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Management of Swallowing Disorders

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Changes in head/neck and upper body position can have a powerful effect on bolus ... Tilting the upper body or the head changes the impact of gravity on the bolus. ... – PowerPoint PPT presentation

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Title: Management of Swallowing Disorders


1
Management of Swallowing Disorders
2
Treatment Planning
  • Eating involves the whole person.
  • It is not possible or practical to separate the
    person from his/her eating difficulty.
  • One should consider the whole personcognitive,
    physical, and/or environmental barriers that may
    affect treatment progression.
  • The goal of treatment is improved nutrition and
    hydration status while focusing on techniques and
    strategies to eliminate eating difficulty and
    increase swallow safety.
  • Swallowing therapies fall into several
    categories behavioral, medical, or surgical.

3
Behavioral Therapy
  • Behavioral therapies are provided by the SLP
    sometimes in conjunction with PT, OT, and/or
    nursing when
  • the strength, endurance, and/or mobility of
    structures involved in swallowing are diminished
  • diagnostic probes have indicated that swallowing
    may be facilitated, or made safer by bolus
    manipulation, postural compensations,
    facilitative maneuvers, or adaptive devices or
  • it is believed that more appropriate initiation
    or timing of certain swallowing events may be
    induced by selective stimulation of particular
    structures or systems.

4
Behavioral Therapy
  • Indications for therapy directed toward improving
    the strength, range of motion, endurance, and
    agility of gestures involved in swallowing
    include clear evidence of weakness or limited
    movement of the mandible, lips, tongue, pharynx,
    or larynx.
  • These symptoms are typical in certain patient
    populations (e.g., head and neck cancer,
    neurogenic).
  • Exercises should be aimed at improving the
    capabilities of residual, impaired swallowing
    gestures, and/or those with the most obvious
    compensatory potential.

5
Behavioral Therapy
  • Bolus manipulation of selected materials should
    be individually tailored to the patient.
  • Bolus characteristics can be manipulated to
    compensate for timing/coordination or
    construction/patency impairments of the oral,
    and/or pharyngeal chamber or of the
    lingual-palatal, velopharyngeal, laryngeal, or
    PE sphincter.
  • Characteristics of the bolus that lend themselves
    to manipulation include
  • Properties that maximize sensory feedback about
    the bolus and its position, e.g., temperature,
    taste, size, and texture and

6
Behavioral Therapy
  • Properties that affect bolus deformability and/or
    bolus flow in response to gravity or compression,
    e.g., bolus viscosity, bolus size, and bolus
    placement.
  • Postural manipulation is indicated when it
    appears that a patient can either redirect bolus
    material in a manner that improves swallowing
    efficiency, improves protection of the airway, or
    both.
  • Changes in head/neck and upper body position can
    have a powerful effect on bolus flow through the
    oral and pharyngeal chambers.
  • Tilting the upper body or the head changes the
    impact of gravity on the bolus.

7
Behavioral Therapy
  • Capital flexion, extension, or rotation change
    the size and shape of the pharyngeal cavity and
    may impact PE opening.
  • Positional changes do not have to be dramatic to
    be effective.
  • Positions that exploit gravity include tilting
    the upper body (making sure to keep cervical
    spine neutral in relation to the thoracic spine),
    and tilting the head (flexion or extension, or
    extend-flex).

8
Behavioral Therapy
  • Facilitative maneuvers refer to physiologic
    postures or gestures that have been demonstrated
    to improve swallowing efficiency or safety and
    that a patient can learn to utilize for these
    purposes.
  • Facilitative maneuvers require sophisticated and
    active participation by the swallower, good
    muscular kinesthetic and proprioceptive sense,
    movement control, and ability to understand,
    learn, and apply the strategy during swallow.
  • Some maneuvers are very familiar and are applied
    spontaneously by patients.

