Management of Swallowing Disorders

1
Management of Swallowing Disorders
2
Treatment Planning

• Eating involves the whole person.
• It is not possible or practical to separate the
  person from his/her eating difficulty.
• One should consider the whole personcognitive,
  physical, and/or environmental barriers that may
  affect treatment progression.
• The goal of treatment is improved nutrition and
  hydration status while focusing on techniques and
  strategies to eliminate eating difficulty and
  increase swallow safety.
• Swallowing therapies fall into several
  categories behavioral, medical, or surgical.

3
Behavioral Therapy

• Behavioral therapies are provided by the SLP
  sometimes in conjunction with PT, OT, and/or
  nursing when
• the strength, endurance, and/or mobility of
  structures involved in swallowing are diminished
• diagnostic probes have indicated that swallowing
  may be facilitated, or made safer by bolus
  manipulation, postural compensations,
  facilitative maneuvers, or adaptive devices or
• it is believed that more appropriate initiation
  or timing of certain swallowing events may be
  induced by selective stimulation of particular
  structures or systems.

4
Behavioral Therapy

• Indications for therapy directed toward improving
  the strength, range of motion, endurance, and
  agility of gestures involved in swallowing
  include clear evidence of weakness or limited
  movement of the mandible, lips, tongue, pharynx,
  or larynx.
• These symptoms are typical in certain patient
  populations (e.g., head and neck cancer,
  neurogenic).
• Exercises should be aimed at improving the
  capabilities of residual, impaired swallowing
  gestures, and/or those with the most obvious
  compensatory potential.

5
Behavioral Therapy

• Bolus manipulation of selected materials should
  be individually tailored to the patient.
• Bolus characteristics can be manipulated to
  compensate for timing/coordination or
  construction/patency impairments of the oral,
  and/or pharyngeal chamber or of the
  lingual-palatal, velopharyngeal, laryngeal, or
  PE sphincter.
• Characteristics of the bolus that lend themselves
  to manipulation include
• Properties that maximize sensory feedback about
  the bolus and its position, e.g., temperature,
  taste, size, and texture and

6
Behavioral Therapy

• Properties that affect bolus deformability and/or
  bolus flow in response to gravity or compression,
  e.g., bolus viscosity, bolus size, and bolus
  placement.
• Postural manipulation is indicated when it
  appears that a patient can either redirect bolus
  material in a manner that improves swallowing
  efficiency, improves protection of the airway, or
  both.
• Changes in head/neck and upper body position can
  have a powerful effect on bolus flow through the
  oral and pharyngeal chambers.
• Tilting the upper body or the head changes the
  impact of gravity on the bolus.

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Behavioral Therapy

• Capital flexion, extension, or rotation change
  the size and shape of the pharyngeal cavity and
  may impact PE opening.
• Positional changes do not have to be dramatic to
  be effective.
• Positions that exploit gravity include tilting
  the upper body (making sure to keep cervical
  spine neutral in relation to the thoracic spine),
  and tilting the head (flexion or extension, or
  extend-flex).

8
Behavioral Therapy

• Facilitative maneuvers refer to physiologic
  postures or gestures that have been demonstrated
  to improve swallowing efficiency or safety and
  that a patient can learn to utilize for these
  purposes.
• Facilitative maneuvers require sophisticated and
  active participation by the swallower, good
  muscular kinesthetic and proprioceptive sense,
  movement control, and ability to understand,
  learn, and apply the strategy during swallow.
• Some maneuvers are very familiar and are applied
  spontaneously by patients.

9
Behavioral Therapy

• These include effortful swallow, repetitive
  swallows, and expectoration of pharyngeal
  residue.
• More difficult maneuvers to learn include
  altering the extent and/or timing of laryngeal
  behaviors for swallow, e.g., supraglottic and
  super supraglottic swallow, or for improving or
  prolonging PE opening, e.g., Mendelsohn maneuver.
• Adaptive devices modify the delivery of the bolus
  material into the swallowing tract or change the
  shape of the tract in a manner that positively
  impacts swallowing efficiency and/or safety.

10
Behavioral Therapy

• Examples of such devices include a syringe, a
  modified spoon, different nipples, different
  sizes and shapes of cups and bowls.
• A palatal augmentation appliance or palatal
  prosthesis may be useful in helping reshape the
  oral cavity.
• Finally, communication and environment must be
  considered in behavioral therapy.
• Reduction of noise, light, and other
  distractions, selective positioning, and verbal
  cueing may enhance the patients level of
  alertness.

