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

PHYSIOLOGIC ABNORMALITY chin tuck

• Primarily used for delayed onset of pharyngeal swallow where

protection of airway is latent.

• Secondarily may have applications in management of pharyngeal

weakness or decreased laryngeal elevation resulting in post swallow

vallecular or pyriform sinus residual

• Although research has shown that pharyngeal pressures are not

altered, the repositioning of structures may facilitate pharyngeal

clearance.

chin tuck SYMPTOMS

pre-swallow pharyngeal pooling secondary to delayed pharyngeal

swallow; post swallow vallecular residual

chin tuck EFFECT

• Improves bolus control and decreases delayed onset

• Widens valleculae

• Narrows airway entrance

• Pushes epiglottis posteriorly

• Positions base of tongue (BOT) towards posterior pharyngeal wall

(PPW)

chin tuck POTENTIAL CONTRAINDICATIONS

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

airway)

• Poor lip/oral closure • Reduced neck flexibility (e.g., due to radiation therapy)

• Recent C-spine surgery, need for cervical collar/brace

Head Rotation/Turn

effect

EFFECT

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

opposite side • Makes lumen of pharynx smaller, increases pressure • Reduces UES tone • Extrinsic pressure on thyroid cartilage

Head Rotation/Turn

CONTRAINDICATION

Reduced neck flexibility (e.g., following radiation therapy)

• Recent C-spine surgery, need for cervical collar/brace

head tilt

PHYSIOLOGIC ABNORMALITY

Structural abnormality, reconstruction of pharynx, obstruction in

pharynx unilaterally resulting in poor bolus flow, weakness, residue on one side

head tilt effect

Uses gravity to direct bolus down one side

head tilt

CONTRAINDICATION

• Reduced neck flexibility (but sometimes head tilt is more possible than

head rotation)

• Recent C-spine surgery, need for cervical collar/brace

neck extension

PHYSIOLOGIC ABNORMALITY:

Primarily suggested for use in patients with profound oral phase

impairment but intact airway protection

• Post swallow oral residual, poor bolus transfer

neck extension

EFFECT

Employs the effects of gravity to aid bolus transfer; bolus falls off of

base of tongue into the pharyngeal cavity. Gravity pulls the bolus into pharynx

neck extension

CONTRAINDICATION

• Reduced neck flexibility (e.g., following radiation therapy)

• Recent C-spine surgery, need for cervical collar/brace

• Poor airway protection

airway protection stratagies

supraglottic swallow

super-supraglottic swallow

Supraglottic Swallow

• PHYSIOLOGIC ABNORMALITY

• Utilized in cases of inadequate airway protection mechanisms when

aspiration is documented or at high risk

• Indicated particularly when patient is known to be a silent aspirator.

Supraglottic Swallow

EFFECT

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

airway protection

• The lungs are filled and the vocal folds firmly sealed through conscious

effort prior to the swallow, with a volitional cough/forced expiration

immediately following to clear laryngeal coating/potential aspiration

Airway protection: Supraglottic Swallow Steps

1. hold the food in your mouth taje a breath through your nose

2. hold your breath

3. swallow

4. cough and swallow again

Supraglottic Swallow

• CONTRAINDICATION:

• Unable to tolerate apneic periods

• Cognition - need to be able to coordinate steps accurately

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

Poor bolus drive

• Pharyngeal residue

Effortful Swallow

EFFECT

• Generally thought to target decreased pharyngeal stripping, and/or

pharyngeal weakness

• Increased pressure on the bolus is generated by effortful swallow

Effortful Swallow

• Rationale

• Hind, Nicosia, Roecker, Carnes, Robbins (2001)

• Increased oral pressure with effortful swallow • Increased duration of

• Maximal anterior hyoid excursion

• Laryngeal vestibule closure

• UES opening • Increased superior hyoid movement (not anterior) • Trend toward increased oral bolus clearance

• Huckabee & Steele (2005)

• Tongue emphasis during effortful swallow à increased sEMG, lingual pressure,

and manometric pressure

Mendelsohn Maneuver

• PHYSIOLOGIC ABNORMALITY

• Inadequate UES opening

• Pharyngeal residue in the pyriform sinuses • Weak hyolaryngeal excursion or pharyngeal contraction

Mendelsohn Maneuver

• EFFECT

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

• Prolonging the swallow prolongs UES opening

Mendelsohn Maneuver

• Rationale

• Logemann & Kahrilas (1990) Case report

• 45 year old medullary infarct; studies over 60 month period. Mendelsohn

improved swallowing efficiency greater than two-fold over other techniques.