9
Behavioral Therapy
  • These include effortful swallow, repetitive
    swallows, and expectoration of pharyngeal
    residue.
  • More difficult maneuvers to learn include
    altering the extent and/or timing of laryngeal
    behaviors for swallow, e.g., supraglottic and
    super supraglottic swallow, or for improving or
    prolonging PE opening, e.g., Mendelsohn maneuver.
  • Adaptive devices modify the delivery of the bolus
    material into the swallowing tract or change the
    shape of the tract in a manner that positively
    impacts swallowing efficiency and/or safety.

10
Behavioral Therapy
  • Examples of such devices include a syringe, a
    modified spoon, different nipples, different
    sizes and shapes of cups and bowls.
  • A palatal augmentation appliance or palatal
    prosthesis may be useful in helping reshape the
    oral cavity.
  • Finally, communication and environment must be
    considered in behavioral therapy.
  • Reduction of noise, light, and other
    distractions, selective positioning, and verbal
    cueing may enhance the patients level of
    alertness.

11
Behavioral Therapy
  • Verbal cues, such as the patients name, or
    instructions, such as swallow, close your
    lips, or chew, may be accompanied by visual
    cues or demonstration.
  • With children, prefeeding preparation may involve
    rituals, attendance to state, including fatigue,
    readiness/playtime activities, and prosthesis
    placement.
  • Sensory cues involving taste or smell can be used
    to heighten alertness.
  • During feeding, pacing of bolus delivery may help
    improve breath control and stamina.

12
Medical Therapy
  • Medical therapy targets the underlying medical
    condition that results in dysphagia.
  • When a neuromuscular disease is the etiology of
    the dysphagia, medications prescribed for the
    patient must be reviewed to determine if any
    contribute to dysphagia (e.g., cholinergic
    drugs).
  • GER may contribute to swallowing difficulties and
    may require an antireflux regimen and well
    behavioral modifications.
  • Xerostomia impedes bolus lubrication and bolus
    flow and is deleterious to oral mucosal and
    dental health and esophageal GER defense.

13
Medical Therapy
  • Treatment of xerostomia includes maximizing
    hydration, limiting mouth-breathing, minimizing
    use of products that contribute to xerostomia
    (e.g., medications, mouthwashes, toothpastes) or
    favor bacterial growth.

14
Surgical Therapy
  • Selective condition may benefit from surgical
    therapy.
  • Some structures which may be repaired or altered
    surgically with skin flaps include the soft
    palate and the tongue .
  • Surgical procedures are available to correct some
    vocal fold paralyses and other causes of glottic
    incompetence.
  • Problems with cricopharyngeal relaxation due to
    neuromuscular disease and/or GERD may necessitate
    a myotomy.
  • Esophageal achalasia and strictures are often
    treated with esophageal dilations.

15
Surgical Therapy
  • Dysphagia is often multifactorial.
  • Surgical therapy may be able to correct part of
    the problem but often other difficulties will
    persist.
  • Patients need to be counseling about the
    limitations of surgery so that their expectations
    will be realistic.
  • Progress after surgery is more likely to be
    gradual, and a period of post-operative swallow
    therapy may be required to realize the fullest
    benefit from surgery.

16
Nutrition Hydration
  • Patients who are experiencing dysphagia are at
    risk for malnutrition and dehydration.
  • Physical signs of malnutrition include
  • dry, flaky skin
  • spoon-shaped nails
  • small yellowish lumps around the eyes
  • dull, dry hair
  • night blindness
  • gums that bleed easily
  • red, swollen lips
  • slow-healing wounds

17
Nutrition Hydration
  • 5 weight loss in 1 month
  • 10 weight loss of total body weight and
  • weight below 90 of the ideal.
  • Factors which can lead to malnutrition include
  • NPO status or significantly reduced dietary
    intake for more than 3 days
  • burns, trauma, infection, disease processes, or
    surgery increasing nutritional needs
  • anorexia from illness or drug use
  • alcoholism or substance abuse
  • depression
  • dysphagia

