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Recovery (actual changes in brain)
____ _____ ____ showed during 3 months of recovery post CVA< changes occurred in undamaged hemisphere with no change in undamaged hemisphere (compensatory)
Possible recovery due to reorganization in ______ hemisphere
- Transcranial magnetic stimulation
- Undamaged
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General goals: Safety first
2 (sometimes 3) goals?
- Airway protection (prevention of aspiration through sensory awareness and proper bolus transit)
- Adequate hydration/nutrition
- Quality of life (enjoyment of food)
- *Oral hygiene priority--brushing, oral rinses
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Dysphagia therapy: Remember overarching goals, safety and nutrition/hydration
What are compensatory strategies?
Active treatment?
- Redirect bolus flow (head turn, head tilt, chin tuck); Food/liquid modification (thickness, volume, texture); Swallow control (supraglottic)
- Improve impaired functions (motor or sensory based, Shaker MTDP, weakness, incoordination, sensory stimulation)
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Oral Strength Training Exercises
Muscle basics
What are Type 1 fibers?
Type 1 (a&b)?
Hybrid?
- Slower to contract, fatigue resistant, aerobic (anterior tongue, tonically active--endurance)
- Larger, more adept at force generation, easily fatigable (BOT), anaerobic (lifting a chair)
- Uniquely adapted to multiple actions--muscles of mastication
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Muscles
Type ___ usually recruited first followed by type __ in volitional movements. Re-training can take ___ weeks. Re-training w/o energy can result in _____. Endurance exercise builds type ___, resistance exercises build type ___.
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Muscle training basics
Early change?
Middle Changes?
Motor map reorganization? (Does it occur?)
Detraining?
Sarcopenia?
Maintenance?
- Nervous system activation
- Morphologic changes w/in muscle tissue; fiber type shifts from type 1 to type 2; hypertrophy is enlargement of muscle fiber resulting in greater force generation
- Decrease in strength after 4 weeks; bed rest, disuse, tube feeds; type 1 more prone to disuse
- Noticeable in 60s; age related loss in muscle fibers; affects fast twitch type 2 fibers more than type 1
- Elders maintain performance 5-31 weeks, 1x/wk results in strength and muscle size maintenance
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Principles of Strength Training *FITT* Frequency, intensity, time, type
Neuromuscular system must be forced beyond usual activity to elicit change.
Intensity= ____- load, volume, duration of stimulus; ___% of 1 rep max; improvement in lingual strength and A-P (Aspiration-Penetration) scale using IOPI (Iowa Oral Pressure Instrument)
Expiratory muscle strength training (EMST)-- ___ stimulation to brain stem swallow centers via tongue/orpharynx sensory receptors and strengthening muscles of swallowing
Studies of skeletal muscles suggest 8-12 reps/set= ___ and ___; may be better for clients that demonstrate ____
6-8 reps/set= ___ with ___ ___; may be better for clients with generalized ____
- resistance
- Afferent
- Strength, endurance; fatigue
- strength; greater power; weakness
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What is specificity?
Not always possible with patients who are ___
Begin with ____ ____ then progress to more goal specific areas
What is transference?
Examples of exercises for this?
- Task correspondence with targeted outcome
- NPO
- strength training
- Cross training; drill--improving somatosensory processing and optimizing neuromuscular fringe patterns
- Shaker, lingual strengthening, LSVT improve overall swallowing
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What does evidence suggest? Is it supportive?
- Strength training may improve general force generating capacity; increase functional reserve; allow patient to participate one extended task specific exercise
- Small sample size, few controlled (e.g. Robbins et al. 2008), Baseline and good data necessary, evince for use in head and neck cancer cases, must have rationale for tx (not to reduce coughing, but to increase coordination of swallow)
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Evidence and Exercise
Traditional oral motor exercises lack ___ related to functional outcomes. Traditional OME's do not overload the system enough to produce change.
Specificity
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Skill vs. Strength
Strength with IOPI + accuracy--Try and reach x target
Strength changes?
Functional changes seen?
What is isometric?
What is isokinetic?
- Target isometric pressures, pressure accuracy, saliva swallows
- Improved bolus position at swallow onset with thins, unchanged or improved valecular residue scores with thins, overall improved thin and thick liquid scores (bolus position at swallow onset, depth of airway invasion, vallecular residue, pyriform)
- Push & hold
- Reps
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Integrated training
What is the McNeill Dysphagia Treatment Program?
Systematic exercise-based tx for adults (15+); volume + viscosity increases difficulty
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Component #1: Lip Closure tx
Sensory?
Motor?
Strategies/Compensatory
- Visual and tactile feedback
- Resistive exercise for strengthening and ROM
- Presentation, bolus modification (volume, texture)
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Component #2: Tongue control
Sensory?
