Special topics - Vision and FES

Where are the most refined muscles in the body?

The muscles of the eye are the most refined NM areas of the body – 1 nerve
to 6 muscle fibers in the eye (1:10 in the hand, 1:200 in the back)

Functional Anatomy of the eye

Cornea
Lens
Iris
Vitreous gel
Retinal vessels
Retina
Optic nerve

Extraocular eye muscles

Superior, inferior, lateral and medial rectus muscles and inferior, superior obliques
Allow movement in all directions of gaze and responsible for position of eye

Visual & Visual perceptual Skills (A whole list)

Acuity
Scanning, tracking/pursuits
Saccades
Visual fixation of gaze
Oculomotor control/alignment
Convergence/ Divergence (eye teaming/binocularity)
Visual attention
Depth perception
Figure ground (3)
Position in space/spatial relations
Visual discrimination – like/unlike, figure/object closure, color
Visual memory
Directionality – right/left, topographical, etc.
Contrast discrimination
‘Glare modulation’/recovery
Accommodation (3)
Awareness of visual fields
Concurrent processing of simultaneous visual stimuli – ambient vs. focal

List of Common pathologies of eye

Glaucoma

Cataracts

Macular

degeneration

Myopia

Hyperopia

Astigmatism

Diabetes/diabetic retinopathy

o Strabismus/Phoria

o CVA/TBI

Glaucoma

increased intra-ocular pressure resulting in compression of optic nerve (producing ‘tunnel vision’).
If left untreated, can result in atrophy of optic nerve.

Cataracts

clouding of the lens. Decreases
acuity and contrast discrimination, however,
does not typically affect visual fields

Macular Degeneration (ARMD)

– ‘wet’ vs. ‘dry’.
Degeneration of macula (portion of retina) due to
vascular changes, resulting in loss of central vision.

Myopia vs Hyperopia vs Astigmatism (Refractive errors)

Myopia – near sightedness (light rays pass through lens and are focused at a point in front of the retina)
Hyperopia – far sightedness (light rays pass through the lens and are focused at a point behind the retina)
Astigmatism - refractive error due to oval (rather than spherical) shape of eye.

What is a refeactive error?

relating to how the lens focuses the image) are treated with
corrective lenses (in therapy, this can be addressed by use of prescribed
lenses, magnification, enlarged print, changing focal distance, as well as
other interventions to maximize functional use of vision, including ensuring
adequate lighting, enhancing contrast, etc.).

Diabetic Retinopathy

Complication of diabetes. Retinal

vessels weaken, leaking blood and fluid into vitreous.

Glaucoma (pressure, creating restricted VF’s) cataracts

(clouding of the lens), retinal detachment, floaters and clouding

of the vitreous may occur.

Strabismus/Phora

Misalignment of the eyes (may be

congenital, developmental or acquired). ‘Dysconjugate gaze’

Dependent upon degree of deviation, image(s) may

range from slightly ‘blurred’, to 2 distinct images

(‘diplopia’/double vision). Images may be

horizontally, vertically or diagonally displaced.

Common types of ocular deviation

Tropia - visible when both eyes are open

Phoria- visible when one eye is covered

Developmental considerations for vision

1.Prior to 3-4 years of age, standardized testing is typically not

administered due to developing visual perceptual skills, and

requisite cognitive/linguistic skills

Functional Changes to vision as we age

1. Color Sensitivity - discrimination of brightness decreases with age (most notably over 60 years), diminished ability to discriminate full spectrum (decline beginning at 30 years of age)

   – most notable with similar shades/hues (i.e. pastels, navy/black/dark brown)

2. Visual/spatial abilities – decline in depth perception and spatial abilities beginning at age 40 and progressing

3. Glare recovery – decreased recovery from direct or reflected glare

4. 4. Lighting/illumination – overall, increased illumination required

5. Transitioning light/dark – increased time to transition from light to dark and dark to light

6. Visual acuity – declines with age (typically optimal late teens/early 20’s), thought to be due to diminished corneal transparency or changes in vascular efficiency in the retina'

7. Visual fields – gradual narrowing of the visual field(s) until mid to late 50’s, more significantly during/after 60’s.