11
Behavioral Therapy

• Verbal cues, such as the patients name, or
  instructions, such as swallow, close your
  lips, or chew, may be accompanied by visual
  cues or demonstration.
• With children, prefeeding preparation may involve
  rituals, attendance to state, including fatigue,
  readiness/playtime activities, and prosthesis
  placement.
• Sensory cues involving taste or smell can be used
  to heighten alertness.
• During feeding, pacing of bolus delivery may help
  improve breath control and stamina.

12
Medical Therapy

• Medical therapy targets the underlying medical
  condition that results in dysphagia.
• When a neuromuscular disease is the etiology of
  the dysphagia, medications prescribed for the
  patient must be reviewed to determine if any
  contribute to dysphagia (e.g., cholinergic
  drugs).
• GER may contribute to swallowing difficulties and
  may require an antireflux regimen and well
  behavioral modifications.
• Xerostomia impedes bolus lubrication and bolus
  flow and is deleterious to oral mucosal and
  dental health and esophageal GER defense.

13
Medical Therapy

• Treatment of xerostomia includes maximizing
  hydration, limiting mouth-breathing, minimizing
  use of products that contribute to xerostomia
  (e.g., medications, mouthwashes, toothpastes) or
  favor bacterial growth.

14
Surgical Therapy

• Selective condition may benefit from surgical
  therapy.
• Some structures which may be repaired or altered
  surgically with skin flaps include the soft
  palate and the tongue .
• Surgical procedures are available to correct some
  vocal fold paralyses and other causes of glottic
  incompetence.
• Problems with cricopharyngeal relaxation due to
  neuromuscular disease and/or GERD may necessitate
  a myotomy.
• Esophageal achalasia and strictures are often
  treated with esophageal dilations.

15
Surgical Therapy

• Dysphagia is often multifactorial.
• Surgical therapy may be able to correct part of
  the problem but often other difficulties will
  persist.
• Patients need to be counseling about the
  limitations of surgery so that their expectations
  will be realistic.
• Progress after surgery is more likely to be
  gradual, and a period of post-operative swallow
  therapy may be required to realize the fullest
  benefit from surgery.

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Nutrition Hydration

• Patients who are experiencing dysphagia are at
  risk for malnutrition and dehydration.
• Physical signs of malnutrition include
• dry, flaky skin
• spoon-shaped nails
• small yellowish lumps around the eyes
• dull, dry hair
• night blindness
• gums that bleed easily
• red, swollen lips
• slow-healing wounds

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Nutrition Hydration

• 5 weight loss in 1 month
• 10 weight loss of total body weight and
• weight below 90 of the ideal.
• Factors which can lead to malnutrition include
• NPO status or significantly reduced dietary
  intake for more than 3 days
• burns, trauma, infection, disease processes, or
  surgery increasing nutritional needs
• anorexia from illness or drug use
• alcoholism or substance abuse
• depression
• dysphagia

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Nutrition Hydration

• chemotherapy and radiation and
• intestinal malabsorption disorders.
• Factors which can lead to dehydration include
• decreased water access due to immobility, poor
  visual ability, and/or altered mental status
• presence and severity of dysphagia, leading to
  fear of oral intake
• fear of urinary incontinence, leading to
  diminished food intake
• administration of diuretics
• anorexia
• acute illness imposed on chronic disability

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Nutrition Hydration

• feeding dependency
• impaired communication skills
• impaired cognitive skills
• low frequency of medications
• low frequency of meal consumption
• poor fluid intake of both beverages and solid
  foods and
• administration of either IV radiographic contrast
  agents or high protein enteral feeding, causing
  an osmotic diuresis.
• Physical signs of dehydration include
• dry tongue, mouth, and great thirst
• less urination and dark urine

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Nutrition Hydration

• sunken eyes
• wrinkled skin
• dizziness and confusion and
• rapid heartbeat and breathing.
• In infants, dehydration may be evidenced by dry
  mouth or thick saliva, and small amounts of dark
  urine in diaper.
• The fontanel on the head sinks in when the baby
  is held upright or in sitting position.

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Nutrition Hydration

• Skin forms a "tent" when pinched and stays
  pinched up.
• Dark circles appear around eyes.
• The baby may be fussy, sleepy, not hungry, or
  difficult to wake up.

