NEUROGENICS EXAM 3

swallowing regions

Nasopharynx, Oropharynx, Hypopharynx

phases in the swallow

oral preparatory phase, oral transport phase, pharyngeal transport phase, esophageal transport phase

oral preparatory phase

-first stage of deglutition, & a voluntary process
-sometimes referred to as the buccal phase
-includes: mastication & bolus formation

oral transport phase

transfers bolus from mouth to pharynx

pharyngeal transport phase

transfers bolus from pharynx to esophagus

esophageal transport phase

transfers bolus through esophagus into stomach

dysphagia

-difficulty swallowing
-symptom, not a disease

clinical signs of dysphagia

choking & coughing while or after eating, food sticking in throat, regurgitation, pain while swallowing, drooling, weight loss & nutritional deficiencies, recurrent pneumonia (aspiration pneumonia)

odynophagia

swallowing is painful

aphagia

swallowing is impossible

diagnosing dysphagia (assessment methods)

videofluroscopy & fiberoptic endoscopic evaluation of swallowing (FEES)

videofluroscopy

-x-ray video
-modified barium swallow (MBS) study
-exposes to radiation
-visualizes all phases of the swallow

fiberoptic endoscopic evaluation of swallowing (FEES)

-fiberoptic camera introduced through nose
-dyed food
-can't see pharyngeal phase, just results

nasoendoscopy

flexible endoscopic evaluation of swallowing (FEES), no radiation exposure, cannot ascertain full function of pharyngeal phase, nor any of esophageal phase

clinical swallow exams (screening)

-"bedside swallow exam"
-screening test, no instruments, to see if instrumental assessment is required
-make sure dentures are being worn
-observe feeding history, respiration patterns, mental & neurological status, cough, and voice quality
-sit the patient upright at 90 degrees if possible
-two-ounce water screening test (high specificity, low sensitivity)
-feed different textures
-meal observation

treatment methods for dysphagia

diet modification, postural adjustments, environmental modifications, training of swallowing maneuvers, muscle strengthening, & other

diet modification (treatment methods for dysphagia)

which changes should be made
-what is the expected effect of the change on the person's ability to safely swallow
-specific diets (may be too broad- watch still for individual variability)
-not just texture (temperature & taste, too)

NDD

national dysphagia diet

NDD I (national dysphagia diet)

pureed (homogeneuous texture very cohesive, pudding like, no chewing required)

NDD II (national dysphagia diet)

mechanically altered (cohesive, moist, semi-solid, requires some chewing)

NDD III (national dysphagia diet)

advanced - soft-solid foods that require more chewing ability

NDD IV (national dysphagia diet)

regular (all foods allowed)

postural adjustments (dysphagia)

sit up, chin-down, chin-up, head rotation, head tilt

environmental modifications (dysphagia)

increase alertness, decrease distractions, improve vision

training of swallowing maneuvers

mendolsohn, effortful swallow, supraglottic swallow, supra-supraglottic swallow

mendolsohn (training of swallowing maneuvers)

hold larynx up longer than usual (pause)

effortful swallow (training of swallowing maneuvers)

high effort, lips closed

supraglottic swallow (training of swallowing maneuvers)

-take small sip of liquid, hold breath, swallow
-cough
-and swallow again

super-supraglottic swallow (training of swallowing maneuvers)

same as supraglottic, except with high effort & bearing down during swallow

muscle strengthening exercises

masako, shaker, laryngeal elevation, lingual isometrics

masako (muscle strengthening exercises)

put tongue tip on between teeth, and do a dry swallow

shaker (muscle strengthening exercises)

lay flat on surface, raise head (chin towards chest so you can see your toes), either hold there for a time, or lift and relax multiple times in a sequence

laryngeal elevation (muscle strengthening exercises)

lift larynx & hold (glide up a scale and hold at high note)

lingual isometrics (muscle strengthening exercises)

tongue strengthening against resistance

respiratory swallow training

-pace swallowing & breathing
-pause breathing during an exhalation, so after the swallow, there is still some exhalation left

transcutaneous electrical stimulation

used fairly widely, evidence far from certain

aphasia

an acqiured selective impairment of language modalities and functions resulting from a focal brain lesion in the language-dominant hemisphere that affects the person's communicative and social functioning, quality of life, and the quality of life of his or her relatives and caregivers