Visual Feild Screening Position

Position: Eye level, knee to knee (or within arm’s length)

• Present stimulus equal distance between you and

patient ... why??

• Finger count, static presentation (gross) vs. pen/penlight/finger, dynamic presentation

high contrast dowel vs. penlight : Visual field screening

 Rod (vs. cone) cells in detection of movement and

light –

ambient vs focal vision ... choosing the right tools

 Smartphone flashlight could be used for many of

these screening measures.

What’s a normal visual field?

Visual Acuity Review

NVA (near visual acuity):

Acuity near (letters)

Acuity near (symbols)

Acuity near – continuous text ... what is this and why is it important? (not just ‘print size’ – what about cadence, rate, accuracy, efficiency ... what they can ‘technically see’,nmay not be the same as what is ‘functional’)

DVA (distance visual acuity)

Acuity distance (letters)

Acuity distance (symbols) ... ways this can be modified

Acuity entered is the last line for which the patient
got > 50% correct

Visual Acuity - test eyes together or separate? Referral?

Referral for anything less than 20/40, or difference of greater than one line on eye chart between eyes

Normal: 20/12 – 20/25 (no corrective lenses to see newsprint, 1M)

Near normal: 20/30 – 20/60 (can see newsprint with glasses)

Moderate low vision: 20/70 – 20/160 (begin to experience difficulty with ADL)

Severe low vision: 20/200 – 20/400 (‘legal blindness’)

Profound low vision: 20/500 – 20/1000

Near blindness: 20/1250 – 20/2500

Total blindness: no vision and no light perception

Traditionally, ICD definition of ‘low vision’ <20/60 (20/70) best corrected acuity in better eye

Testing ocular Alignment

Position at rest (clinical
observation and corneal
reflection)
Teaming during pursuits
Cover test – strabismus
Uncover test & Alternate cover
test - phoria

Near point convergence

Why important? – functional impact/symptoms
Refer if break greater than 4 inches, recover greater than 6 inches, or if
no report of double vision

• Setting expectations (not being afraid to report blurry or double

vision)

Saccadic eye movements

16” from pt, 4” either side of midline (8” apart)

5 round trips/10 fixations

Other options – 2 pens, 2 penlights

Processing Simultaneous Visual Stimuli

Why is this important functionally?

Presented 30-45 degrees from midline on right/left

Another option – Colored discs

Screen basic perceptual skills during vision

• Can just ask them questions

Everything a vision eval from checks (1-10)

1. Visual Attention

2. Visual Feilds

3. Visual Acuity

4. Ocular ROM and Pursuits

5. Ocular Alignment

6. Binocular Function - Vergence

7. Saccadic Eye Movements

8. Processing of Simultaneous Visual Stimuli

9. Perceptual Assessment

10. General appearance of eye and eye lids

Intervention: Visual Attention/Fixation

Bold black and white designs, blocks/patterns using bold primary colors

Incorporate movement

Place items on grids/mats with movement (transfer discs with contrast, ‘lazy susan ’with grid/mat placed on top) to facilitate fixation, incorporate visual pursuit and increase motivation

Mazes for visual fixation/attention – ease of access, variety, themes, easy to grade task

Line tracing tasks - commercially available assessments and workbooks, or create your own!

Sustained visual attention with visual perceptual skills –
puzzles in Highlights magazine, hidden object and ‘find the differences’ puzzles, workbooks and apps (great for both clinic and ‘homework’)

Intervention: Visual Feilds & Scanning

• Flashlight/Laser-light Tag (Stimulating &/or increasing awareness - incorporating scanning)

• Options for surfaces, positioning, AE

  Variations – ‘tag’ , ‘chase’, ‘2 overlapping’, ‘jumps’

low tech adaptations for scanning text

• Ruler

• Bookmark

• Index card

• Reinforce visual scan across line by “‘tracing’ across line with finger

• Graph paper, or turning regular (or ‘bold’ or ‘raised’) lined paper to ‘landscape’ orientation (for vertical lines) for ‘math’/banking.

