Week 11 Flashcards
What are the different behavioral therapies for improving the components of swallowing?
Shaker exercise Tongue strengthening Masako maneuver EMST Transcutaneous e-stim Effortful pitch glide
Intramuscular stimulation
Neural stimulation
Shaker maneuver
Head raising exercise to target improved UES muscle function
Pt lies on their back and raised head to look at toes without shoulders lifting
What are the physiological targets of shaker manuever
Poor UES opening (extent and/or duration) resulting in post-swallow residue
What are the desired outcomes of the shaker manuever?
Improved UES function
decrease pharyngeal residue
Tongue strengthening
Lingual resistance exercises for weak tongue muscles to improve strength for swallowing. Resistance provided bt pressure sensitive bulb or tongue depressor
What are the physiological targets of tongue strengthening?
Poor bolus formation Premature spill oral residue poor base of tongue to posterior pharyngeal wall pharyngeal residue
What are the desired outcomes of tongue strengthening?
Improve tongue strength to functional levels
impacting bolus formation, spill
Bolus driving forces and post swallow residue
Masako maneuver
Swallow initiated with tongue held firmly bt teeth to improve posterior pharyngeal wall contraction
What are the physiological targets of masako?
Poor tongue to posterior pharyngeal wall contact
Poor pharyngeal constriction
pharyngeal residue
What are the desired outcomes of masako?
Improve bolus driving forces and post-swallow residue
Expiratory muscle strength training (EMST)
Calibrated, one way, spring loaded valve
Valve blocks the flow of air until enough pressure is produced
Exercises the expiratory and submental muscles
Treatment lasts 4 5o 5 weeks with 25 breaths a day 5 days a week
What are the physiological targets of EMST?
Weak cough Poor respiratory support Disrupted exhale-swallow-exhale pattern ? poor hyolaryngeal elevation penetration/aspiration caused by respiratory issue listed above
What are the desired outcomes of EMST?
Improve airway protection and respiratory support
Possibly improve hyolaryngeal elevation
Transcutaneous electical stim
or e-stim, VitalStim, NMES
Use of electical current to stimulate the nerves or nerve endings that innervate the muscles beneath the skin
Controversial
Must be assessed under VFSS
causes depression of the hyolaryngeal structure at rest
Effortful pitch glide
Pt phonated on a low to high gliding pitch with effort. Causes elevation of the arytenoids/larynx and constriction of the pharynx
What are the physiological targets of effortful pitch glides?
Poor pharyngeal constriction
Poor laryngeal elevation
What are the desired outcomes of effortful pitch glide?
Improve pharyngeal constriction (and reduce residue)
Improved laryngeal elevation (and improve safety)
Muscle stimulation
Ongoing research to look at utility of intramuscular electrical stimulation
Most precise but more invasive
Early research phases, no clinical application available
Facilitative maneuvers
- postures or gestures demonstrated to improve swallowing safety or efficiency
- need to confirm function on instrumental exam
- some naturally occurring or easier to teach such as increased effort, jaw thrust (may pull open UES) or expectoration of pharyngeal residue
- should be taught before instrumental for ALARA principle
Effortful swallow
“swallow as hard as you can. squeeze your throat muscles harder”
“Pretend you are swallowing a big grape or pill”
Can be used on initial swallow or as a secondary clearing swallow for residue
Requires strength and endurance over meal
Some SLPs consider it an exercise/treatment
What are the physiological targets of effortful swallow?
Significant post-swallow residue
Poor pharyngeal constriction
Poor base of tongue to posterior pharyngeal wall
What are the desired outcomes of effortful swallow?
Improve pharyngeal efficiency
Decrease pharyngeal residue
Mendelsohn maneuver
Prolonged elevation of the larynx during swallowing to increase both displacement and duration of hyolaryngeal excursion. Prolong UES opening
MUST BE assessed instrumentally
What are the physiological targets of mendolsohn maneuver?
Early UES closure
Incomplete UES opening
Poor pharyngeal constriction
(post-swallow residue)
What are the desired outcomes of mendolsohn maneuver?
Improve and prolong UES opening to decrease pharyngeal residue
Supraglottic swallow
close airway prior to bolus entry into the pharynx and to keep the airway closed for the duration of bolus transport
“Put the bolus in mouth, hold breath, and keep holding it as you swallow. Then do and audible breath or cough to clear your airway.”
Best tested under endoscopy or AP view of VF
- Hold
- Swallow
- Cough
What are the physiological targets of supraglottic swallow?
Premature spill
delayed swallow initiation
delayed/poor laryngeal closure
What are the desired outcomes of supraglottic swallow?
Ensure airway protection before and during the swallow
Super supraglottic swallow
Supraglottic + increased effort of airway closure (bear down)
“Put the bolus in your mouth, hold your breath and bear down like you are lifting something heavy, keep holding as you swallow. Then cough”
What are the physiological targets of super supraglottic swallow
Premature spill
delayed swallow initiation
Delayed/poor laryngeal closure
difficulty with VF closure
What are the desired outcomes of supraglottic swallow?
Ensure airway protection before and during the swallow
What are surgical treatments for dysphagia?
Reconstruction of structures (lips, tongue, palate, VF augmentation or medialization)
Cricopharyngeal (CP) bar - failure of the cricopharyngeus muscle to relax during swallowing as a result of fibrosis, GERD, neuromuscular disease. Causing dificulty with increased texture viscosity
Myotomy (surgical) - cut the CP muscle
Dialation (non-surgical) - physically expand the UES
Botox (non-surgical) - inject botox into CP muscle temporarily
Zenker’s diverticulum
Ballooning out of the pharyngeal wall due to high pressure
Globus sensation, regurgitation, penetration/aspiration of regurgitated material, halitosis, infection
If small with no discomfort - no intervention warranted
Large and symptomatic - surgically manages with endoscopic stapling or fiberoptic laser