18
Nutrition Hydration
  • chemotherapy and radiation and
  • intestinal malabsorption disorders.
  • Factors which can lead to dehydration include
  • decreased water access due to immobility, poor
    visual ability, and/or altered mental status
  • presence and severity of dysphagia, leading to
    fear of oral intake
  • fear of urinary incontinence, leading to
    diminished food intake
  • administration of diuretics
  • anorexia
  • acute illness imposed on chronic disability

19
Nutrition Hydration
  • feeding dependency
  • impaired communication skills
  • impaired cognitive skills
  • low frequency of medications
  • low frequency of meal consumption
  • poor fluid intake of both beverages and solid
    foods and
  • administration of either IV radiographic contrast
    agents or high protein enteral feeding, causing
    an osmotic diuresis.
  • Physical signs of dehydration include
  • dry tongue, mouth, and great thirst
  • less urination and dark urine

20
Nutrition Hydration
  • sunken eyes
  • wrinkled skin
  • dizziness and confusion and
  • rapid heartbeat and breathing.
  • In infants, dehydration may be evidenced by dry
    mouth or thick saliva, and small amounts of dark
    urine in diaper.
  • The fontanel on the head sinks in when the baby
    is held upright or in sitting position.

21
Nutrition Hydration
  • Skin forms a "tent" when pinched and stays
    pinched up.
  • Dark circles appear around eyes.
  • The baby may be fussy, sleepy, not hungry, or
    difficult to wake up.

22
Special Treatment Protocols DPNS
  • Deep Pharyngeal Neuromuscular Stimulation (DPNS)
    is a therapeutic technique for adults developed
    during a two-year period by Karlene Stefanakos
    (1993).
  • Stefanakos claims that traditional compensatory
    techniques have as their focus minimizing the
    function/effect of pharyngeal musculature when
    decreased muscle strength, endurance, absent or
    diminished reflex responses and discoordination
    between pharyngeal reflexes disrupt swallow
    function.

23
Special Treatment Protocols DPNS
  • DPNS is a systematized therapeutic method for
    pharyngeal dysphagia which utilizes 11 specific
    stimulation techniques within the oral/pharyngeal
    areas. (http//www.speechteam.com/workshops.htm)
  • To date, no published results of her ongoing
    study, or specific stimulation techniques are
    available except by attendance at her workshop.

24
Special Treatment Protocols Frazier Water
Protocol
  • The Frazier Water Protocol (Panther, 2005) was
    implemented in 1984 at the Frazier Rehabilitation
    Institute in Louisville, KY.
  • The Frazier Water Protocol was developed in
    response to patients who were non-compliant with
    recommendations for no thin liquids or refusing
    to drink thickened liquids.
  • Despite videofluoroscopic evidence of aspiration,
    non-compliant patients at the Frazier
    Rehabilitation Institute were not developing
    pneumonia.

25
Special Treatment Protocols Frazier Water
Protocol
  • The guidelines that were developed through the
    multidisciplinary cooperation of physicians,
    SLPs, and a dietician at Frazier were tailored to
    the patients seen in this acute rehabilitation
    environment.
  • The acute rehabilitation population can generally
    tolerate three hours of therapy/day, are upright,
    mobile, and relearning to manage functional
    activities.
  • A doctors order is not required to implement a
    free water protocol.
  • Any patient receiving tube feedings or on
    thickened liquids may have water.

26
Special Treatment Protocols Frazier Water
Protocol
  • For patients who are eating orally, water is
    allowed between meals only.
  • Clinicians who decide to pursue allowing patients
    who aspirate thin liquids to drink water should
    be sure that the water source is safe.
  • Make sure that the facilitys internal water test
    meets, or exceeds, the strict requirements
    enacted by the EPA.
  • At your initial bedside visit, screen the patient
    with water to determine if the patient is
    demonstrating signs and symptoms of dysphagia.