  
  

Visual Fields & Scanning – Low Tech

(stimulating &/or increasing awareness – incorporating scanning)

 Look for additional resources available within your department to address scanning:

1. VisAbilites Workbook

(pre-reading/reading)

2. ‘Look to the Left’

3. Resources posted in

D2L (‘worksheets’)

Visual Fields Awareness, Scanning, Ocular

ROM & Pursuits Low Tech: Vision Tube

•Inexpensive and can be used with wide range of ages, dx/conditions and can easily be graded

•Examples of ways to grade activities – supine, seated (firm surface, Dynadisc), standing (solid surface, foam mat, wobble board), with mobility, with

Visual Fields Awareness, Scanning, Ocular

ROM & Pursuits Low Tech: Marsden Ball

How can you grade the activity? (supine, seated, standing, plain ball, numbers/letters, bunt with bat/dowel, catch [both hands, one hand, alternating hands,etc.)

Inexpensive option – suspended whiffle ball with ‘Command Strip’ hook

Interventions: Ocular ROM and Pursuits

Tracking/pursuits with wands/dowels, penlights, fixator sticks or any other item – make it interactive (tell stories, make it a game, etc.) ... be creative!

These products available from Bernell/VTP

Ball games –roll, bounce or toss-pass, dribble, toss/throw to target, kick, juggle (different sizes, colors, textures, shapes)

intervention: Scanning & Tracking/Pursuits - TracKIT

Intervention: Intervention: Binocularity, Teaming and vergenge

• Ball games –roll, bounce or
  toss-pass, dribble,
  toss/throw to target, kick,
  juggle (different sizes, colors,
  textures, shapes)

• Rebounder, or, bounce against wall

• Balloon toss, ball toss, seated ‘badminton’
  Addition of dual task demands ..

• Binocular function - Vergence: ‘Super Slider’/‘Forward Pass’/‘Zoom Ball’ – great treatment option for peds and adult populations (other benefits)

  
  

Other vergence and accommodative shifts - Intervention

‘Bulls-Eye Target’ – alternating focus between bulls-eye target in near
space, with a target in intermediate to far space.

Brock String

Intervention: Saccades

• Remember ... saccades are a (visual) transition from one point in space to another (fixation/release/fixation)
  Commercially available work books
  Penlight or fixator stick exercises
  Flashlight or laser light tag on wall

• Use scan boards, eye charts or make sheets of letter, shapes, numbers, etc. for table-top use, or posted on wall

• Post-its with letter/numbers randomly arranged on wall

Intervention: Perceptual Skills

• R/L Discrimination & Directionality

• Remediation of reversals

Vision Intervention: Ways of Grading activites

• Easel – change the plane/visual field ... also offers nice opportunity gross motor involvement and for kinesthetic input

• Transition from monocular to binocular (when appropriate)

• Change seating/standing surface
   Improvement can be measured by
  1. Time/speed
  2. Accuracy
  3. Activity tolerance
  4. Fatigue
  5. Test scores (standardized tests)
  6. Subjective report
  7. Improved level of function in ADL, IADL tasks, education-related tasks, functional mobility, etc.

  
  

DeBenabib’s Sequence of visual skills

Intervention: Low Vision

free magnifiers

(Stand – may require pt to move magnifier, but not hold)

(Stand – may require pt to move magnifier, but not hold)

Intervention: Low Vision

free magnifiers

Binoculars, Cip on spectacles, around the neck

Intervention: Low Vision

Low vision optics/magnification - Monocular, Loupes

(Clip on or hand-held)

Intervention: Low Vision

Low vision optics/magnification – Globes
(magnifier sits on top of reading material and pt moves glove
magnifier over text)
Illuminated globe, globe with guideline, globe with guideline
and contrast ring
These products available from Bernell, MaxiAids and/or ILA

Intervention: Low Vision

Low vision optics/magnification – Hand-held magnifiers
Hand-held – illuminated and non-illuminated, pocket, pendant, multiple sizes/shapes,
monoculars (near and far) + ‘stand’ which are place directly on the reading material
(but still require pt to move magnifier over material)

Intervention: Low Vision

Low vision optics/magnification – Hand-held
magnifiers: Strength and size may impact
reading/use (i.e. ‘spot checking’

Intervention: Low Vision

Low vision optics/magnification – Hand-held
magnifiers (Bar)
Bar with guide-line, bar with contrast line,
typoscope with bar
These products available from Bernell, MaxiAids and/or ILA

Intervention: Low Vision - HIGH TECH!

