Comprehensive Guide to Dysphagia Strategies and Motor Learning in Speech Therapy

what is direct strategy

• Directly affecting the bolus or

swallowing physiology

• Posture, compensatory

maneuver, modified diet

• What are we doing for the

patient today?

what is Indirect strategy

• Addresses underlying

physiologic or structural

impairment

• How are we going to make

the patient better for the long-

term?

Direct treatment

• Postural strategies

• Volitional airway protection techniques

• Bolus control strategies

postural stratagies

chin tuck

head rotation

head tilt

neck extension

chin tuck

PHYSIOLOGIC ABNORMALITY

SYMPTOMS

EFFECT

POTENTIAL CONTRAINDICATIONS

postural stratagies

PHYSIOLOGIC ABNORMALITY• Primarily used for delayed onset of pharyngeal swallow where

protection of airway is latent.

SYMPTOMS

pre-swallow pharyngeal pooling secondary to delayed pharyngeal

swallow; post swallow vallecular residual

EFFECT

• Improves bolus control and decreases delayed onset

• Widens valleculae

POTENTIAL CONTRAINDICATIONS

• Residue in pyriform sinus after the swallow (could dump right in to

airway)

• Poor lip/oral closure

• Reduced neck flexibility

Head Rotation/Turn

PHYSIOLOGIC ABNORMALITY:

EFFECT

CONTRAINDICATION

postural stratagies

PHYSIOLOGIC ABNORMALITY:

Unilateral weakness of larynx (vocal fold paralysis)

EFFECT

• Turning head closes off pharynx on that side, forces bolus flow through

opposite side

CONTRAINDICATION

Reduced neck flexibility

head tilt

PHYSIOLOGIC ABNORMALITY

EFFECT

CONTRAINDICATION

postural stratagies

PHYSIOLOGIC ABNORMALITY

obstruction in pharynx unilaterally resulting in poor bolus flow

EFFECT

Uses gravity to direct bolus down one side

CONTRAINDICATION

Reduced neck flexibility

neck extension

PHYSIOLOGIC ABNORMALITY:

EFFECT

CONTRAINDICATION

postural stratagies

PHYSIOLOGIC ABNORMALITY:

profound oral phase impairment but intact airway protection

EFFECT

Gravity pulls the bolus into pharynx

CONTRAINDICATION

Reduced neck flexibility

airway protection stratagies

supraglottic swallow

super-supraglottic swallow

Supraglottic Swallow

• PHYSIOLOGIC ABNORMALITY

EFFECT

airway protection stratagies

PHYSIOLOGIC ABNORMALITY

inadequate airway protection mechanisms when

aspiration is documented or at high risk - silent aspiration

EFFECT

The supraglottic swallow provides volitional, in the absence of reflexive,

airway protection

• CONTRAINDICATION:

• Unable to tolerate apneic periods

• Cognition - need to be able to coordinate steps accurately

Supraglottic Swallow how to do it

1. Hold the food in your mouth, take a breath through nose

2. Hold your breath

3. swallow

4. cough and swallow again

Super-Supraglottic Swallow

same as the other but with more effort

bolus control stratagies

bolus control

Mendelsohn Maneuver

Bolus size/rate of intake

Effortful Swallow

PHYSIOLOGIC ABNORMALITY

bolus control stratagies

PHYSIOLOGIC ABNORMALITY

Poor bolus drive

EFFECT

target decreased pharyngeal stripping, and/or

pharyngeal weakness

Mendelsohn Maneuver

• PHYSIOLOGIC ABNORMALITY

EFFECT

CONTRAINDICATIONS

bolus control stratagies

PHYSIOLOGIC ABNORMALITY

• Inadequate UES opening

• Pharyngeal residue in the pyriform sinuses

• Weak hyolaryngeal excursion or pharyngeal contraction

EFFECT

• Prolonging the swallow prolongs UES opening

CONTRAINDICATIONS:

hard to teach

Mendelsohn Maneuver

how to do it

How to do it: Swallow---at height of laryngeal excursion maintain

suprahyoid contraction to prolong the swallow---relax/complete the swallow

Bolus size/rate of intake

• PHYSIOLOGIC ABNORMALITY

EFFECT:

• CONTRAINDICATION

bolus control stratagies

PHYSIOLOGIC ABNORMALITY

patients with poor oral control or pharyngeal weakness in which a large bolus is too difficult to manage, or a small bolus provides too little sensory input

EFFECT:

Smaller boluses may allow for greater control and less scatter to oral

recesses with more efficient manipulation and a more cohesive bolus.

• With a heavier bolus and more variable texture, the patients sensory system

is better stimulated, thus facilitating greater oral-pharyngeal awareness and

more efficient bolus control

• CONTRAINDICATION

Alterations in rate of intake or bolus size should be carefully validated

during diagnostic exam to assure that strategy does not increase aspiration risk

Ta k e h o m e p o i n t s of componsation

• Direct compensatory strategies are to be used immediately

during instrumental eval, to change bolus flow or physiology

• Need to test with instrumental evaluation! Can't assume they

will help!