27
Special Treatment Protocols Frazier Water
Protocol
  • Check for level of alertness and presence of
    impulsivity.
  • Decide if further dysphagic instrumental
    evaluation is warranted.
  • Patients exhibiting impulsivity or excessive
    coughing and discomfort should be restricted to
    water taken under supervision.
  • Patients with extreme choking may not be
    permitted oral intake of water due to the
    physical discomfort of coughing, although this is
    a rare occurrence.

28
Special Treatment Protocols Frazier Water
Protocol
  • Occasionally, a physician may order strict NPO
    for a patient and water or ice chips will not be
    permitted.
  • For patient on oral diets, water is permitted
    between meals.
  • Water intake is unrestricted prior to a meal and
    allowed 30 minutes after a meal.
  • The period of time following the meal allows
    spontaneous swallows and gravity to clear pooled
    solid or thickened liquid residues.

29
Special Treatment Protocols Frazier Water
Protocol
  • NPO patients are permitted water any time.
  • Patients who are thin liquid restricted wear
    yellow bands to communicate the liquid
    restrictions to all staff.
  • The band may also include wording to
    individualize specific compensations, such as no
    thin liquids except water between meals or no
    thin liquids except water by teaspoon between
    meals.
  • Water is freely offered to patients throughout
    the day according to the guidelines documented on
    the yellow arm band.

30
Special Treatment Protocols Frazier Water
Protocol
  • Patients for whom compensations, e.g., chin tuck,
    head turn, etc., have proven successful are
    encouraged to use compensations while drinking
    water.
  • Aggressive oral care should be provided to those
    patients who are unable to clean their own teeth
    and mouth so that pathogenic bacteria are less
    likely to contaminate secretions.
  • Medications are never given with water.
  • Pills are given in a spoonful of applesauce,
    pudding, yogurt, or thickened liquid.
  • Family education includes emphasis on the
    rationale for allowing water intake.

31
Special Treatment Protocols Frazier Water
Protocol
  • Written material is provided as well.
  • Education is documented in the medical record.
  • To date, the only published research related to
    the consumption of water by patients with
    dysphagia was conducted by Garon, Engle, and
    Ormiston (1997).
  • 20 patients with hx of stroke and aspiration of
    thin liquids during a videofluoroscopic swallow
    study were randomly assigned to two groups.
  • The control group received thickened liquids
    while the experimental group received thickened
    liquid and water between meals only upon request.

32
Special Treatment Protocols Frazier Water
Protocol
  • Prior to drinking water, patients were required
    to pre-rinse in an effort to reduce the volume of
    bacteria in the oral cavity.
  • No patients in either group developed pneumonia
    or dehydration during the conduction of the study
    or during a 30-day follow-up period.
  • A significant difference in thickened liquid
    intake per day was found between the groups.
  • The control group took more thickened liquids,
    although the experimental group drank more fluids
    overall.

33
Special Treatment Protocols Frazier Water
Protocol
  • Mean days from onset of stroke to end point of no
    thin liquid aspiration was 39 days for the
    control group and 33 days for the experimental
    group.
  • Patients allowed water reported a high degree of
    satisfaction and reported that thickened liquids
    did not quench thirst.
  • None of the patients in the control group
    reported satisfaction with thickened liquids and
    all reported a desire for ice chips or water to
    quench thirst.

34
Special Treatment Protocols E-Stim
  • Functional Electrical Stimulation (FES) or
    E-stim, is the artificial elicitation of a muscle
    action potential to generate useful body
    functions.
  • Electrical stimulator devices, called
    neuroprostheses, provide short bursts of
    electrical impulses to the nervous system to
    produce sensory and/or motor functions.
  • Over the past 40 years, neuroprostheses have been
    developed for a wide variety of applications.
  • Cochlear implants are one type of neuroprosthesis
    that has achieved great success.