Motor?
Strategies/compensatory?
- Awareness training
- Bolus hold via tongue to palatal seal
- Bolus modifications (volume, texture)
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Component #3: Bolus prep/mastication
Sensory?
Motor?
Strategy/Compensatory?
- Awareness
- Resistive tongue strengthening, tongue ROM, mandibular resistive, mandibular ROM
- Bolus modification (volume, texture, placement)
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Oral Strength Training Exercises
Derived from speech and voice studies
Labial Strength exercises?
Lingual/mandibular strength/ROM?
- Resistive exercise, flexibility/ROM
- Therabite (mandibular), Iowa Oral Performance Instrument--apply resistance to tongue bulb, maintenance of pressure, visual feedback
- Madison Oral Strengthening Therapeutic Device (MOST)--measures pressure generation via custom mouthpiece, calculates target, feedback
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Chewing exercises
Lack of evidence but seen in clinical practice cloth or gauze around straw or sucker, move side to side. Client practices chewing and oral bolus movement. May infuse gauze with different tastes to stimulate more movement
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Component 4: Bolus transport/lingual motion & 5: Oral Residue
Sensory?
Motor?
Strategies/Compensatory
- Awareness
- Resistive tongue strengthening, tongue ROM, suck-swallow squeeze
- bolus modifications (texture, volume placement)
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Tongue base (No evidence)--what might you see in practice?
Vocal fold/laryngeal elevation
- Pull tongue straight back on mouth, yawn and hold most retracted position, gargling, holding most retracted position
- LSVT, some evidence of improved oral and pharyngeal transit times
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Component 6: Initiation of pharyngeal swallow
Sensory
Motor
Compensatory
- Hold bolus, tongue to palatal seal, sensory stimulation plus tongue movement, taste enhancement
- Tongue resistance exercise, tongue ROM
- Bolus modifications (volume, texture, placement)
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Sensory techniques
Use in delay in ___ onset
Delay in triggering of ____ swallow
Alert CNS to presence of bolus and need to swallow; elicit faster ora and pharyngeal swallow
Carbonated beverage--how much, assess what?
Sour bolus--what and assess what?
Textured bolus--what?
- oral
- pharyngeal
- 3 mL; assess speed of swallow, follow with 4-5 regular liquid swallows monitoring speed
- ½ lemon juice + ½ water or barium; assess speed of swallow then provide 4-5 swallow of regular liquid
- Crushed potato chips to barium pudding, crackers to pudding or mashed potatoes
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Thermal Stimulation
limited evidence but used in clinical practice. Heighten __ awareness and present altering stimulus to brainstem resulting in faster pharyngeal trigger. Rub double sided laryngeal mirror against ___ ___ ___ 4-5 times; Assess ___ of swallow and repeat when swallow slows; Effects not long lasting. Cold water bolus may have effect
- Oral
- anterior faucial arch
- speed
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7. Soft palate elevation
Obturator, compensatory--bolus modification (volume and texture)
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Prosthetic management
Palatal lowering prostheses
Decrease volume of __ cavity. Improve bolus ___. Increase ___-___ pressures. Team members? Surgical obturator for trial, removed and modified, permanent or semi permanent
Soft palate prosthesis
Resotre __-___ contact; improves oral __ and oral phases of swallow. Maintain maximal ___ control. May include __ exercises. Use in ___
- Oral. transit. tongue-palate. Prosthodontist and SLP.
- tongue-palate. prep. bolus. BOT. VPI.
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8. Laryngeal Elevation
Motor
Pharyngeal contraction exercise--swallow and squeeze, super-supraglottic swallow
Increased consistencies=Increased resistance
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9. Anterior hyolaryngeal elevation
Sensory
Motor
- Visual feedback
- Suprahyoid strengthening, sustained hyolaryngeal movement at height of swallow, shaker exercise, expiratory muscle strength training, Mendelsohn maneuver
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Shaker exercise
Focus on ___ _____.
What muscles?
2 parts--3x/day x 6 weeks.
Explain the exercise.
Three traditional improvements?
- UES opening
- ABD, mylohyoid, geniohyoid
- Sustained head raise for 60 seconds followed by 60 seconds of rest (isometric)
- Increased superior laryngeal movement with paste
- Increased superior hyoid movement with paste
- Increased anterior laryngeal movement with liquids
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10. Epiglottic movement
Sensory?
Motor?