• Kahrilas et al. (1991) Manofluorographic study

• Mendelsohn results in prolonged UES opening but not increased diameter of the

UES. Increases hyolaryngeal superior displacement but not anterior displacement.

• Kahrilas, Logemann, Krugler, Flanagan (1991)

• Manofluorography evaluation of Mendelsohn in normals

• Increased anterior superior excursion of the larynx and hyoid

• Thereby delayed UES closure

Mendelsohn Maneuver

CONTRAINDICATIONS:

• One issue... It's hard to teach!

• Augmentative techniques for training - sEMG

• Consider cognitive abilities

Bolus size/rate of intake

• PHYSIOLOGIC ABNORMALITY

May be beneficial for 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

Bolus size/rate of intake

SYMPTOMS:

• Post swallow oral or pharyngeal residual, pre-swallowing pooling

secondary to delayed pharyngeal swallow; impaired oral-pharyngeal response to bolus.

Bolus size/rate of intake

• EFFECT:

Highly variable

• 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. Rate of intake is likewise variable among

patients. • In general slowing the rate of intake may allow for greater oral pharyngeal

efficiency by giving the patient more time to manage the bolus. • Additionally, patients with neurodegenerative disease or chronic obstructive

pulmonary disease may demonstrate significant fatigue during oral intake,

thus requiring control of the length of the meal or rate of intake.

Bolus size/rate of intake

• 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: Use it or lose it

• Early deprivation experiments

• Visual

• Somatosensory

• Auditory

• Motor systems/cerebellum

• Reallocation of cortex

• Tube feeding --> disuse of

swallowing neural circuitry?

Neuroplasticity principle: Use it and improve it

Plasticity induced with training

• Dendritic growth

• Synaptogenesis

• Cortical reorganization

• Neuronal activity • Early intervention!

Neuroplasticity principle: Specificity

• Gains are greatest when training activity matches goal activity

• PO trials - best match

• To n g u e s t r e n g t h e n i n g - second best match

• Bicep curls - furthest match

• May not be possible with severe dysphagia

Neuroplasticity principle: Repetition/Duration

• # reps in a set

• # sets completed

• Duration of rest between sets

• # days exercised during the week

• # weeks exercise is performed

• Dose-dependent studies have not been performed!

Neuroplasticity principle: Intensity

• Needed for adaptation!

Neuroplasticity principle: Salience

• Must weigh the importance of

our experiences

• Motivation

• Attention

• Reward systems

• Plasticity induced best when

movement is purposeful and related to behavior trained

Neuroplasticity principle: Age

• Reduction in:

• Synaptic potentiation

• Neuronal/synaptic atrophy

-age realted swallowing changes

Neuroplasticity principle: Transference

• Complex biological systems are

activated during exercise, with

widespread effects

• Isolated strength training may be

used as a precursor to more

dynamic tasks

• Effects on swallowing mechanism

yet to be seen

How to fix an oropharynx...

Find out how it is broken

Treating Oropharyngeal Dysphagia

• Greater specificity in patient management will ultimately lead to

improved outcomes

• Selecting interventions requires careful consideration of multiple

factors

• Can combine direct (compensatory) and indirect (exercise)

treatment approaches

Goals of Rehabilitation

• To p r o v i d e t h e p a t i e n t w i t h t h e l e a s t -restrictive diet while

protecting the airway and maintaining adequate nutrition and

hydration

• Quality of life and patient preferences are vital in the decision-making

process

• Secondary goals

• Re-establish independent oral feeding

• Meet caregiver's needs and assist them caring for a person with

dysphagia

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 • Provides peak amplitude data - point of greatest muscle activity

in microvolts

• Provides duration of activity

Acplus.com

-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

• Designed specifically to address inadequate tongue base to

posterior pharyngeal wall approximation

• 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 repetitively (x30),

raise and hold (30 sec), x3. • Not a direct swallowing task • Intended for use in patients with inadequate opening of the UES due to

reduced anterior hyolaryngeal excursion

Head-lifting Maneuver

• Ta k e h o m e m e s s a g e

• First option for addressing poor anterior hyoid movement in isolation

• May be first line rehabilitation approach given the importance of hyoid

movement

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; the valve

remains opened as long as air pressure continues.

McNeil Dysphagia Therapy Program (MDTP)

• Uses the act of swallowing as an exercise

• "A simple swallowing technique was employ

NMES

Neuromuscular Electrical Stimulation

• Elicitation of muscle contraction using electric impulses • 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