35
Special Treatment Protocols E-Stim
  • Other neuroprostheses, such as those for upper
    limb and lower limb function have not yet matured
    to a level that creates a significant consumer
    demand.
  • Attempts to develop electrical stimulation
    devices for assisted swallowing have been few,
    but researchers have begun building a foundation
    for future developments.
  • Some preliminary studies have been carried out to
    assess the feasibility of electrical stimulation
    in the treatment of chronic dysphagia.

36
Special Treatment Protocols E-Stim
  • The major problems with the proposed
    neuroprostheses are that they use very primitive
    forms of electrical stimulation and do not aim to
    produce specific muscle actions that contribute
    to the dynamic process of swallowing (Thrasher
    Popovic, 2004).
  • The first pilot study of neuromodulation
    (electrical stimulation of sensory neurons to
    induce a reflex arc) to facilitate the swallowing
    reflex was conducted in 1997 by Park, ONeill,
    and Martin.

37
Special Treatment Protocols E-Stim
  • The neuroprosthesis they constructed consisted of
    an appliance worn on the palatal surface that
    delivered a continuous train of electrical
    impulses to the soft palate via a pair of
    electrodes.
  • The stimulation was well tolerated by all four
    subjects who participated.
  • Somewhat positive results were reported for this
    type of approach, suggesting that continuous,
    twitch-like stimulation of the soft palate might
    heighten the sensitivity of the swallow reflex
    although there is no physiological theory to
    support this.

38
Special Treatment Protocols E-Stim
  • Another study by Freed, Freed, Chatburn, and
    Christian (2001) examined the effects of
    continuous electrical pulse delivery by a pair of
    surface electrodes located on the neck in
    reducing severity of aspiration and subsequent
    need for gastrostomy in a group of 110 patients
    with a history of swallowing disorders caused by
    stroke.
  • Specifically, a pair of electrodes was placed in
    one of two configurations one electrode above
    the lesser horns of the hyoid bone and the other
    roughly 4 cm below it or both electrodes above
    the lesser hyoid bones bilaterally.

39
Special Treatment Protocols E-Stim
  • The digastric and thyrohyoid muscles likely
    received direct stimulation from this electrode
    placement.
  • The neuroprosthesis was applied as an
    intervention for 60 minutes per day and was
    tested against another intervention, thermal
    stimulation.
  • While the authors reported overwhelming success,
    their methodology was judged to be flawed.
  • Subsequent studies, with more rigorous
    methodology, are being undertaken

40
Special Treatment Protocols E-Stim
  • A 2-channel version of the neuroprosthesis
    described by Freed et al. has been commercialized
    as the VitalStimTM and has received FDA approval.
  • A more recent study has looked at different
    muscle recruitment strategies for augmenting
    laryngeal elevation via FES (Burnett, Mann,
    Cornell, Ludlow, 2003).
  • Many suprahyoid and infrahyoid muscles are
    simultaneously active early in the pharyngeal
    phase of swallowing, when laryngeal elevation
    begins.

41
Special Treatment Protocols E-Stim
  • Geniohyoid, mylohyoid, and digastric muscles are
    used selectively by different individuals, with
    some individuals using all three muscles at the
    onset of swallowing and other using different
    pairs (Spiro, Rendell, Gay, 1994).
  • In their study, Burnett et al. utilized
    hooked-wire monopolar electrodes inserted into
    mylohyoid, thyrohyoid, and geniohyoid muscle
    regions in 15 healthy men selected for having a
    highly visible thyroid prominence for
    videotaping.

42
Special Treatment Protocols E-Stim
  • During trials of single, bilateral, and combined
    muscle stimulations, thyroid prominence movements
    were video recorded, digitized, and normalized
    relative to elevation during a 2-ml water
    swallow.
  • When an individual muscle was stimulated, it
    induced approximately 30 of the elevation
    observed during a swallow and about 50 of
    swallow velocity.