22
Special Treatment Protocols DPNS

• Deep Pharyngeal Neuromuscular Stimulation (DPNS)
  is a therapeutic technique for adults developed
  during a two-year period by Karlene Stefanakos
  (1993).
• Stefanakos claims that traditional compensatory
  techniques have as their focus minimizing the
  function/effect of pharyngeal musculature when
  decreased muscle strength, endurance, absent or
  diminished reflex responses and discoordination
  between pharyngeal reflexes disrupt swallow
  function.

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Special Treatment Protocols DPNS

• DPNS is a systematized therapeutic method for
  pharyngeal dysphagia which utilizes 11 specific
  stimulation techniques within the oral/pharyngeal
  areas. (http//www.speechteam.com/workshops.htm)
• To date, no published results of her ongoing
  study, or specific stimulation techniques are
  available except by attendance at her workshop.

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Special Treatment Protocols Frazier Water
Protocol

• The Frazier Water Protocol (Panther, 2005) was
  implemented in 1984 at the Frazier Rehabilitation
  Institute in Louisville, KY.
• The Frazier Water Protocol was developed in
  response to patients who were non-compliant with
  recommendations for no thin liquids or refusing
  to drink thickened liquids.
• Despite videofluoroscopic evidence of aspiration,
  non-compliant patients at the Frazier
  Rehabilitation Institute were not developing
  pneumonia.

25
Special Treatment Protocols Frazier Water
Protocol

• The guidelines that were developed through the
  multidisciplinary cooperation of physicians,
  SLPs, and a dietician at Frazier were tailored to
  the patients seen in this acute rehabilitation
  environment.
• The acute rehabilitation population can generally
  tolerate three hours of therapy/day, are upright,
  mobile, and relearning to manage functional
  activities.
• A doctors order is not required to implement a
  free water protocol.
• Any patient receiving tube feedings or on
  thickened liquids may have water.

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Special Treatment Protocols Frazier Water
Protocol

• For patients who are eating orally, water is
  allowed between meals only.
• Clinicians who decide to pursue allowing patients
  who aspirate thin liquids to drink water should
  be sure that the water source is safe.
• Make sure that the facilitys internal water test
  meets, or exceeds, the strict requirements
  enacted by the EPA.
• At your initial bedside visit, screen the patient
  with water to determine if the patient is
  demonstrating signs and symptoms of dysphagia.

27
Special Treatment Protocols Frazier Water
Protocol

• Check for level of alertness and presence of
  impulsivity.
• Decide if further dysphagic instrumental
  evaluation is warranted.
• Patients exhibiting impulsivity or excessive
  coughing and discomfort should be restricted to
  water taken under supervision.
• Patients with extreme choking may not be
  permitted oral intake of water due to the
  physical discomfort of coughing, although this is
  a rare occurrence.

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Special Treatment Protocols Frazier Water
Protocol

• Occasionally, a physician may order strict NPO
  for a patient and water or ice chips will not be
  permitted.
• For patient on oral diets, water is permitted
  between meals.
• Water intake is unrestricted prior to a meal and
  allowed 30 minutes after a meal.
• The period of time following the meal allows
  spontaneous swallows and gravity to clear pooled
  solid or thickened liquid residues.

29
Special Treatment Protocols Frazier Water
Protocol

• NPO patients are permitted water any time.
• Patients who are thin liquid restricted wear
  yellow bands to communicate the liquid
  restrictions to all staff.
• The band may also include wording to
  individualize specific compensations, such as no
  thin liquids except water between meals or no
  thin liquids except water by teaspoon between
  meals.
• Water is freely offered to patients throughout
  the day according to the guidelines documented on
  the yellow arm band.

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Special Treatment Protocols Frazier Water
Protocol

• Patients for whom compensations, e.g., chin tuck,
  head turn, etc., have proven successful are
  encouraged to use compensations while drinking
  water.
• Aggressive oral care should be provided to those
  patients who are unable to clean their own teeth
  and mouth so that pathogenic bacteria are less
  likely to contaminate secretions.
• Medications are never given with water.
• Pills are given in a spoonful of applesauce,
  pudding, yogurt, or thickened liquid.
• Family education includes emphasis on the
  rationale for allowing water intake.

31
Special Treatment Protocols Frazier Water
Protocol

• Written material is provided as well.
• Education is documented in the medical record.
• To date, the only published research related to
  the consumption of water by patients with
  dysphagia was conducted by Garon, Engle, and
  Ormiston (1997).
• 20 patients with hx of stroke and aspiration of
  thin liquids during a videofluoroscopic swallow
  study were randomly assigned to two groups.
• The control group received thickened liquids
  while the experimental group received thickened
  liquid and water between meals only upon request.