language modalities affected (aphasia)

auditory speech comprehension (individual words and sentences), reading (print comprehension), speech production (spontaneous talking), writing, gestural responses, repetition (comprehension + production), oral reading

types of speech production errors (aphasia)

paraphasia (semantic/ phonological), perseveration, neologism, jargon, circumlocution, echolalia, stereotypy

major aphasia types

-8 major types
-often categorized by name, location, extent of insult
-general descriptions only- actual symptoms may vary widely in each individual- individualized assessment still critical

cortical center aphasia types

Broca's, Wernicke's, Global

neural pathway aphasia types

Conduction, Transcortical Sensory, Transcortical Motor, Transcortical Mix

not localized aphasia type

Anomic

Broca's Aphasia

-lesion location: Broca's area
-output: nonfluent; slow, pauses, mostly just content words
-comprehension: mostly intact
-repetition: poor
-writing: nonfluent, matches speech-and usually prints rather than cursive

Wernicke's Aphasia

-lesion location: Wernicke's area
-output: fluent; relatively effortless, but with paraphasias, jargon and circumlocutions
-comprehension: impaired
-repetition: poor
-writing: poor-matches speech-effotless, fast, typically uses cursive

Global Aphasia

lesion location: large area of MCA region
-output: nonfluent; may be limited to a stereotypy or two
-comprehension: poor; even y/n responses may be impaired
-repetition: poor
-writing: poor or absent

Conduction Aphasia

lesion location: arcuate fasciculus
-output: fluent with paraphasia
-comprehension: good
-repetition: poor (often dramatically impaired compared to fluent output)
-writing: probably fluent with paraphasias

Transcortical Motor Aphasia

-lesion location: anterior superior frontal lobe (Broca's area intact but isolated from other areas)
-output: nonfluent (like Broca's)
-comprehension: okay (like Broca's)
-repetition: good (NOT like Broca's)
-writing: nonfluent probably like Broca's

Transcortical Sensory Aphasia

lesion location: upper parietal lobe, isolating perisylvian area
-output: fluent (like Wernicke's); echolalia
-comprehension: poor (like Wernicke's)
-repetition: good (NOT like Wernicke's)
-writing: fluent probably like Wernicke's

Transcortical Mixed Aphasia

-lesion location: areas surrounding perisylvian area ("isolation of the speech area")
-output: poor (like Global)
-comprehension: poor (like Global)
-repetition: good (NOT like Global)
-writing: probably poor like Global

Anomic Aphasia

-lesion location: not clearly localized
-output: fluent, but occasional problems with word finding (anomia) resulting in long pauses, nonspecific words ("thing"), and circumlocutions
-comprehension: good
-repetition: good
-writing: probably good (though with anomia)

epidemiology of aphasia

acute stage (immediately following stroke), chronic stage (long term effects), impacts on healthcare (compared to those with stroke but not aphasia)

-acute stage
-immediately following stroke (epidemiology of aphasia)

30-35% of stroke survivors have aphasia at discharge

-chronic stage
-long term effects (epidemiology of aphasia)

out of every 100,000 people, between 30 and 50 people may have aphasia chronically (ongoing)

-impacts on healthcare
-compared to those with stroke but not aphasia (epidemiology of aphasia)

-increased hospital stay length
-increased medical costs
-reduced communication with nurses

psychosocial effects of aphasia

-impact on quality of life (QOL)
-smaller social networks
-emotional responses to acquiring aphasia
-consequences of acquiring aphasia

impact on quality of life (QOL) (psychosocial effects of aphasia)

reduced, even compared to those with stroke but no aphasia; affected by severity, long term impact

smaller social networks (psychosocial effects of aphasia)

-why? think genres of discourse
-linked to level of social participation and quality of social relationships

emotional responses to acquring aphasia (psychosocial effects of aphasia)

may be fear, anxiety, bewilderment, despair, fury, amusement, frustration, isolation, shock, embarrassment, depression, resignation

consequences of acquiring aphasia (psychosocial effects of aphasia)

