistency
- Check constantly for correct lip seal
Frequency/Duration of EMST
- Minimum of 25 reps per day
- Five days per week
- For five (preferably many more) weeks
- Building exercise principles
Laryngeal elevation exercises
- High pitched “ee” – will also see pharyngeal wall movement
- Pitch glides
- Effortful pitch glides
- Mendelsohn Maneuver – “squeeze” at the height of the swallow to keep the larynx up high in the neck- exercise and compensation (meal and exercise)- want them to raise their larynx and hold it
a. Change pitch, it raises the larynx
b. Add effort or tension as you move up the scale
c. In the height of the swallow hold your larynx up
Base of tongue exercises (5)
- Lingual isometrics – best (residue at the valleculae)
- Yawn: “pull your tongue back during a yawn and hold for a second”
- Gargle: “pull your tongue back during a gargle and hold for a second”
- Eel, Earl, Ale (hold them)
- Forceful repetition of “k” words (exagg. Car, cat, cake)
Masako Maneuver (tongue hold)
- Designed to increase the forward movement of the posterior pharyngeal wall to meet the base of the tongue.
- Ask the patient to protrude the tongue and hold it between his teeth while he swallows.
- Done with saliva swallows,
- NOT with food.
- The more the tongue is protruded the better - Evidence with both tongue resection cancer patients and with normal pts.
- Increased PPW anterior bulging at mid and inferior levels of second cervical vertebra
- More bulging with greater tongue resection
- Suggested that PPW could compensate
Masako Maneuver (what it does)
- Do NOT use with food as this impairs some of the natural movements of swallowing (inhibits tongue base retraction).
- Increases pharyngeal residue
- Shortens duration of airway closure
- Increases pharyngeal delay time
*** ONLY USE AS A STRENGTHENING EXERCISE NOT A COMPENSATION WITH FOOD
Laryngeal Adduction
- Same techniques as used in voice therapy.
- (pushing, pulling, hard glottal attack) - Valsalva maneuver (breath hold or effortful breath hold)
- Supraglottic swallow
(reduces laryngeal aspiration)
Decreased closure of the airway
- Super supraglottic swallow
- (reduces laryngeal penetration)
Supraglottic Swallow Procedure
Designed to close the airway at the level of the TVC (true vocal cords)
1. Take a breath
2. Let a little out 3. Hold your breath tightly (gets pharyngeal closure) 4. Swallow 5. Cough 6. Swallow again a. Used with reduced or late vocal cord closure; delayed pharyngeal swallow b. Voluntary breath hold usually closes vocal folds before and during swallow.
*** Closes off the airway
Super-supraglottic swallow procedure
- Take a breath
- Let a little out
- Hold your breath as tightly as possible. (bear down)
- Swallow, squeezing as hard as you can.
- Cough
- Swallow again
Caution: supraglottic and super-supraglottic techniques
- SG and SSG were found in one study to be contraindicated in stroke or CAD patients due to the high likelihood of abnormal cardiac findings (supraventricular tachycardia, premature atrial and ventricular contractions) – in as many of 86% of their patients.
- don’t do it with cardiac pts.