32
Special Treatment Protocols Frazier Water
Protocol

• Prior to drinking water, patients were required
  to pre-rinse in an effort to reduce the volume of
  bacteria in the oral cavity.
• No patients in either group developed pneumonia
  or dehydration during the conduction of the study
  or during a 30-day follow-up period.
• A significant difference in thickened liquid
  intake per day was found between the groups.
• The control group took more thickened liquids,
  although the experimental group drank more fluids
  overall.

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Special Treatment Protocols Frazier Water
Protocol

• Mean days from onset of stroke to end point of no
  thin liquid aspiration was 39 days for the
  control group and 33 days for the experimental
  group.
• Patients allowed water reported a high degree of
  satisfaction and reported that thickened liquids
  did not quench thirst.
• None of the patients in the control group
  reported satisfaction with thickened liquids and
  all reported a desire for ice chips or water to
  quench thirst.

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Special Treatment Protocols E-Stim

• Functional Electrical Stimulation (FES) or
  E-stim, is the artificial elicitation of a muscle
  action potential to generate useful body
  functions.
• Electrical stimulator devices, called
  neuroprostheses, provide short bursts of
  electrical impulses to the nervous system to
  produce sensory and/or motor functions.
• Over the past 40 years, neuroprostheses have been
  developed for a wide variety of applications.
• Cochlear implants are one type of neuroprosthesis
  that has achieved great success.

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Special Treatment Protocols E-Stim

• Other neuroprostheses, such as those for upper
  limb and lower limb function have not yet matured
  to a level that creates a significant consumer
  demand.
• Attempts to develop electrical stimulation
  devices for assisted swallowing have been few,
  but researchers have begun building a foundation
  for future developments.
• Some preliminary studies have been carried out to
  assess the feasibility of electrical stimulation
  in the treatment of chronic dysphagia.

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Special Treatment Protocols E-Stim

• The major problems with the proposed
  neuroprostheses are that they use very primitive
  forms of electrical stimulation and do not aim to
  produce specific muscle actions that contribute
  to the dynamic process of swallowing (Thrasher
  Popovic, 2004).
• The first pilot study of neuromodulation
  (electrical stimulation of sensory neurons to
  induce a reflex arc) to facilitate the swallowing
  reflex was conducted in 1997 by Park, ONeill,
  and Martin.

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Special Treatment Protocols E-Stim

• The neuroprosthesis they constructed consisted of
  an appliance worn on the palatal surface that
  delivered a continuous train of electrical
  impulses to the soft palate via a pair of
  electrodes.
• The stimulation was well tolerated by all four
  subjects who participated.
• Somewhat positive results were reported for this
  type of approach, suggesting that continuous,
  twitch-like stimulation of the soft palate might
  heighten the sensitivity of the swallow reflex
  although there is no physiological theory to
  support this.

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Special Treatment Protocols E-Stim

• Another study by Freed, Freed, Chatburn, and
  Christian (2001) examined the effects of
  continuous electrical pulse delivery by a pair of
  surface electrodes located on the neck in
  reducing severity of aspiration and subsequent
  need for gastrostomy in a group of 110 patients
  with a history of swallowing disorders caused by
  stroke.
• Specifically, a pair of electrodes was placed in
  one of two configurations one electrode above
  the lesser horns of the hyoid bone and the other
  roughly 4 cm below it or both electrodes above
  the lesser hyoid bones bilaterally.

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Special Treatment Protocols E-Stim

• The digastric and thyrohyoid muscles likely
  received direct stimulation from this electrode
  placement.
• The neuroprosthesis was applied as an
  intervention for 60 minutes per day and was
  tested against another intervention, thermal
  stimulation.
• While the authors reported overwhelming success,
  their methodology was judged to be flawed.
• Subsequent studies, with more rigorous
  methodology, are being undertaken

40
Special Treatment Protocols E-Stim

• A 2-channel version of the neuroprosthesis
  described by Freed et al. has been commercialized
  as the VitalStimTM and has received FDA approval.
  
• A more recent study has looked at different
  muscle recruitment strategies for augmenting
  laryngeal elevation via FES (Burnett, Mann,
  Cornell, Ludlow, 2003).
• Many suprahyoid and infrahyoid muscles are
  simultaneously active early in the pharyngeal
  phase of swallowing, when laryngeal elevation
  begins.

