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brainstem stroke affects on dysphagia

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brainstem stroke affects on dysphagia

(oral stage difficulty, delayed/absent pharyngeal swallow)

*incomplete laryngeal elevation/ closure and reduced upper esophageal sphincter opening (aspiration, inability for bolus to enter esophagus)

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dementia affects on dysphagia

(reduced oral awareness, food help in mouth, pharyngeal swallow delay)

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prematurity affects on dysphagia

swallow abilities - 30-40 weeks gestation

weak facial muscles, under developed lungs

uncoordinated or week suck (reflexes 3-8 weeks before birth)

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cerebral palsy affects on dysphagia

degree of motor deficit important

cognitive difficulties inadequate velopharyngeal closure

larynx doesnt elevate, pharyngeal peristalsis

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childhood language disorders

significant difficulties with cognitive or linguistic abilities that support language. Limitation in language form, content, or use that interfere with participation in social academic activities.

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patterns of language impairment

content (semantics), form (syntax, morphology, phonology), use (pragmatics)

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impairments of language form

infants/toddlers (normal is 2 by 2)

-low frequency of vocalization

-lack of syllable productions in babbling

preschoolers (2-5)

-immature or disordered phonology

-grammatical morphology errors

school-age children (5-18)

-difficulties with complex sentences

-poor narratives and expository texts

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impairments of language content

infants/toddlers (0-2)

-understands few words in context

-less than 50 words by 2

preschoolers (2-5)

-restricted vocabulary size

-reduced comprehension of basic concepts

school-age children (5-18)

-incoherent stories

-difficulties with figurative language

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immpairments of language use


-lack of intentionality

-restricted range of communicative functions (appear to be passive observers)

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Indicators of language disorders in children

-test scores

-language sample measures

-negative social, psychological, educational, and vocational consequences

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diagnostic conditions characterized by a language disorder

-specific language impairment (SLI)

-neurodevelopmental disorders

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Specific language development

-significant developmental delays despite normal cognitive functioning, normal childhood experiences, normal hearing and vision, no signs of neurological impairment.

-approximately 7% of the school-age children

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intellectual disability

-significantly subaverage general intellectual functioning (IQ below 70)

-significant limitations in adaptive functioning (self-care, home living, social/interpersonal skills)

-2% of the population

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autism spectrum disorder

pervasive impairments in reciprocal social interaction skills, communication skills, stereotypical behaviors, interests, and activities

-1% of the population

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specfic learning disorder

-difficulty in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities

-cannot be explained by intellectual disabilities, sensory problems, neurological disorders, or poor instruction

-many professionals believe that learning disorders in the areas of speaking and listening are language disorders

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transdisciplinary team approach

one professional is coordinator of care

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multidisciplinary team approach

everyone does their own assessment

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norm-referenced standardized testing

testing against their peers

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Assessment of infants and toddlers

-Known etiologies easiest to diagnose

-Prediction: Which delays will lead to normal development and which will not?

-Parent report is very important (asks how often they have longer sentences, ask questions, and use grammatical morphemes)

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Assessment of Preschoolers

(using language samples of at least 100 udderances) Mean length of utterance, syntactical structures, vocabulary knowledge

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Assessment of School-Age Children

-usually referred by teacher because of academic performance

-narrative analysis (read and retell - looking for form, content, or use issues)

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clinician-centered approaches

-behavioral principles (stimulus, response, reward)

-structured activities

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child-centered approaches (MILEU)

-language facilitation through play

-modeling, self-talk, parallel talk

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expansion language simulation

-repeat the child’s utterance and complete it

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extenstion language simulation

-adds information to what has been said (ex. blue truck -> big blue truck)

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recast language simulation

say the same meaning in a different form (statement becomes a question)

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build-ups and breakdowns language simulation

expansion + breaking utterance into component parts

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intervention for school-age children

literature based intervention - pre-reading discussions, multiple readings of the books, reinforcing concepts (mini-lessons focusing on semantics)

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service delivery: legal issues

section 504 - illegal to discriminate against individuals with disabilities

PL 99-457 (birth to 3) - help families address children’s needs (infant parent programs)

IDEA (3 to 21) - free appropriate public education, less restrictive environment

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causes of brain damage

-Cerebrovascular Accident (CVA)

- Strokes

-Head Injury

- Traumatic Brain Injury


- Neoplasms (tumors)