43
Special Treatment Protocols E-Stim
  • When paired muscles (bilateral mylohyoid,
    bilateral thyrohyoid, or ipsilateral mylohyoid
    and thyrohyoid) were stimulated, there was
    approximately 50 of the elevation and about 80
    of the velocity produced during a swallow.
  • Paired muscle stimulation produced significantly
    greater elevation than single muscle stimulation.
  • The authors felt that their findings suggested a
    possible role for paired muscle stimulation as a
    means for augmenting laryngeal elevation and
    improving airway protection in patients with
    dysphagia.
  • Be on the look out for more studies by these
    folks!

44
Special Treatment Protocols Muscle Interventions
  • Strength training is a common strategy approach
    in dysphagia management for muscle weakness from
    either acute insult or atrophy.
  • If your aim is to increase the strength of a
    muscle, you should have the patient participate
    in short repetitions of the movement under heavy
    load/resistance.
  • If you work the muscle in lengthy repetitions
    under light load/resistance, you are going to
    increase muscle endurance not strength.
  • Stretching is another active exercise sometimes
    used in dysphagia management.

45
Special Treatment Protocols Muscle Interventions
  • Stretching can be passive or active.
  • It can increase or decrease tone.
  • If you stretch a muscle quickly, you increase its
    tone.
  • If you stretch a muscle slowly, you decrease its
    tone.
  • Decreased tone can improve range of motion.
  • Active range of motion can reduce tissue
    adhesions, scars, and contractures.
  • Passive range of motion does not increase
    strength or endurance nor prevent atrophy.
  • Passive warming before stretch can increase range
    of motion.
  • Warming without stretch does not change range of
    motion.

46
Special Treatment Protocols Muscle Interventions
  • Warming elevates threshold for pain so one is
    able to stretch further without pain.
  • Warming reduces muscle spasm and improves blood
    flow which may facilitate muscle strength.
  • Icing temporarily reduces nerve conduction and
    may be effective for increasing range of motion
    at the early stages of the stretch.
  • There is limited data on range of motion
    exercises for swallowing.
  • Range of motion exercises without resistance may
    not act against atrophy.

47
Special Treatment Protocols Muscle Interventions
  • Lets look at some traditional swallow treatments
    and the focus of the exercise and the outcome.
  • Lip puckeran endurance exercise maintains
    muscle.
  • Tongue protrusion/retractionan endurance
    exercise maintains muscle.
  • Sucking/blowingan endurance exercise maintains
    muscle.
  • Hard swallowan endurance exercise slow to
    fatigue.

48
Special Treatment Protocols Muscle Interventions
  • Pushing tongue against tongue bulba strength
    exercise increases tongue strength bit faster to
    fatigue.
  • Mendelsohns maneuvera strength exercise
    increases strength but faster to fatigue.
  • Falsetto maneuver (lateral movement of the
    pharyngeal walls)an endurance exercise
    maintains muscles.
  • Pushinga strength exercise increases strength
    but faster to fatigue.

49
Special Treatment Protocols Muscle Interventions
  • Supraglottic swallowa strength exercise
    increases strength but faster to fatigue.
  • Shakera strength exercise increases strength,
    but faster to fatigue.
  • Many of our exercises are aimed at the right goal
    but how they are delivered does not achieve the
    level required to change muscle function.
  • Force level and duration are important issues in
    retraining the muscular system of swallowing.
  • Short periods of activity under loaded conditions
    have significant impact.

50
Special Treatment Protocols Muscle Interventions
  • Many treatments do not have appropriate intensity
    nor repetitions to make impact.
  • After stroke, one should wait about 2 weeks
    before beginning strength and endurance training.
  • Muscle atrophy is an important factor in
    swallowing impairment.
  • Atrophy happens rapidly.
  • Atrophy is greater in regularly used muscles and
    in power muscles.
  • Retraining is beneficial
  • Exercising atrophic muscles in the malnourished
    individual can cause damage.
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