41
Special Treatment Protocols E-Stim

• Geniohyoid, mylohyoid, and digastric muscles are
  used selectively by different individuals, with
  some individuals using all three muscles at the
  onset of swallowing and other using different
  pairs (Spiro, Rendell, Gay, 1994).
• In their study, Burnett et al. utilized
  hooked-wire monopolar electrodes inserted into
  mylohyoid, thyrohyoid, and geniohyoid muscle
  regions in 15 healthy men selected for having a
  highly visible thyroid prominence for
  videotaping.

42
Special Treatment Protocols E-Stim

• During trials of single, bilateral, and combined
  muscle stimulations, thyroid prominence movements
  were video recorded, digitized, and normalized
  relative to elevation during a 2-ml water
  swallow.
• When an individual muscle was stimulated, it
  induced approximately 30 of the elevation
  observed during a swallow and about 50 of
  swallow velocity.

43
Special Treatment Protocols E-Stim

• When paired muscles (bilateral mylohyoid,
  bilateral thyrohyoid, or ipsilateral mylohyoid
  and thyrohyoid) were stimulated, there was
  approximately 50 of the elevation and about 80
  of the velocity produced during a swallow.
• Paired muscle stimulation produced significantly
  greater elevation than single muscle stimulation.
• The authors felt that their findings suggested a
  possible role for paired muscle stimulation as a
  means for augmenting laryngeal elevation and
  improving airway protection in patients with
  dysphagia.
• Be on the look out for more studies by these
  folks!

44
Special Treatment Protocols Muscle Interventions

• Strength training is a common strategy approach
  in dysphagia management for muscle weakness from
  either acute insult or atrophy.
• If your aim is to increase the strength of a
  muscle, you should have the patient participate
  in short repetitions of the movement under heavy
  load/resistance.
• If you work the muscle in lengthy repetitions
  under light load/resistance, you are going to
  increase muscle endurance not strength.
• Stretching is another active exercise sometimes
  used in dysphagia management.

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Special Treatment Protocols Muscle Interventions

• Stretching can be passive or active.
• It can increase or decrease tone.
• If you stretch a muscle quickly, you increase its
  tone.
• If you stretch a muscle slowly, you decrease its
  tone.
• Decreased tone can improve range of motion.
• Active range of motion can reduce tissue
  adhesions, scars, and contractures.
• Passive range of motion does not increase
  strength or endurance nor prevent atrophy.
• Passive warming before stretch can increase range
  of motion.
• Warming without stretch does not change range of
  motion.

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Special Treatment Protocols Muscle Interventions

• Warming elevates threshold for pain so one is
  able to stretch further without pain.
• Warming reduces muscle spasm and improves blood
  flow which may facilitate muscle strength.
• Icing temporarily reduces nerve conduction and
  may be effective for increasing range of motion
  at the early stages of the stretch.
• There is limited data on range of motion
  exercises for swallowing.
• Range of motion exercises without resistance may
  not act against atrophy.

47
Special Treatment Protocols Muscle Interventions

• Lets look at some traditional swallow treatments
  and the focus of the exercise and the outcome.
• Lip puckeran endurance exercise maintains
  muscle.
• Tongue protrusion/retractionan endurance
  exercise maintains muscle.
• Sucking/blowingan endurance exercise maintains
  muscle.
• Hard swallowan endurance exercise slow to
  fatigue.

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Special Treatment Protocols Muscle Interventions

• Pushing tongue against tongue bulba strength
  exercise increases tongue strength bit faster to
  fatigue.
• Mendelsohns maneuvera strength exercise
  increases strength but faster to fatigue.
• Falsetto maneuver (lateral movement of the
  pharyngeal walls)an endurance exercise
  maintains muscles.
• Pushinga strength exercise increases strength
  but faster to fatigue.

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Special Treatment Protocols Muscle Interventions

• Supraglottic swallowa strength exercise
  increases strength but faster to fatigue.
• Shakera strength exercise increases strength,
  but faster to fatigue.
• Many of our exercises are aimed at the right goal
  but how they are delivered does not achieve the
  level required to change muscle function.
• Force level and duration are important issues in
  retraining the muscular system of swallowing.
• Short periods of activity under loaded conditions
  have significant impact.

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Special Treatment Protocols Muscle Interventions

• Many treatments do not have appropriate intensity
  nor repetitions to make impact.
• After stroke, one should wait about 2 weeks
  before beginning strength and endurance training.
• Muscle atrophy is an important factor in
  swallowing impairment.
• Atrophy happens rapidly.
• Atrophy is greater in regularly used muscles and
  in power muscles.
• Retraining is beneficial
• Exercising atrophic muscles in the malnourished
  individual can cause damage.