-Progressive Deterioration (Dementia)

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cerebrovascular accident causes

embolus-moving clots from another part of the body

thrombosis-clot from gradual accumulation of plaque (more common and more recoverable than hemorrhages)

hemorrhages-bleeding in the brain

aneurysm-weakening in the artery that bulges and breaks

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stroke immediate affects

(most prominant 3-5 days after stroke)

-edema-swelling of brain tissue

-infarct-tissue death

-spontaneous recovery- neural reorganization

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TBI immediate affects

-contusions-brain bruising (seen on surface of the brain)

-lacerations- tearing of structures and vessels

-hematomas-areas of encapsulated blood (intracranial-within the blood, meninges-in the tissue surrounding the brain)

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acquired language disorder that results from brain damage, usually to the left hemisphere.

-naming problems (verbal/literal paraphasias, circumlocution)

-fluency problems

-auditory comprehension problems

-agrammatism (function words/ closed class words)

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Broca's Aphasis

-nonfluent, awkward verbal expression

-short phrases and sentences

-slow rate


-auditory comprehension is minimally impaired (good receptive, poor expressive)

-caused by a lesion to broca area (in posterior inferior frontal lobe)

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wernickies aphasia

-impaired auditory comprehension

-fluent speech (normal intonation, stress patterns)

-verbal paraphasias

-"jargon aphasia"

-poor repetition

-reading and writing areas impacted

-damage to wernickies area

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automatic sequences

-"how are you?"

-"doing good"

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talking around a word

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conduction aphasia

-arcuate fasciculus damaged (connects wernickies to brocas)

-minimally impaired auditory comprehension

-good spontaneous speech (fluent ex. hellos and goodbyes)

-hallmark is poor repetition

-literal paraphasias (phonemic paraphasias)

-aim for correction

-should be conductive reading+writing

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anomic aphasia

-"without words"

-inferior parietal/posterior temporal lobe damaged

-word-finding problems (difficulty finding names of objects, pictures, and concepts. paraphasias and circumlocution)

-fluent speech

-good comprehension (good receptive)

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transcortical aphasia

-"watershed strokes"

-widespread damage to the frontal lobe (transcortical motor)

----good conversation but difficulty initiating utterances

-widespread damage to parietal lobe (transcortical sensory)

----poor auditory comprehension but good repetition (looks like wernickies but can repeat phrases. EVERYTHING is a repetition task for people with this aphasia)

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global aphasia

-wide lateral damage to the left hemisphere (typically to larger arteries)

-all parts of language processing severely impaired

-nonfluent, poor reading+writing skills, poor comprehension, poor repetition, hardest to work with

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aphasia assessment

-immediately following brain injury

-spontaneous recovery (SR)

-more formal assessment after SR: focusing on expressive, receptive, reading, and writing,

---conversation, informal diagnostic testing, repetition, reading+writing

-faster we get them into rehab, better we can take advantage of neuroplasticity

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aphasia intervention

empower the patient to communicate successfully -> communication tasks to activate neural plasticity mechanisms ->cues and prompts (pictures, phonemic cues, phonological rhyming) -> compensatory strategies ->family support groups

-"life participation model"

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right hemisphere stroke

-emotional recognition impaired

-demonstrate sensory neglect

-narrative and conversational discourse skills impaired \n -over-detailed

-don’t remain of topic

-visual neglect


-lack deficit awareness

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brain injury

-lack of deficit awareness

-cognitive processing, pragmatics, word finding are most prominent deficits

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-Alzheimers disease is most frequent etiology

-progressive degeneration of both hemispheres of the brain

-problems with working memory, orientation, reasoning, judgment

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generating sound

-object requires mass

-requires elasticity

-example: guitar string or vocal folds (stiff= higher pitch, less tension= lower pitch)

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wavefrom (graph) terminology

simple vs. complex waves

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simple vs. complex waves

simple waves

-vibrates at a single frequency

-rarely occurs in real world


complex waves

-vibrations that contain 2 or more frequencies

-nearly all sounds in real world are complex

-speech, music, applause

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sound propagation

-vibrations cause molecules in air to move

-molecules bump into other molecules making them move

-sound travels at roughly 350 meters per second (roughly 7783 mph)

-as you move further from the sound source the amplitude decreases due to friction in the air