-negative: decreased life satisfaction
-positive: freedom from previous restrictions, obligations

supported communication (communicating with individuals with aphasia)

goal: natural sounding, adult conversation
-a good conversation partner can act as a "ramp"
-principle 1: acknowledge competence
-principle 2: reveal competence

principle 1 (communicating with individuals with aphasia)

acknowledge competence: implicity (humor, tone of voice) or explicity (verbal acknowledging they know what they want to say); show you know that aphasia is just covering up their competence, and that they really are still themselves

principle 2 (communicating with individuals with aphasia)

-reveal competence: ensure comprehension (make your message clear)
-ensure avenues for expression (give adequate time, use fixed or yes or no questions, provide pen and paper, etc)
-check responses (show your understanding of what they have communicated)

tips for communicating with individuals with aphasia

-time (be patient, their responses may be unusually slow)
-cognitive load (keep it simple)
-be creative (try writing, gesturing)
-avoid elderspeak (don't "talk down")
-speak directly with the person with aphasia (don't speak primarily with their family or conversational partner) with the person with aphasia as a spectator
-you may need to train their conversational partners in supportive communication

different types of assessment (aphasia)

-interview
-language screenings
-formal full language assessments (WAB-R, BDAE)
-informal assessment of different language tasks (picture description, story telling, following instructions)

background for treatment decision-making (aphasia)

-case history information
-reports from neurology, PT, OT, RP, etc.- what type of limitations, disabilities
-sensory: audiology, ophthalmology
-emotional lability, grief, psych consult

case history information

-prior speech & language & reading pattern, competence
-educational background
-family occupation
-personal interests

treatments for specific language modalities and cases (aphasia)

-based on outcome of evaluation must decide between treatments for language vs treatments for communication: mild and very severe may benefit from communication tips and modification
-examples of language treatment: global aphasia, auditory comprehension, reading comprehension, speech production, writing, functional communication

treatments for global aphasia

-treatment of aphasia perseveration program (TAPP)
-voluntary control of involuntary utterances
-in general, keep goals minimal

treatment of aphasia perseveration program (TAPP) (treatments for global aphasia)

involves imposing delays, increase awareness inhibition of perseveration responses

voluntary control of involuntary utterances (treatments for global aphasia)

take what is already being said, make it the right answer, vary the questions, order, responses required, to obtain the propositional and volitional control over it

in general, keep goals minimal (treatments for global aphasia)

-tx foci: consistent y/n response
-simple gestures, such as for y/n
-small set of "communicative intentions"
-improve auditory comprehension for 1-step commands
-improve patient's writing of daily life word
-improve patient's drawing

treatment for auditory comprehension deficits

picture identification (can build up to multiple words)
-answering y/n questions (q can vary on many levels)
-following spoken directions (hierarchy of complexity
-sentence verification (ex. based on clinician-provided picture descriptions)
-task-switching
-answering questions about discourse samples (play sample recording, then ask questions)

treatment for reading comprehension

-requires word comprehension, syntactic analysis, semantic mapping
-how much of a priority is reading (possibly survival level only)
-starting point: single-word vs discourse comprehension
-surface dyslexia vs deep dyslexia
-flash cards, retraining grapheme to phoneme correspondence, comprehension drills
-adjust difficulty as needed as in treatments for auditory comprehension deficits

treatment for speech production

-repetition drills
-confrontation naming
-sentence completion
-semantic feature analysis (SFA)
-phonologic components analysis (PCA)
-response elaboration treatment (RET)
-verb network strengthening treatment (VNeST)
-helm elicited language program for syntax stimulation (HELPSS)
-melodic intonation therapy (MIT)
-script training

confrontation naming (treatments for speech production)

-present stimulus (object, picture, etc)
-use cueing hierarchies to facilitate (semantic, phonological)
-example that seems to work for multiple aphasia types (first sound, sentence completion, rhyme, function, superordinate)

semantic feature analysis (SFA) (treatment for speech production)

-assisted analysis of the meaning of the word
-frequent association of the word's sound with the word's meaning

response elaboration treatment (RET) (treatments for speech production)

a loose training technique designed for aphasia patients in order to increase the length and information content of verbal responses

melodic intonation therapy (treatment for speech production)

