Dysphagia Knowledge Check #3 (STOPPED AT COMPENSATORY STRATEGIES SLIDE)

Instrumentation and adult treatment

Name some documentation essentials. (10)

• mental status

• severity

• disorder description

• dysfunction description

• location of residue

• presence/absence of aspiration

• when did penetration/aspiration occur during the swallow

• sensory response to penetration/aspiration

• completion of compensatory strategies

• effectiveness of compensatory strategies

sign/symptom of reduced oral control

premature spillage

sign/symptom of reduced tongue strength

increased residue as bolus viscosity increases

sign/symptom of reduced velopharyngeal closure

nasal regurgitation

sign/symptom of delayed pharyngeal swallow

• head of the bolus reaches the lower edge of the mandible

• no laryngeal elevation is seen

sign/symptom of reduced tongue base movement

residue in valleculae

sign/symptom of pharyngeal wall weakness

residue on pharyngeal wall

sign/symptom of reduced airway closure

penetration or aspiration during swallow

sign/symptom of reduced laryngeal elevation

residue in pyriform sinuses

sign/symptom of cricopharyngeal dysfunction

residue in pyriform sinuses

Name the 10 principles of plasticity.

• use it or lose it

• use it and improve it

• specificity

• repetition matters

• intensity matters

• time matters

• salience matters

• age matters

• transference

• interference

What is the best exercise to improve a swallow?

swallowing!

Name the three groups of treatment approaches.

• medical

• surgical

• behavioral

What are the 3 surgical interventions for adults with dysphagia?

• improved glottal closure

• protection of the airway

• improved pharyngoesophageal segment opening

What are the 4 behavioral compensations for adults with dysphagia?

• diet modification

• positioning

• trained strategies or accommodations

• adaptive tools

chin up positioning

• tongue dysfunction

• facilitates bolus transfer using gravity

chin down positioning

• delayed pharyngeal swallow, reduced base of tongue

• widens vallecula, base of tongue (BOT) closer to posterior pharyngeal wall (PPW)

head turn to damaged side positioning

• unilateral pharyngeal weakness (stroke)

• closes off pyriform sinus on weaker side

head tilt to stronger side positioning

• unilateral tongue or pharyngeal weakness

• facilitate transfer on stronger side

reclined positioning

• bilateral pharyngeal weakness

• gravity

chin down and head turn to damaged side positioning

• reduced airway closure; unilateral pharyngeal dysfunction

• moves weaker VF to midline

head rotated positioning

• cricopharyngeal dysfunction

• pulls cricoid cartilage away from posterior pharyngeal wall (PPW)

supraglottic swallow manuveur

1. take a deep breath and hold it

2. swallow

3. cough

What’s the rationale for using a supraglottic swallow maneuver?

it closes the VFs before and during the swallow (airway protection!)

super supraglottic swallow maneuver

1. inhale and hold breath tightly

2. bear down

3. swallow

4. cough

What’s the rationale for using a super supraglottic swallow maneuver?

it closes airway entrance by tilting the arytenoid cartilages anteriorly and toward the base of the epiglottis (airway protection!)

modified Valsalva/breath hold maneuver

1. bear down, then swallow

What’s the rationale for using a modified Valsalva/breath hold maneuver?

it closes the VFs before and during swallow (airway protection!)

effortful swallow maneuver

1. swallow hard; push and squeeze with all muscles of the mouth/throat

What is the rationale for using an effortful swallow maneuver?

it improves pharyngeal contraction, decreasing pharyngeal residue (improves bolus clearance!)

Mendelsohn maneuver

1. swallow as you notice the voice box moving up

2. as you swallow, hold it and don’t let it come back down for several seconds

What’s the rationale for using a Mendelsohn maneuver?

it improves laryngeal elevation and duration/width of the cricopharyngeal opening (improves bolus clearance!)

preparatory set/oral hold maneuver

1. hold bolus in mouth for 2-3 seconds then swallow

What is the rationale for using the preparatory set/oral hold maneuver?

it increases oral control/decreases premature spillage

nose hold maneuver

1. hold your nose while swallowing

What is the rationale for using the nose hold maneuver?

it decreases nasal regurgitation

volume regurgitation

a compensatory strategy that limits the amount of liquid per bolus; goal is to reduce penetration/aspiration by controlling quantity and increase oral control

Name two bolus transfer devices.

glossectomy spoon and syringe

glossectomy spoon

a bolus transfer device that moves it to the oropharynx

syringe

a bolus transfer device that places it in the buccal region to bypass the oral cavity

List a few strategies to increase bolus transfer.

• larger bolus (increases sensory awareness)

• sour or cold

• spicy

• carbonated drinks

• put pressure on the tongue with a spoon

• liquified solids

• use a straw or pipette

• adaptive devices

• thermal-tactile stimulation

What are the two restorative exercises for dysphagia?

swallowing and non-swallowing maneuvers

What is the goal of lip closure exercises?

to increase the oral containment of liquids/solids

What is the goal of tongue control exercises?

having a cohesive bolus without any escaping

What is the goal of bolus prep/mastication exercises?

to improve jaw stability and strength

What is the goal of tongue control and bolus transport exercises?

to improve tongue strength and endurance for manipulation, mastication, and front to back bolus movement

What is the goal of practicing initiating a pharyngeal swallow?

to increase the timing of one’s swallow

What is the goal of practicing soft pharyngeal elevation?

to improve nasopharyngeal closure to prevent nasal regurgitation

What is the goal of laryngeal elevation/anterior hyoid excursion exercises?

to improve laryngeal vestibule closure to reduce supraglottic penetration/aspiration

What is the goal of laryngeal vestibule closure exercises?

to improve airway closure/prevent aspiration

expiratory muscle strength training (EMST)

rehabilitative therapy that uses a handheld resistance device to strengthen the expiratory (breathing out) muscles by having the patient forcefully exhale against resistance; used to improve cough strength, airway protection, swallowing function, and respiratory muscle performance.

What is the goal of pharyngeal stripping wave/contraction exercises?

to make bolus clearing through the pharynx more efficient/reduce residue

What is the goal for tongue base retraction exercises?

to improve tongue base movement and strength in order to better propel the bolus

What is the goal for pharyngoesophageal (PE) segment opening exercises?

to improve pharyngoesophageal (PE) segment opening for bolus clearance

What is the goal for esophageal clearance exercises?

to have more timely clearances of the bolus through the esophagus

myofascial release

a manual therapy technique that involves stretching the fascia (layer of connective tissue between the skin and muscles)

done to help loosen hardened/tightened fascia post-trauma; increase ROM, decrease pain