Intervention

Short-term

Compensation in dysphagia treatment is intended to be what length of time?

Adjusts aspects to increase safety & efficiency

What do compensations do to the swallowing mechanism?

Chin tuck / head flexion

This compensation narrows the oropharynx and is often used to prevent premature spillage of the bolus

Double swallow or re-swallow

This compensatory strategy focuses on reducing residue

Pacing

This group of compensations may include putting down utensils between bites

Long-term

Rehabilitation is intended to result in what type of effects? (time period)

Improves aspects of the swallowing mechanism

What impact does rehabilitation have on the swallowing mechanism?

Mendelsohn maneuver

This rehabilitation approach targets hyolaryngeal excursion and cricopharyngeal opening. It can be difficult for patients to learn

Supraglottic swallow

This rehabilitation techniques includes a breath hold for glottic closure and a re-swallow to decrease residue

Chin tuck against resistance

This rehabilitation technique is similar tothe Shaker technique or head-lift exercise, but is completed with resistance

Aspiration

This word describes food, liquid, or other material entering the airway.  It is the word missing from this category title

Health status

Which of the three pillars of pneumonia from aspiration refers to immunity and body conditioning?

Oropharyngeal environment / oral hygiene

This one of the three pillars of pneumonia from aspiration refers to a specific bodily environment and bacterial levels

Tube feeding

This method of nutrition/hydration was associated a higher risk of aspiration, according to Langmore et. al.

Dependence for oral care or feeding

Langmore et. al. found that dependence for two specific tasks is associated with higher risk of developing aspiration pneumonia.  Name one of these tasks

• Diagnoses

• Voluntary or involuntary process

• Stage of deficit

• Severity of deficits

• Eating history

• Psychosocial factors

• Caregiver factors

• Treatment options available

• Anticipated risk and benefits

• Functional outcomes

List 2 considerations in choosing a dysphagia treatment

• Chin tuck / flexion

• Head extension

• Head tilt

• Head turn

• Side-lying

List two compensatory strategies that use posture or body position

• Decreased hydration

• Poor compliance

• Decreased QOL

• Increased residue

Name 2 potential negative impacts of thickened liquids, other than aspiration

• Improved glottal closure

• Improved PES opening

List the 2 primary goals or physiological impairments targeted by surgical interventions in dysphagia intervention

• Decreased risk of dehydration

• Increased compliance with swallowing precautions

• Improved QOL

2 benefits of free water protocol

Prevention

Dysphagia management focuses on 3 areas: compensation, rehabilitation, and the third area which involves screening, education, oral care, and development of best practices

Adjunctive modalities

This group of interventions are paired with traditional rehabilitative techniques in dysphagia treatment

Neuroplasticity

The ability of the nervous system to change itself, form new connections and create new neurons in order to compensate for injury or adapt to changes in the environment

Progression

This exercise principle is described as systematically increasing the intensity and demands spent in exercise

Dosage

This term refers to when, how, and how often exercises or parts of exercises are completed

• Demonstration of skilled need

• Specificity-targeted to a particular treatment goal

• Effectiveness-expectation of improvement within a reasonable time

• Education

These items should be included in dysphagia documentation to demonstrate medical necessity

• What options are available?

• Which option(s) match the clinical indicators of the client?

• Anticipated risks & benefits

• Functional outcome – is it something we can improve? What do we expect in the outcome?

• Patient empowerment – want them to make informed decisions (patients can say no & need an active role in therapy)

Additional questions when choosing a specific treatment technique

• What is the purpose of the technique?

• What are the details of the technique?

• What is the physiological impact on the swallowing mechanism?

• Does this technique fit with the needs and limitations of my patient?

When looking at evidence-based practice of a technique, what questions should you ask yourself?

Anti-reflux medications

What type of pharmacological intervention is used for esophageal dysphagia?

• Screening

• Education

• Oral care

• Development of best practices

What are some things we look at when preventing or minimizing dysphagia in high-risk populations?

