Homebased, family delivered rehabilitation of oropharyngeal dysphagia 4 years post onset a case stud

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Home-based, family delivered rehabilitation of
oro-pharyngeal dysphagia 4 years post onset - a
case study

• Jocelyn Harpur Reg MRCSLT
• Speech and Language Therapy Dept
• Down Lisburn Trust
• N. Ireland

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Contents

• Background
• What is DPNS
• Assessment
• Intervention
• Outcomes
• Where to next
• Challenges

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• The role of the doctor, nurse and therapist is
  to entertain the patient while nature takes its
  course
• Voltaire

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Background

• 35 year old male
• 4 years post severe brain injury - CHI
• living at home
• remote part of N Ireland
• supportive family, 2 young children
• returning to employment
• persisting neurological dysphagia - social
  reintegration issues

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What is DPNS?

• Stefanakos (1990s)
• Bobath and Blomston (1970s)
• therapeutic programme
• built on anatomical and physiological fact
• restores muscle strength and reflexes within
  oropharynx
• sensory and motor
• improved, efficient swallow function

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Impaired muscle function

• decreased muscle strength
• decreased muscle range of motion
• decreased muscle reaction times
• decreased co ordination between sequential
  reflexes required for efficient, safe swallow
• with these observed muscle impairments it then
  becomes critical for improving these parameters
  of muscle function in order to improve SWALLOW
  function

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Improving the parameters of muscle function

• Direct stimulation
• Sensation via thermal stimulation
• 3 main sites

• 1. Tongue base bitter taste buds to improve
  tongue base retraction
• 2. Soft palate musculature for improving palatal
  reflex and velopharyngeal closure
• 3. Superior medial pharyngeal constrictor
  musculature to improve pharyngeal constrictor
  reflex

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But how does this impact upon swallowing?

• Sensory stimulation elicits strong withdrawal
  reflexes
• Strong withdrawal reflexes activate group
  contractions
• group contractions strengthen lingual, laryngeal
  and pharyngeal musculature
• change in muscle function impacts upon swallow

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Why choose DPNS ?

• No contra indications
• Consistent
• Errorless
• Muscle group contractions
• Neuroplasticity principles

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Trainee background

• 34 year old female
• wife of patient
• 3rd level education
• highly motivated

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ASSESSMENT

• Pre/post intervention videofluoroscopy
• Follow up videofluoroscopy at 6 months
• 11 oral/pharyngeal stimulation techniques

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Pre intervention status...

• awareness of tongue and taste sensation
• lengthy oral preparation
• slow, laborious tongue movements with reduced
  range
• greatly reduced tongue base retraction reflex,
  reflexive tongue groove, laryngeal elevation
  reflex, pharyngeal constrictor reflex.
• swallow trigger site at pyriform sinus
• oral and pharyngeal residue
• airway penetration and choking episodes
• Modified diet - thickened liquids / soft, mashed,
  moist consistency foods

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INTERVENTION

• Consent from patient and family member
• Programme prescribed by SLT
• Training programme for family member
• Duration of intervention TBI 8 wks
• Open access telephone monitor/review
• Face to face review x 2 during 8 week programme

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Training Programme

• 90 minute training programme for family member
• explanation of DPNS
• equipment required - lemon glycerine swabs, gauze
  
• techniques to be used - 7/11 DPNS techniques to
  stimulate weak/absent reflexes
• demo /practice in techniques
• length of treatment sessions - up to 30 minutes
• frequency of sessions - 1 x daily
• observations to note
• contact details

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Patient 0utcomes.

• Impairment
• non spontaneous recovery of swallow function
• intact and efficient tongue base and lingual
  groove reflexes
• increased speed, range tongue movement
• increased laryngeal reflex with increased
  laryngeal/ hyoid ROM
• no airway penetration
• swallow trigger site at vallecula
• no oral/pharyngeal residue

• Functional
• ease of oral prep and increased speed
• normal diet
• increased rate of meal completion
• increased family/social integration
• no choking
• maintenance of gains 6 months post programme

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Service outcomes...

• Value/impact of treatment programme 4 years post
  injury
• Goals met
• Effective use of SLT time
• Method of service delivery enabled access to
  service

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• The role of the doctor, nurse and therapist is
  to entertain the patient while nature takes its
  course

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Where to next.

• Rolled out method of service delivery to include
  
• family member
• care assistant
• nursing auxilliary
• nurses
• SLT student
• SLTs not DPNS trained

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Challenges

• Detail of training programme
• Motivation - patient/ trainee
• Type of patient
• Type of non SLT
• family v healthcare ?
• educational background?
• age?

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Conclusion

• Oro-pharyngeal dysphagia can respond to DPNS 4
  years post onset
• DPNS prescribed by SLT and carried out by non SLT
  is an effective use of SLT time
• Method of outreach service delivery enabled
  access to service
• Further case series and controlled studies are
  indicated re use of non professionals to carry
  out prescribed DPNS programmes