-using rhythm and melody (processed in the right hemisphere) to facilitate verbal production
-important that melody used is not a recognizable melody (popular tune)-could interfere
-rhythm and melody gradually faded down to that of typical speech

script training

the client & clinician work together to create scripts
-a script is a predictable sequence of sentences (story/monologue, between two people/ ordering at a restaurant, words/ sentences easy to predict)

treatments for writing

-often a less important goal than speech production training (normal primary communication mode)
-ex. include, anagram & copy treatment (ACT), copy & recall treatment (CART)

treatment focused on functional communication

-PACE (promoting aphasics' communicative effectiveness)
-supported communication training for conversation partners
-life participation approach to aphasia (LPAA): focus on functional activities/ participation in life

PACE: Promoting Aphasic's Communicative Effectiveness (treatment focused on functional communication

-convey information to a partner (info unknown to the partner), with the clinician modeling behaviors he/she would like the PWA to use
-emphasized that communication requires sender & receiver
-provides practice with comprehension & production

group treatment (benefits)

-economical, efficient
-provides support network
-shares techniques, strategies
-provide opportunities for communication practice with a variety of communication partners in a supported environment

group treatment (disadvantages)

=requires homogenous grouping of patients so everyone experiences success (can't couple severe with mild- frustrating for both)
-scheduling issues
-billing & third party payment issues

basic neurological processes of speech production

cognition (conceptualization), symbolization (linguistic encoding), speech motor planning/ programming, speech motor execution (control and performance), sensory feedback

cognition (conceptualization) associated disorder (processes of speech production)

dementia, cognitive impairments

symbolization (linguistic encoding) associated disorder (processes of speech production)

aphasia

speech motor planning/ programming associated disorder (processes of speech production)

apraxia of speech (AOS)

speech motor execution (control & performance) associated disorder (processes of speech production)

the dysarthrias

sensory feedback associated disorders (processes of speech production)

sensory impairments

motor speech planning/ programming phase

-typically left hemisphere network (linguistic coding, speech motor programming, speech motor execution)
-"transformation of abstract phonemes (or syllables, words, or phrases) into a neural code that is compatible with the operations of the motor system" (from symbolization)
-kinematic parameterization of phoneme strings; translating the abstract phonemes into a motor plan
-generalized motor programs & speech sound maps
-"programming: the musical score/ sheet music"

speech motor execution (control & performance) phase

-the neural and neuromuscular activity required for coordinating & carrying out the physical movements required for speech (execution: the musicians & the instruments)
-anatomically, involves CNS & PNS structures
-functionally, includes: the direct activation pathway (DAP-PCG, SMA, PMA), the indirect activation pathway (IAP/ basal ganglia control circuit, cerebellar control circuit, the final common pathway (LMN-PNS)

motor system

-pyramidal system: mostly voluntary movements)
-extrapyramidal system: involuntary coordination & support of voluntary movements
-includes basal gangliar, thalamic, & cerebellar components
-autonomic nervous system (not completely motor): a branch of it controls basic life- sustaining functions, controlling the heart, smooth muscle, and glands

orchestra metaphor

motor planning & programming: the musical score
-motor execution & performance: the orchestra (apraxia: problems w score, orchestra is okay/ dysarthria: good score, problems with orchestra)

deficit in speech planning & programming =

apraxia of speech

deficit in control circuits, sensory system (feedback), final common pathway, or speech =

one of the dysarthrias

apraxia of speech (AOS)

-impairment at the level of speech motor planning & programming (not a cognitive or symbolization or language deficit/ not a motor control or motor performance/ execution deficit)
-a problem with the sheet music
-often occurs with Broca's aphasia
-developmental form is called childhood apraxia of speech (CAS) or developmental apraxia of speech (DAS)

AOS planning & programming difficulties

may display as difficulty with transitions between sounds, transposition of phonemes, increasing difficulty with increasing complexity of words, slow rate
-inconsistent rate of speech, & trial/ groping behaviors of articulators

dysarthria

-impairment at the level of motor speech execution: control and/or performance (not a cognitive or symbolization or language deficit/ not a motor programming or motor planning deficit/ a problem with the "orchestra")
-deficits in various parameters of neuromuscular movement for any part of the speech subsystems