False

T or F: Compensation techniques have a lasting effect on the swallowing mechanism

Overload

·       Exercise at sufficient intensity, time, and frequency to challenge muscle and create muscle change

·       Increase total time or load used in training

Progression

·       Systematically increasing the intensity (load) and demands (time / frequency) spent in exercise

·       Continually and gradually increase the demands of the exercise activity applied – perform more repetitions, increase the load, go faster

Intensity

·       The load used in an exercise

·       Alter the amount pushed, pulled, or lifted in exercise

Adaptation

·       Repeatedly practicing a movement, skill, or task to alter muscle condition

·       Use continued (regular) practice of a particular exercise patterns

Reversibility

·       The effect of exercise training on muscle will be lost with lack of activity

·       “If you don’t use it, you lose it” – a maintenance plan is needed to prevent detraining

Specificity

·       Exercise should be specific to the goal

·       If your goal is to be a runner, then exercise should include running

Recovery

·       Rest between repetitions of movement or sets of strength-training exercises

·       Ensure sufficient rest between activity to reduce fatigue and stabilize muscle

Head back

Uses gravity to clear oral cavity as there is an inefficient oral transit (reduced posterior propulsion of bolus by tongue)

• Widens valleculae to prevent bolus entering airway; narrows airway entrance, reducing risk of aspiration

• Pushes tongue base backward toward pharyngeal wall

What is the rationale for the chin down technique?

• Delay in triggering the pharyngeal swallow (bolus past ramus of mandible but pharyngeal swallow is not triggered)

• Reduced posterior motion of tongue base (residue in valleculae)

Disorder observed for chin down technique to be done

Places extrinsic pressure on thyroid cartilage, improving vocal fold approximation, and deficits bolus down stronger side

Rationale for head rotated to damaged side

Unilateral vocal fold paralysis or surgical removal (aspiration during the swallow)

Disorder observed for head rotated to damaged side technique to be done

Puts epiglottis in more protective position; narrows laryngeal entrance; improves vocal fold closure by applying extrinsic pressure

Rationale for chin down; head rotated to damaged side

Reduced closure of laryngeal entrance and vocal folds (aspiration during the swallow)

Disorder observed for chin down; head rotated to damaged side technique to be done

Eliminates gravitational effect on pharyngeal residue

Rational for lying down on one side

Reduced pharyngeal contraction (residue spread throughout pharynx)

Disorder observed for lying down on one technique to be done

Eliminates damaged side of pharynx from bolus path

Rationale for head rotated to damaged side

Unilateral pharyngeal paresis (residue on one side of pharynx)

Disorder observed for head rotated to damaged side technique to be done

Directs bolus down stronger side via gravity

Rationale for head tilt to stronger side

Unilateral oral and pharyngeal weakness on same side (residue in mouth and pharynx on same side)

Disorder observed for head tilt to stronger side technique to be done

Pulls cricoid cartilage away from posterior pharyngeal wall, reducing resting pressure in cricopharyngeal sphincter

Rationale for head rotated technique

Cricopharyngeal dysfunction (residue in pyriform sinuses)

Disorder observed for head rotated technique to be done

• Voluntary breath hold usually closes vocal folds before and during swallow

• Closes vocal folds before and during delayed swallow

Rationale for supraglottic swallow

• Reduced or late vocal fold closure

• Delayed pharyngeal swallow

For supraglottic swallow, what is the problem for which it is designed for?

Reduced closure of airway entrance

For super-supraglottic swallow, what is the problem for which it is designed for?

Effortful breath hold tilts arytenoids forward, closing airway entrance before and during swallow

Rationale for super-supraglottic swallow

Effort increases posterior tongue base movement

Rationale for effortful swallow

Reduced posterior movement of the tongue base

For effortful swallow, what is the problem for which it is designed for?