• (closed circuit television/televiewer – stationary table-top units)
  Stand alone unit (approximately $2,000-4,000)

• ‘Plug and play’ using existing TV or monitor – $2,000-4,000 ... May offer greater flexibility for a wider variety of tasks since the
  camera is separate from the monitor

• ‘plug and play’ using existing TV or monitor – $200-400 (more cost-effective and portable option)

• Portable electronic hand-held magnification devices - $300-1,500

• App-based magnification options for smartphones and
  tablets (generally, less than $5) Many offer variable
  magnification, ‘lighting’,

  
  

Low Vision - Lighting

•  Is there such a thing as ‘too much of a good thing???
   Direct lighting/‘task lighting’
   Assessing lighting- is there enough, & for the specific tasks being performed in that location
   Where should light be for reading/writing?
   Light meter
   Types of bulbs
   Other inexpensive options for adding lighting in closets and in/under cabinets

“Low Vision” - Contrast

•  Polarized lenses with various tints to block UV and increase contrast – avoiding dark lenses – more to come on wrap-
  around shades in a few minutes!
   Acetate sheets for contrast
   Other common examples of contrast use – reading, marking
  steps/entries and thresholds, grab bars, door frames, counters/cabinets, place setting, etc!

• ‘Low vision’ – contrast: railings and grab bars

• Duct Tape on cabinets

• Colored cutlery

• Stairs

• Tactile info from a rail

  
  
  

Vision Interventions: Glare reduction

‘Polar shields’ (outdoors)
Transitions lenses
Tinted lenses (indoors)
Windows
Table and counter surfaces
Flooring

Low vision’ – Sampling of Household Low Vision AE/AD

 Television and computer screen magnification
 Phones – large button, one touch dial, Braille, speakerphone, flashing LED

Low vision timers
Low vision watches – bold face with large numbering + digital ‘talking’
watches (can also be set to remind of medication routines)
Large print thermostats dials

Marking dots, paint, ‘hi marks’ for tactile identification
 ‘therapist on a shoe string’ – ‘puff paint’ from fabric store, and ‘bump dots’

Low Vision - Adaptive Equipment

Color identifiers
Tactile marking systems for clothing
Label readers

Magnified syringe guides (or ‘click’/dial insulin pens) and large print screen blood glucose meters
Magnified/illuminated tweezers and clippers (important for safe nail care with diabetics)

Large Print screen and talking thermometers and BP monitors

Talking pill bottle base
Pillboxes with large print, raised numbering with
voice or alarm medication schedule reminders

Large print on bottle tops
Organizational strategies (consistent location, by time of day, by location taken, etc.)
Large print pill box or electronic pill box, alarm on watch, or radio plugged into timer (as reminder), etc.

• Decrease visual clutter + Inc contrast + Large print

• Black and white cutting boards

• Finger gaurds

• Desk top/hand held readers

• High contrast keyboards

• Remote controllers (Less and larger buttons)

• LV board games, cards, puzzles
  

REFERAL OPTIONS FOR VISION

What is the difference between the
Family physician,
Optometrist
Ophthalmologist,
Neuro-Ophthalmologist,
Behavioral (Developmental)
Optometrist,
Neuro-Optometrist,
Low Vision Optometrist,
How do I decide who is the
most appropriate to refer to?,
and
Who refers? (a ‘trick’y
question)

Vision Team members

Optometrists (and specialties)
Ophthalmologists (and
specialties)
PT
OT
ST
COVT
COMS
CLVT
CVRT
Social Work
Psychologist

Specialty Certification options for OT

• CLVT

• SCLV - AOTA

Why are we addressing FES - statics

1/3 of hospitalized patients may experience difficulty to swallow related
to pathology of mouth, pharynx or esophagus
• Up to 70% of patients in extended care setting may experience difficulty to swallow
• 50-75% of those in acute phase of recovery s/p CVA will experience some form/degree of dysphagia

60,000 Americans die each year from complications
associated with swallowing dysfunctions.

