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Swallowing Therapies: The Evidence, How To

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Title: Swallowing Therapies: The Evidence, How To


1
Swallowing Therapies The Evidence, How To Why
NotTheme and Variations Clinical Observations
  • Adeline R. Schultz, M.Ed, CCC-SLP/L, BRS-S
  • Department of Rehabilitation Medicine
  • Thomas Jefferson University Hospital
  • Philadelphia, Pennsylvania
  • ASHA 2006

2
Chin Tuck
  • What kind of chin tuck do you instruct patients
    to use?
  • Total flexion of the cervical spine with chin
    down to chest Look at your belly button.
  • Chin pulled back toward spine like a military
    stance cervical spine is straight
  • Head flexed but in fairly neutral position
    Look down at you knees.

3
Head in Extension
  • Patients with spinal cord injury with head
    immobilized in a halo
  • Patients post spinal surgery for anterior
    cervical fusion in hard collar
  • Patients after head and neck surgery with poor
    oral stage function. Head extended to let
    gravity move bolus back in oral cavity

4
Breath Hold Controlled Swallow
  • Variation of the Supra-Glottic Swallow
  • Combination of the breath hold, preparatory set
    and effortful swallow
  • Directions
  • Hold liquid or chewed food in mouth, but dont
    swallow.
  • Breathe in through nose, hold your breath.
  • Swallow one or two times.
  • Breathe out.

5
  • Helps patient to feel as though s/he has some
    control over swallow initiation
  • Patient can breathe back out through nose if
    unable to initiate the swallow, and try again,
    while still containing the bolus in the mouth
  • Helps with oral retention
  • Helps to organize the swallow

6
  • Provides for a stronger pharyngeal contraction
  • Gives patients a sense of control to cough out if
    worried about choking
  • Patients must be able to follow 3-4 directions
    in a sequence
  • Start with swallow of own saliva, and work up to
    foods that are feared or difficult

7
Patients who have a fear of swallowing
  • Patients who have previously choked
  • Patients who have pain upon swallowing
  • Patients who have difficulty initiating and/or
    coordinating the swallow
  • Patients who cannot take pills or capsules

8
Patients who have pain upon swallowing
  • Post or during Radiation Therapy
  • Post head and neck surgery
  • Post surgery for Anterior Cervical Fusion
  • Post extubation

9
Other Patient Populations
  • Paralysis of one or both vocal folds
  • Paradoxical Vocal Fold Dysfunction or Spasms
  • Esophageal dysmotility and reflux
  • Neurological conditions causing inco-ordination
    of the swallow

10
Variation of Masako
  • Pharyngeal Wall strengthening
  • Without food or liquid
  • Stick your tongue out as far as it will go, bite
    on tongue to stabilize, now try to swallow.
  • Variation to make it harder Stick your tongue
    out as far as it will go, and swallow with your
    mouth open.

11
Lee Silverman Voice Therapy
  • Extensively researched for Parkinsons patients
  • Current research with other types of dysarthric
    patients for improved volume, improved vocal fold
    function and improved articulation
  • Improved strength and coordination of swallowing

12
Organic Bases for Functional Swallowing Problems
  • Pulmonary
  • Reflux and GI related
  • Post-Traumatic Event or Surgery
  • Post-intubation
  • Aneurexia/bulemia
  • Irritable Larynx/Neurogenic cough

13
Holistic Approach
  • Relaxation Techniques, Stress Management and
    Guided Imagery
  • Self-Hypnosis with rehearsal for swallowing
    different foods/textures and medications
  • Referral for counseling or psychotherapy
  • Life style, behavioral and dietary modifications
    for GERD and LPR

14
  • Physician prescribed medications such as Proton
    Pump Inhibitors (PPIs), anti-spasm medications,
    and BoTox
  • Medical Interventions such as Esophageal
    Dilitation
  • Hierarchical introduction of foods, from the
    easiest to the most feared
  • Feared foods eaten in treatment session

15
Food Journals
  • What was tried
  • Amounts
  • Time it took to eat
  • Any difficulty with the swallow
  • This log can also be shared with the nutritionist
  • Helps the patient to see progress

16
Bibliography Stress Management, Meditation and
Self-Hypnosis
  • Kabat-Zinn, J, (2005 Re-issue), Full Catastrophe
    Living Using the Wisdom of your Body and Mind to
    Face Stress, Pain, and Illness, Bantam Dell, A
    Division of Random House, Inc., New York, New
    York
  • Kabat-Zinn, J (2005), Coming to Our Senses
    Healing Ourselves and the World Through
    Mindfulness, Hyperion, New York, New York

17
  • Alman, BM, (1992), Self-Hypnosis the Complete
    Manual for Health and Self-Change, 2nd Edition,
    Routledge, New York, New York
  • Hunter, ME (1994), Creative Scripts for
    Hypnotherapy, Bruner-Mazel, Inc., United Kingdom
  • Weil, A, Gurgevich, S, Heal Yourself with Medical
    Hypnosis, (2005), Self-Healing, Mt. Morris,
    Illinois

18
Bibliography Nutrition Websites and Texts
  • www.dysphagiabooks.com Site for ordering
    dysphagia books for texture modifications
  • www.dysphagia-diet.com Site with links to
    companies who carry dysphagia products
  • www.eatright.org American Dietetic
    Associations web site. Includes the National
    Dysphagia Diet.
  • www.hciglobal.org Healthcare Caterers
    International. Educational resources on
    dysphagia.
  • www.novartisnutrition.com Novartis Medical
    Nutrition
  • www.oley.org The Oley Foundation. Information
    and support for patients on IV and tube feedings.
  • Worthington,P, Practical Aspects of Nutritional
    Support, (2004), Elsevier, Philadelphia.

19
Bibliography Dysphagia Treatment
  • Huckabee,ML, Pelletier, CA (1999), Management of
    Adult Neurogenic Dysphagia, Singular, San Diego,
    29-50
  • Logemann, JA, (1998) Evaluation and Treatment of
    Swallowing Disorders, Pro-Ed, Austin, 205-240
  • Murry, T, Carrau, RL, (2006), Clinical Management
    of Swallowing Disorders, Plural Publishing, San
    Diego, 139-167
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