• Reduced laryngeal movement

• Discoordianted swallow

For Mendelssohn maneuver, what is the problem for which it is designed for?

• Laryngeal movement opens the UES; prolonging laryngeal elevation prolongs UES opening

• Normalizes timing of pharyngeal swallow events

Rationale for Mendelsohn maneuver

Improves contact between tongue base and posterior pharyngeal wall

Rationale for tongue hold / mask maneuver

Lack of posterior pharyngeal wall contact with tongue

For Masako maneuver, what is the problem for which it is designed for?

• Health Status

• Airway Protection

• Oropharyngeal Environment

What are the 3 aspects of pneumonia from aspiration?

Free Water Protocol

Permits patients who are NPO or on thickened liquids to have ice chips and/or water between meals when following specific guidelines

Oral hygiene

What is a key ingredient of the free water protocol?

• Adequate cognitive skills to follow instructions

• Motivation to improve

• Willingness to practice independently or with encouragement from caregivers

• A need to increase muscle strength and range of motion

Who is rehabilitative swallowing therapy suitable for?

• Severe cognitive impairments

• Susceptible to fatigue (e.g., those with ALS)

Who is rehabilitative swallowing therapy not useful for?

• Breath hold

• Supraglottic swallow

• Super-supraglottic swallow

• Mendelssohn maneuver

• Effortful swallow

• Masako maneuver

• chin tuck against resistance

• Shaker technique

• McNeill Dysphagia Therapy Program

Examples of rehabilitation approaches and swallow maneuvers

Swallowing and cough treatment

FEES as biofeedback has potential targets for what type of treatment?

Iowa Performance Instrument

This quantifies lingual pressure and endurance as it measures peak lingual pressure in kilopascal

• Objective data

• Immediate feedback to client

• Repeated isometric lingual pressure exercises have been shown to improve tongue pressure and swallow function

Pros of Iowa Performance Instrument

• Consistent placement of the bulb

• Cost

What are some cons of the Iowa Performance Instrument?

Respiratory muscle strength training

Focuses on increasing force-generating capacity of inspiratory and/or expiratory muscles

´Muscle fiber shifts, hypertrophy, increased recruitment of muscle fibers

Physiological changes of peripheral (neuromuscular) adaptation

• Biofeedback can increase appropriate movement

• Increased force & accuracy of movement to facilitate change

Functional change of peripheral (neuromuscular) adaptation

Resistance training

Training methods for peripheral (neuromuscular) adaptation

Synaptogenesis, glial cell proliferation in areas of task behavior

Physiological changes of central (neuroplasticity) adaptation

Sustained & improved neural function in trained task

Functional changes of central (neuroplasticity) adaptation

Motor learning, skill training and how we enhance sensorimotor learning to make permanent changes to make skilled and accurate movements

Training methods of central (neuroplasticity) adaptation

• Compensation

• Rehabilitation

• Prevention

What are the 3 aspects of dysphagia management?

Compensation

Short-term adjustments to facilitate safe oral intake. Adjustments to: posture, food, patient

Rehabilitation

Improvement in swallow physiology that permits increased / expanded safe oral intake

Prevention

• Avoiding or minimizing negative outcomes; food or liquid restriction, nutrition / hydration, deficits, infections, and more

• Preventing or minimizing dysphagia in high-risk population

Development of lingual strength to improve swallowing

What is the goal of lingual resistance?

To strengthen supra hyoid musculature and improve upper esophageal sphincter opening

What is the goal of shaker head lift?

Progressive development, strengthening, and refinement of the muscular components of the swallowing process

What is the goal of MDTP?

• Progression

• Overload

• Adaptation

• Intensity

• Recovery

What are the principles utilized for lingual resistance?

• Adaptation

• Recovery

What are the principles utilized for shaker head lift?

• Progression

• Overload

• Adaptation

• Intensity

• Reversibility

• Specificity

• Recovery

What are the principles utilized for MDTP?