Who is at risk for swallowing issues

• By diagnosis: CVA, TBI, MS, ALS, MD, Parkinson’s, Dementia, Guillain
Barre
• By clinical presentation (refer to dysphagia signs/symptoms)
• By co-morbidities/other medical and clinical factors: GERD, pneumonia, etc.

Muscles for FES: Temporalis, Masseter, Buccinator, Orbicularis Oris

Muscles for FES:

Suprahyoid

Mylohyoids

Diagastrics

Geniohyoid

Infrahyoids

Thyrohyoid

Sterno-thyriod

Stero-hyoid

Omohyoid

Sternoclenomastiod

Anatomy FES: Anterior and Lateral Sulci

Soft palate, Uvula, Anterior and Posterior faucial arches

Pocketing

Anatomy of the Larynx

Stages of swallow

Oral preparatory stage
Oral stage
Pharyngeal stage
Esophageal

Oral Preparatory stage

lip closure, bolus is held in cupped tongue (in ‘dipper’ or ‘tipper’ position), chewing (rotary movement), velum lowers to approximate the posterior portion of the tongue

Role of types of teeth – shape and function

1. Central and lateral incisors
2. Canines
3. ‘Pre molars’ and molars

Role of Saliva in FES

• Role in bolus formation
• Impact on hygiene (residue)
• What it means as a risk factor
• ‘Xerostomia’ - dry mouth
• What can be done about it? (saliva substitute, adjustment of medications causing dry mouth, encourage fluids + recommendations during mealtime [alternating sips/bites, choosing foods with higher fluid content, use of gravies and sauces, sour/tart flavors to stimulate salivation, etc.])

Oral Stage:

1. Tongue propels food posteriorly (anterior/posterior ‘A-P’ transit).
2. Tongue elevates anterior to posterior, forming groove in midline of tongue to hold/move bolus back to faucial arches (sensory fibers signaling next stage of swallow).
3. This stage usually takes 1-1.5 seconds.

Pharyngeal Stage:

1. Velum (velopharyngeal soft tissues/soft palate) elevate and approximate pharyngeal wall,
2. Retraction of tongue base toward pharyngeal wall
3. Pharyngeal wall contracts toward base of tongue
4. Elevation of hyoid
5. Larynx (airway) closes at true and false
vocal folds and epiglottis ‘flips’ down
6. Laryngeal superior and anterior movement
7. Upper esophageal sphincter (UES) relaxes and opens

What stage is the biggest red flag? FES

Pharyngeal Stage

Esophageal Stage:

1. UES relaxes/opens
2. Peristalsis (wave-like muscle contractions to move food)
3. LES (Lower Esophageal Sphincter) relaxes/opens, allowing food to pass into the stomach
4. This stage takes 8-20 seconds

Clinical Signs and Symptoms of Dysphagia

• Temperature spike
• Coughing or choking (& why this ‘gold standard’ may not
be as reliable as you think! – silent aspiration)
• Drooling/ difficulty managing secretions

• ‘Gurgly’/‘wet’ or ‘hoarse’/‘breathy’ vocal quality or cough
• Patient c/o
• Loss of food or liquid from mouth
• Holding food or liquid in mouth (delayed initiation of swallow)

• Multiple swallows
• Watery eyes when
feeding
• Change in
coloration
• Reflux
• Change in diet

Dehydration
• Dehydration

If a pt needs an eval for dysphagia what do you do?

• Obtain orders

• CHart Review

• Functional mealtime observation (either before or
  after swallow screen [or b/s clinical evaluation]

• Screening, or Bedside/chair side clinical evaluation of F-E-S
• ? Referral for further instrumental testing/evaluation
• Development of plan of care/treatment plan, goals and recommendations
related to aspects of

Are MD orders needed for screening

• No

Screening would
typically involve chart
review and patient
observation, however,
if you are going to trial
consistencies not
currently ordered by
MD, you should have
physician order for use
of test tray in

When MUST you have MD order for FES

For
bedside/clinical
evaluation of
feeding and
swallowing
(‘bedside
dysphagia
evaluation with
test tray’), you
must have MD
order, even if you
already have OT

What to review when looking at a chart

• Dx/HPI

• PMH

• Meds - Xerostomia as a side effect of meds

• LAbs (WBCs)

• • Recent procedures (intubation, supplemental or alternative feeding methods, etc)
  • Reason for referral
  • MD order

• Respiratory status – supplemental O2 and mode of administration, lung sounds, trach, ventilator use, intubations
• Current diet (solids and liquids)
• Any diet restrictions (special diet?)