• Might do them long term, can become habitual

speech motor learning

DIVA model

Motor Performance control

Performance (control)

• Observable behavior

• Te m p o r a r y

• May not be due to practice •

May be influenced by

performance variables

• Fatigue, motivation, attention

motor learning automatic

Learning (automatic)

• Inferred by performance

• Relatively permanent

• Due to practice

• Not influenced by performance variables

Performance (feedback control)

• Diet modifications

• Compensatory strategies

• Postural strategies

• Airway protection strategies

Learning (feedforward - automatic)

• Masako

• Mendelsohn

• To n g u e s t r e n g t h e n i n g

• CTAR/Shaker

• EMST

• PO trials

Goals of Dysphagia Management

• Least-restrictive diet while protecting airway and maintaining

nutrition and hydration

• Independent oral feeding

• Meet caregiver needs and assist them

Depends on the patient and scenario!

motor performance pros

Reduces immediate risks

• Requires less training

motor performance cons

No errors!

• Not learning/retention

• No generalization to other

bolus types

Characteristics of motor learning

• Improvement

• Consistency, stability

• Persistence

• Adaptability

motor learning Consistency

Learning can continue during the course of plateaus • Could also be a ceiling/floor effect

motor learning Persistence

Assess motor skill after a period of no practice • Think "maintenance" or "detraining"

In terms of swallowing, we can get "practice" every day!

motor learning Adaptability

Can you perform a skill that is different than the one you

practiced, or in a different context/situation? • Novel context

• Different stimuli • Physical environment

Stages of motor learning

• Fitts and Posner's Three-Stage Model

1. Cognitive stage

2. Associative stage

3. Autonomous stage

Fitts/Posner 1: Cognitive Stage

• Performance based on cognitive/verbal processes • Gains are dramatic and large

• Result of understanding what

you need to do • Then getting better

at the actual movement

• Determine strategies

• Retain good strategies

• Discard inappropriate strategies • Inconsistent performance

• High variability

Fitts/Posner 2: Associative Stage

• Establish motor patterns

• Determine most effective strategies

• Improvements are more gradual

• Movements are more consistent

• Verbal aspects drop out

• Detect errors as you are performing

the skill (but aren't able to fix it

during movement)

• Can last hours to years

• May never leave this stage

• Depends on complexity, practice

Fitts/Posner 3: Autonomous Stage

• Reduced attentional demands

• Skill has become largely automatic

• Less interference from simultaneous

activities (Can multi-task)

• Processing information from other

aspects of the task (e.g., Playing an

instrument - put emotion into the piece

once you know the notes)

• Detect and correct errors

Swallow Motor Learning Research - Key Points

• Skill-based swallowing training (alternative to muscle strengthening) •

• Exclusive use of short-term compensations can:

With practice, the learner can explore and better converge on a solution

Novel cough skill training for individuals with Parkinson's

Peak flow increased (cough was

stronger) for voluntary cough

But did not translate to an

untrained task (reflexive cough)

Swallow motor learning research is limited!!!

True

Principles of Experience-Dependent Neural Plasticity

• Use it or lose it

• Use it and improve it

• Specificity

• Repetition

• Intensity

Kleim (2008)

• Time

• Salience

• Age

• Transference

• Interference

Neuroplasticity principle: Specificity

• Gains are greatest when training activity matches goal activity

Neuroplasticity principle: Salience

• Must weigh the importance of

our experiences

• Motivation

• Attention

• Reward systems

Swallow Therapy

Principles

• Restore physical

integrity

• Increase airway

protection

• Increase swallowing

efficiency

Strength Training/Motor Adaptation

• In order for change to occur, you must challenge the

system beyond its normal functioning capacity Pollock (1998)

• Simply swallowing may not be enough to improve function!

Must make it more challenging to achieve change!

Oral Motor Exercises

• "Tongue wagging"

• Range of motion exercises

• Pucker/retract lips

• Ya w n

• Gargle

• Hard /k/ or /g/

To n g u e S t r e n g t h e n i n g tool

To n g u e o m e t e r

Progia Swallow Therapy System

tongue strengthening tools

oral motor exersize outcomes vs tongue strengthening

oral motor has no reaserch behind it but tongue strenghting does

effortful swallow

To n g u e e m p h a s i s d u r i n g e f f o r t f u l s w a l l o w --> increased sEMG,

lingual pressure, and manometric pressure

Surface EMG

• Surface electrodes placed at suprahyoid muscles

-immediate biofeedback

Masako Maneuver

What is it?

• To n g u e h o l d i n g maneuver... Swallow with tongue stabilized

anteriorly between teeth

• If tongue cannot retract fully, forces posterior pharyngeal wall

to increase contraction

• Increased aspiration risk with a bolus....not a compensatory

technique! Don't try this with water!

Head-lifting Maneuver

• What is it?

•

• Lying in bed, raise head from level

Not a direct swallowing task •

Intended for use in patients with inadequate opening of the UES due to

reduced anterior hyolaryngeal excursion

First option for addressing poor anterior hyoid movement in isolation

Head-lifting Maneuver

Alternative to head-lifting maneuver

CTAR

chin tuck against resistance

Expiratory Muscle Strength Training (EMST)

Exercise consists of blowing into the device through the

mouthpiece with sufficient effort to release the valve;

McNeil Dysphagia Therapy Program (MDTP)

• Uses the act of swallowing as an exercise

• "A simple swallowing technique was employ

NMES

Neuromuscular Electrical Stimulation

• Functional Electrical Stimulation: pairing the stimulation simultaneously or intermittently with a functional task

In sum

• Treatment should:

• Problems

• Treatment should:

• Provide evidence of physiologic improvement

• Demonstrate a functional benefit to the patient • Problems

• Adherence

• Poor progress

• Clinician desperation!

Suprahyoid stimulation

WHO knows if she asks a question on this just take the loss