- Viscous bolus--residue
- Pharyngeal contraction--swallow and squeeze
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11. Laryngeal vestibular closure
Motor
- Super-supraglottic swallow
- Pre-swallow laryngeal valving (volitional closure)
- Tongue base control
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12. Pharyngeal stripping wave
Sensory
Motor
- thicker bolus
- pharyngeal contraction exercise, swallow and squeeze
-
13. pharyngeal contraction
motor
strategies/compensatory
- Pharyngeal contraction exercise-swallow and squeeze
- Bolus modification (volume, texture)
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14. PES opening
Sensory
Motor
Strategies/Compensatory
- Auditory feedback (auscultation)
- Suprahyoid strengthening & ROM (shaker), sustained hyolaryngeal movement (mendelsohn), pharyngeal contraction exercise
- Bolus modification (volume, texture)
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15. Tongue base retraction
Sensory
Motor
Strategy/Compensatory
- Swallow and squeeze
- Tongue hold-Masako maneuver (stick tongue out hold and swallow), pharyngeal contraction exercise (swallow squeeze)
- Bolus modification (texture, volume)
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Masako Maneuver/tongue hold
Strengthen _____ muscle that moves BOT backward during swallow
DIrections?
Not done with ____ or ____
Evidence supporting use in post surgical oral or lingual cancer patients
Follows principles of muscle training by applying load to system
- glossopharyngeus
- Hold front ⅓ tongue between teeth and swallow, feel pull of muscles n pharynx, feel slight pharyngeal swallow delay
- food, liquid
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16. Pharyngeal residue
Depends on cause. Compensatory?
Bolus modification (volume, texture)
-
17. Esophageal clearance
Patient education
COmpesnatory
- Visual feedback, Referral to GI
- Bolus modification-volume, texture
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LSVT
Designed to improve voice and speech in patients with ___
Intense, high-effort targeting respiratory support and vocal fold adduction
Positive changes in post treatment VFSS. Habituation of increased effort, increased recruitment of supra hyoid and laryngal muscles
PD
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Direct Intervention
May include food/liquid bolus
Practice swallowing techniques and maneuvers
Candidates?
Swallow maneuvers: Improved tongue base pressures and duration of PPW contact in patients post=surgery or radiation due to H&N cancer
Can safely swallow small amounts of food or liquid
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Supraglottic Swallow
Close vocal folds ___ and ___ swallow
3 steps?
- before, during
- Take deep breath and hold, keep holding breath while swallow, immediately after swallow cough/clear throat
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Super-supraglottic swallow
Close airway entrance by tilting arytenoid carriages toward base of ____ before and ___ swallow.
Improve ___ retraction. Can be used as exercise.
3 steps?
- epiglottic, during
- BOT
- INhale and hold breath very tightly, bearing down
- Keep holding breath as swallow, immediately after swallow, cough
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Effortful Swallow
Squeezes hard with tongue as you swallow
Follows principles of motor training by using max effort
Increase effort with ___ bolus
Increased __-___ pressure
Increase tongue base/pharyngeal wall pressure
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Mendelsohn Manuever
Sustain elevation of larynx during swallow
August ____ opening
Steps?
Follows principles of motor training--maximal effort although load cannot be manipulated over time
- UES
- Swallow and feel throat for something that lifts. Now feel elevation during swallow, when reaches its height of elevation, hold it up with muscles for many scones then relax.
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Swallow Postures
Variable results pt to pt
Instruction necessary
Consider fatigue, attention, environ distractions
Examples? (6)
Head back, chin down, head rotation, chin down plus head rotation, side lying, head tilt to stronger side
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Diet modification
Thickened liquids
Aspiration on thin liquids, unimproved by postural techniques. Determine thinnest texture tolerated--FOLLOW UP!!
- Last resort!
- (Hydration) Nectar, honey, pudding-98% absorbed like water
- Powdered thickener, gel thickener
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National Dysphagia Diet
Developed by panel of dietitians, SLPs, food scientist
Classifies foods according to 8 textural properties. Anchor foods represent point along continua for each property. 4 levels of semisolid/solid foods proposed
Level 1: ??
Level 2: ??
Level 3: ??
Regular
- Pureed (pudding-like, very little chewing)
- Mechanical Altered (semisolid, requiring some chewing)
- Advanced (soft foods require more chewing)
- All foods allowed
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Puree examples?
mechanical Soft examples? Mechaincal soft + increased texture examples?
pudding, yogurt, strained soupes, hot cereals, pureed cereals
- Sliced deli meat, moist ground meat, hot cereal, pancakes, casserole, soft canned fruit
- Soft rice, muffins, mac and cheese, pasta, grilled cheese
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Prosthetic Management
Lingual Prostheses
Partial or full glossectomy
Reduces oral cavity size, retained secretions, restoration of spincteric function of bot=soft palate contact
Speaking valves--improves ___ pressure
subglottic
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Other management options?
Balance, head support. tray positioning. lighting, adaptable utensils. hand rails. adaptable syringes. dosed cups. nosey cups. one way straws. cognitive strategies (written reminders, mirrors, max awareness, 3 sec prep)
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