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the ear

outer ear

-funnels sound waves

middle ear

-amplifies waves

inner ear

-turns waves into electrical impluses

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auditory nervous system

auditory nerve, brainstem, auditory cortex

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sound propagation through the ear

-acoustic sound in the ear canal

-sound waves impinge on the TM which vibrates

-causes the ossicular chain to move

-moves the oral window

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outer ear


-visible flap of cartilage attached to the head

external auditory meatus (external ear canal)

-oil gland secrete cerumen (ear wax) - used to protect middle ear pinna

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middle ear

tympanic membrane (ear drum)

-an elastic membrane that separates the outer ear from the middle ear

-converts the acoustic wave into a mechanical wave

ossicular chain

-malleus -connected to tympanic membrane


-stapes-connected to oval window

eustachian tube

-connected to throat, helps equalize pressure in middle ear.

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inner ear

-hollowed-out portion of the temporal bone

-starts at oval window, ends at the round window

contains three sensory organs

-cochlea (hearing)

-vestibule (balance)

-semicircircular canals (balance)

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-hollow tube with 2 1/2 turns

--starts at the oval window

--ends at the round window

-has 3 sections

--scala vestibuli (SV) - filled with perilymph

--scala media (SM) - filled with endolymph

--scala tympani (ST) - filled with perilymph

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basilar membrane

-separates the scala tympani from scala media

-moves in a wavelike manner

-loud sounds create large waves

-soft sounds create small waves


--high pitches are at beginning of membrane

--low pitches are at the end of membrane

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organ of corti

-tonotopic organization

--traveling wave (determined by amplitude and frequency of the sounds)

--hair cells

-outer verses inner

-shearing motion

-depolarization (mechanically gated let channels)

-transduction of energy (cranial nerve VIII-CNS (primary auditory cortex of temporal lobe)) tonotopically organized

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the traveling wave

  1. response always begins at the base of cochlea

  2. amplitude grows as it travels apically

  3. reaches a peak at a point determined by frequency of the sound

  4. vibration then dies out rapidly

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auditory nerve

-8th cranial nerve

-contains 30000 neurons that conduct information in one direction (afferent=neurons from cochlea to brain which conduct sensory information) (efferent=neurons from brain to cochlea which provides feedback for protective functions)

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auditory pathway

cochlea->cochlear nucleus (lower brainstem)->superior olivary complex->lateral leminiscus nucleus->inferior colliculus nucleus->medial genticulate body->auditory complex

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down from brain

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up to the brain

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conductive hearing loss

air conduction - loss

bone conduction - WNL

AB-gap - sig.

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sensorineural healing loss (SNHL)

ac- loss

bc- loss

ab gap-not sig.

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mixed hearing loss



ab gap-sig.

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units of measurement

-sound pressue level (dB SPL)

-hearing level (dB HL)

-sensation level (SL)

-presentation level (patients threshold)

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graph representing levels of hearing

x-axis = frequencies

y-axis = intensity level (in dB HL)

"Normal" hearing level set to 0 dB HL

(0 dB HL is at top of graph)

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possible causes of conductive hearing loss

-outer ear (external auditory meatus occluded ex. cotton swab or wax)

-middle ear (otitis media ex. tubes from ear infection. otosclerosis ex. when ear bones get arthritis)

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possible causes of sensorineural hearing loss

cochlea "sensory"

-prenatal (anoxia, trauma, fetal alcohol syndrome)

-perinatal (disruption during birth process)

-postnatal (meningitis, high fevers, noise exposure, aging)

8th nerve lesion "neural"

-acoustic neuromas (tumor) (ofter starts as tinnitus)

-acoustic neuritis (inflammation)

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degrees of hearing loss threshold values

normal (-10-25 dB HL)

mild (26-40 dB HL)

moderate (41-55 dB HL)

moderately severe (55-70 dB HL)

severe (70-90 dB HL)

profound (90+ dB)

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speech audiometry

speech recognition threshold

-using equally stressed bisyllabic words ex. hotdog, cupcake

word recognition score

-50 word lists that are phonetically balanced. use a carrier phrase ex. "say the word couch"

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Auditory Brainstem Response (ABR)

-testing newborns

-localization of brain lesion sites on auditory pathway

-noncooperative individuals

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Otoacoustic Emissions (OAEs)