• Any supplemental feedings? What type?
• Other testing or procedures (Barium swallow, recent/prior modified barium swallow, GI series, consults – Neurology, dietary, ST, OT, respiratory, Pulmonology, etc)
• Physical and cognitive status (from PT/OT/ST/NSG

During a clinical dysphagia eval, what are we looking at?

1. Postural assessment & trunk control
2. UE ROM, strength & G/FMC
3. Head and neck ROM, strength
4. Sensation
5. Cognition

6. Cardiopulmonary function

ALSO

1. ROM, sensation, praxis
(coordination), strength of lips,
jaw, tongue, mouth (oral
structures), and select observable
aspects of pharyngeal function
2. Test tray/procedures
3. Monitoring for clinical symptoms
of dysphagia

Equipment on the test tray

1. Exam gloves
2. Laryngeal mirror
3. Long cotton swabs
4. Tongue depressor
5. Thickener
6. Utensils and 2-3 cups
7. Straw (optional)
*Suction equipment and
someone trained to operate it

8. At least one item of each liquid consistency

9. At least one item of each solid consistency

10. Stethescope

11. Pulse OX

IDDSI

International Dyshagia DIet standardization initiative

IDDSI Levels

WHat is the appropriate order of presentation for FES

Effect of ice on thickened liquids

• Makes it thinner bc ice melts

Useful clinical gems when eval of dysphagia

• Timing of cough as
indicator of when/where
dysphagia may be
occurring
• Type of cough as useful
clinical indicator of level
at which
penetration/aspiration
may be occurring

• Pulse-oximetry – what do
we look for ... what does it
tell us?
• Palpation

Diff b/w penetration and aspiration

Penetration happens before or at level of vocal folds'

Aspiration happens lower/ in the larynx

Overview of Basic
Compensatory
Strategies for FES

•Chin tuck – why would we use chin tuck?

•Head turn toward affected side – why?

•Combine turn with chin tuck

•Head tilt toward stronger side – why?

•Bolus size & rate of intake

•Crush meds (if able) – need MD clearance

•External pressure to the cheek – limits pocketing, provides support for bolus formation

•Lip (labial) and chin support

•Food presentation – spoon/modified spoons, ‘nosey cup’, cups that measure specific sip sizes, straw, etc

•Double/multiple effortful swallows

•Forced cough

•Alternating sips/bites

•Diet consistency – NPO, thin liquid, nectar thick liquid, honey thick liquid, pudding/spoon thick liquid, puree solids, mechanical soft solids, regular solids, crushed medication (check with MD & PDR), meds with applesauce (and another ‘trick’ for meds!)

•Tongue sweep/finger sweep

•Oral inspection with mirror (self inspection)

•Food placement – midline vs. further back on tongue vs. on the ‘stronger’ side

Thickeners

Liquid consistencies

• Thin

• Mildly Thick (Nectar)

• Moderately thick (honey)

• Extremely Thick (pudding)

Treatment strategies FES - Help w trigger swallow

• Thermal Tactile stimulation - cold to faucial arch

Overview of Common Remedial/Rehabilitative/Restorative Treatment Strategies/Interventions for FES

•Sour lemon bolus

•Oral motor exercises (VHI, Oral Images, etc.)

•Mendelsohn maneuver – maintains elevation of the larynx to decrease pooling and assists to sequence swallow (see handout)

•Supraglottic and super-supraglottic swallow – assists patient with airway closure and clearing of airway (see handout)

• Shaker exercise

• •Laryngeal adduction and breath hold exercises (valsalva maneuver) – used to strengthen and assist with laryngeal closure.  Typically done by pushing/pulling while phonating vowel sound or by taking breath and ‘bearing down”/contracting diaphragm while holding breath (consider cardiac precautions!)