-found more in females

-"echo" from OHCs of cochlea

-evoked vs. spontaneous

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audiologic rehabilitation

for those who need to modify communication skills as a result of aqcuired hearing impairments

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audiologic habilitation

children or those who are listening and learning to use speech and lainguage skills for the first time

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steps in hearing aid process

  1. consultation - test hearing, discuss options, earmold impression

  2. fitting - determining hearing aid specifications

  3. aural rehabilitation (AR) groups

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hearing aid fitting goals

-provide audibility for sounds that cannot be heard due to hearing loss (accomplished by ampllifier - measured by gain)

-ensure that output of the device does not reach intensities that will cause discomfort or damage to the person

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difficult listening environments

reverberations - sound reflects from hard surfaces

-carpeting/drapes + softer surfaces (less reverberation)

-reverberation time - the amount of time it takes for an intense sound to decrease by 60 dB after the source is turned off

signal-to-noise ratio (SNR)

-signal intensity minus noise intensity

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cochlear implant

external :

- microphone

-speech processor




-electrode array

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learning to hear


-document softest sound that can be heard w/o amplification


-ability to determine whether two sounds are same or different


-occurs after a child has learned the symbolic representation of the sound

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ossicular chain

malleus, incus, stapes

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difficulty or inability to swallow, may be unable to consume enough food and liquids safely

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when food enters the airway

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4 stages to the swallow

anticipatory, oral, pharyngeal, esophageal

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anticipatory stage

not completely voluntary, before food reaches the mouth, sensory information helps a person prepare for food (visul, olfactory information), allows someone to discriminate desirable and undesirable things to eat.

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oral stage (part one)


prepatory-food is chewed and mixed with saliva (bolus)

lips sealed; larynx/pharynx are at rest,

Masticated in a rotary lateral manner,

sensory input about food: taste, texture, temperature and bolus size,

back of tounge is elevated-bolus in oral cavity.

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oral stage (part two)


transport-tongue pushes bolus up against palate and moves it posteriorly towards pharynx

(size and consistency of bolus dictate lingual strength needed)

-oral phase is over when bolus passes anterior faucial pillars

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Pharyngeal stage

voluntary but more automatic than oral stage

brainstem and sensorimotor cortex are crucial (medulla in brainstem has nerves that control motor movements of larynx/pharynx/tongue)

Physiological events occur simultaneously

-velum elevates and contracts (so there is no nasal regurgitation)

-larynx closes then moves up and forward (we should not be breathing during this process)

-epiglottis covers larynx (flips to protect airway)

-swallow is triggered by sensory info sent to brain

-pharyngeal peristalsis (wave-like contraction where superior, medial, and inferior pharyngeal constrictor muscles contract)

-upper esophageal sphincter opens

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esophageal stage

begins when larynx lowers backward, breathing resumes \n -upper esophageal sphincter contracts \n -bolus moves through esophagus in peristaltic waves (synchronized smooth muscle movements)

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causes of dysphagia in adults

-cerebrovascular accident

-brainstem stroke



-neuromuscular disease


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cerebrovascular accident affects of dysphagia

-left hemisphere damage (oral stage difficulty, delay in pharyngeal swallow initiation (aspiration)

-right hemisphere damage (oral stage difficulty, reduced pharyngeal peristalsis (food getting "stuck" in throat)

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TBI affects on dysphagia

varies according to location and severity of injury

cognitive deficits: choosing food, rule of eating, maintaining attention + may have reduced tongue control, difficulty chewing

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nueromuscular disease affects on dysphagia

multiple sclerosis, ALS, Parkinson's Disease

progressive disease-muscular movements weak and uncoordinated, difficulty at all levels of the swallow

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cancer affects on dysphagia

automatic structure may change from surgery

radiation irritates tissue of mouth and throat

medications lower immune system painful infections of the mouth

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assessment of dysphagia questions

-are the muscles of the tongue, lips, and jaw functioning?

-can patient elevate larynx?

-can patient feed themselves?

-what foods can patient eat safely?

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dysphagia 1, 2, 3, 4

puree, cottage cheese texture, soft solids, regular diet

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noinstrumental clinical exame (NICE)

bedside clinical assessment (ability to take food off plate- cognitive/motor skills)

-level of alertness, oral-motor exam (lips, jaws, tongue, initiation of the pharyngeal swallow), upward movement of larynx? coughing? gurgling sound?

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