• estim

Supraglottic swallow

1.Inhale and hold breath

2.Small bite or sip

3.Swallow (keep holding breath

4.Cough

5.Swallow

6.Breathe

Remedial/rehabilitative interventions FES

•Pulmonary exercises … Why?? – trunk extension & shoulder/scapular retraction/adduction  with inhalation, trunk forward flexion & shoulder protraction/abduction with exhalation

•IS (‘peak flow meter’), flutter, ‘Breather’

•Inhale/cough

•Pulmonary exercises … Why?? – trunk extension & shoulder/scapular retraction/adduction  with inhalation, trunk forward flexion & shoulder protraction/abduction with exhalation

•IS (‘peak flow meter’), flutter, ‘Breather’

•Inhale/cough

Remedial/Rehabilitative intervention ideas for Oral motor

• – tongue lateralization, tongue movements (praxis, strength)

•‘therapist on a shoe sting’ ideas:  Life Savers

•Oral motor – lip closure and seal (‘Facial Flex’, ‘button pull’)

• multi sensory facilitation/inhibition (flavor, spin, vibration, touch, pressure, texture, may also include the visual input of the prep and the auditory input )

• jaw strengthening for chewing/mastication

Remedial/Rehabilitative intervention ideas for pt, caregiver and staff eductaion resoruces

jaw strengthening for chewing/mastication

Alternative/Supplemental feeding routes

•Nasogastric tube (NG tube) – through nose, down esophagus, into the stomach.  Usually short term (6 weeks or less)

•Gastrostomy (G tube) – directly placed into stomach (surgically – typically concurrent with other abdominal surgery).  Usually for long-term feedings

•Percutaneous Endoscopic Gastrostomy (PEG tube) – performed under local anesthesia, functionally, same as G tube.

Additional clinical considerations

•Ways physicians think of dysphagia evaluation

1.‘Water’ tests (screenings)* … why might this be problematic? 

2.Bedside evaluation with test tray

3.Instrumental evaluations* (MBS & FEES)

•Free water protocols

•Ethical issues (non-compliant patient, non-compliant family [a true story about fried chicken and Cheetos!], non-compliant staff,  end of life issues, balancing nutrition/hydration with risks, informed consent)

•What can be done about purees? (power of presentation!) - MOLDS!!

•Medications – what general types and what symptoms can they produce? 

•Timing of medications (Parkinson’s)

•Respiratory                      swallow cycle

•Can dysarthria of speech be used as indicator? (statistical correlations vs. clinical applications) - NOOOOO

One of the leading risk factors for aspiration is

Being dependent with feeding

• Importance of promoting self feeding'

• Staff training

Role of Oral care

• Clean them out bc we dont want them swallowing gross stuff

When would you refer for an instrumental evaluation?

• Things we cant see

• Request a refferal

• If we see any symptoms of pharyngeal stage issues we refer IMMEDIATELY (E.g. Coughing/Choking, Changes in pulse ox, during palpation not great elevation, delay in swallowing, after swallow there is gurgling, voice quality is gurgly after)

Interventions for FES if OT gains more training/experience w it

1.Everything in the ‘generalist’ category +

2.May be more involved identification and selection of appropriate interventions

3.Intervention areas may expand beyond feeding to include eating and swallowing

4.Interventions may expand to include restorative (as appropriate) in addition to compensatory

5.Train other OTs regarding F-E-S interventions

Intervention of FES as generalist

1. Address feeding (factors influencing independence with self-feeding, including sensory, motor, cognitive, perceptual, task, environment, positioning, AE, &/or compensatory strategies)

2.Collaborate with other members of the IDT (including ST) – observe precautions and carryover compensatory swallow strategies recommended by ST in OT ADL feeding sessions

3.Ensure recommended diet is observed during OT sessions

4. Monitor for s/s of dysphagia and report observations to relevant members of the IDT

Bedside Evaluation of Dysphagia

• More of a speech assessment

• VERY VERY LONG - 7 Pgs long

• Areas of eval: Cog and communication screening, Oral motor exam, Test tray