Dysphagia 101: A Review of the Basics - Ohio Speech
Transcription
Dysphagia 101: A Review of the Basics - Ohio Speech
Dysphagia 101: A Review of the Basics Angela S. Dubis-Bohn M.A., CCC/SLP, BRS-S Objectives • Identify anatomy and physiology as pertaining to the swallowing mechanism • Describe the basic components of a clinical examination for swallowing • Identify appropriate compensatory and rehabilitation techniques based on swallowing dysfunction Stages of Swallowing • Anticipatory Stage • Oral Stage – Oral Preparation – Oral Transit • Pharyngeal Stage • Esophageal Stage Anatomy of Oral Cavity Muscles of Mastication • Temporalis- contraction elevates and retracts the mandible (closing of the jaw). Innervated by c.n. V • Masseter-contraction elevates the jaw (closes the jaw). Innervated by c.n. V • Buccinator-Contraction tenses the cheek, thus maintaining food between the molars. Also active during sucking. Innervated by c.n. VII Muscles of Mastication • Medial PterygoidContraction closes the jaw by raising mandible against maxilla, Innervated by c.n. V • Lateral PterygoidContraction assists in opening mouth and rotary movement of the jaw. Innervated by c.n. V Floor of the Mouth • Geniohyoid Floor of the Mouth • Mylohyoid Floor of the Mouth • Anterior Belly of the Digastric Anatomy of the Tongue • Hyoid bone is the foundation of the tongue body • Composed of muscle fibers going in all directions • Divided into an “oral” portion and “pharyngeal portion” Oral Tongue • Composed of: Tip Blade Front Center Back • Active during speech and oral stage of swallow and is under voluntary cortical control Intrinsic Muscles of the Tongue • Superior Longitudinalbilateral contraction shortens tongue and curls tip and sides of the tongue upward. Innervated by c.n. XII • Inferior Longitudinalbilateral contraction shortens the tongue and curls the tip and sides of the tongue downward Intrinsic Muscles of the Tongue • Verticalis- contraction flattens and widens the tongue. Innervated by c.n. XII • Transversus- contraction narrows and elongates the tongue Innervated by c.n. XII. Extrinsic Muscles of the Tongue • Genioglossuscontraction protracts and depresses the tongue. Innervated by c.n. XII • Hyoglossus- contraction depresses the tongue and pulls it backwards towards the hyoid bone. Innervated by c.n. XII Extrinsic Muscles of the Tongue • Palatoglossuscontraction elevates the floor of the tongue and approximates the tongue to the palatoglossal arch thus closing off the oral cavity from the oropharynx. Innervated by c.n IX Extrinsic Muscles of the Tongue • Styloglossus• Retracts and elevates the tongue. • Innervated by c.n. XII and by pharyngeal plexus (c.n. IX & X) Tongue Base • Active during the pharyngeal swallow • Under involuntary control coordinated in the brainstem • Motor- c.n. XII Salivary Glands • Three main salivary glands Parotid Submandibular Sublingual Parotid Gland • • • Produces serous (thin and watery) saliva, which makes up 25% of our saliva production. Excreted through Swenson’s ducts near the second maxillary molar. Particularly important when eating and drinking Submandibular Gland • Produces both serous and mucoidal saliva (mostly serous) which makes up 60% of our saliva production • Secreted through Wharton’s duct, which is located on either side of the frenulum of the tongue Sublingual Gland • Produces both serous and mucoidal saliva (mostly mucoidal) which is secreted through several ducts in the floor of the mouth and makes up 15% of our saliva production Functions of Saliva • • • • • • • Protects the teeth and gums and assists with oral hygiene Lubricates food to assist with chewing and prepares the food into a bolus for ease of swallowing Lubricates the tongue and lips for speech Facilitates taste Destroys micro-organisms Initiates carbohydrate digestion Regulates acidity in the esophagus Xerostomia • Reduction in salivary function • Can be a problem for geriatric patients secondary to polypharmacy • Drugs that can cause xerostomia Antihistamines Antihypertensives Diuretics Antipsychotics Oral Preparation- Solids • Bolus acceptance and oral transit to posterior teeth for mastication Fracture- breaking food by two directly opposing forces Involves anterior to posterior movement of tongue Bolus Reduction-Mastication • Reduction of the bolus occurs in three phases – Opening, closing, and power stroke or “Crushing phase” • Along with mastication, the parotid/submandibular glands produce serous saliva which is mixed with the bolus during reduction • The buccinator flattens the cheek and holds the bolus in contact with the teeth • The tongue will tilt its dorsal plane toward the working side, while the jaw opens and closes to keep food between the teeth. • Sensory feedback coordinates the tongue position and shape to the moving mandibular arch Oral Preparation-Liquids & Purees • Bolus is placed on the dorsum of the tongue • The intrinsic muscles of the tongue create a groove for the bolus to rest • With puree, there may be compression where the bolus is pressed against the hard palate and mixed with saliva. • The flattening action of the buccinator assists in returning the bolus to a medial position Oral Transit Sequence • Bolus is medialized on the dorsum • The velum (soft palate) elevates (via levator veli palatine and superior pharyngeal constrictor) to close off the nasopharynx • Obicularis oris, Buccinators, and Superior Pharyngeal Constrictor contract creating a circular musculature “sling” to support the positive pressure built up by the posterior 1/3 of tongue during bolus propulsion by closing off the mouth and nasopharynx. Chamber and Valving Action of Swallowing • From Vital Stim training manual, 2008 • Bolus is transited through the various chambers from areas of higher pressure to lower pressure as it moves through the GI tract Oral Transit Sequence • The posterior tongue depresses • The remainder of the tongue presses against the hard palate • Bolus is propelled toward the pharynx Pharyngeal Swallow- Neural Control • Effective function of the pharyngeal swallow is dependent on specific mobile structures as well as precise timing • The mechanisms of the larynx/pharynx require extensive neural control in order to switch between the functions of respiration and deglutition Requirements for “Time-Sharing” of the Laryngopharynx • Intact sensory receptors (afferent pathway) • Muscle effectors (efferent pathway) • Central control to coordinate the sensory input and muscle control Central Control of the Swallow • Central control processors are in the brainstem (medulla) adjacent to the sensory and motor nucleus of the vagus • Pharyngeal swallow takes only 750 milliseconds (approximately three-fourths of a second) • Reflexes of this short of duration must occur at lower brainstem levels without higher cortical involvement Cranial Nerves- Pharyngeal Stage • Vagus Nerve- c.n. X Provides motor and sensory innervations to the palate, pharynx, larynx, esophagus, and stomach Branches of Vagus • Superior Laryngeal Nerve (SLN) • Recurrent Laryngeal Nerve (RLN) Divisions of the Pharynx • Nasopharynx • Oropharynx • Hypopharynx Musculature of the Pharynx • Pharyngeal Constrictors • Superior (c.n. X & XI) • Middle (c.n. X) • Inferior (c.n. X & XI) Pharyngeal Constrictors- Function • Assist in laryngeal elevation and stripping the bolus inferiorly • Arises from the median raphe in the midline of the posterior pharyngeal wall and runs laterally to attach to the bony and soft tissue structures including • • • • • • Pterygoid plates of the sphenoid bone Soft palate Base of the tongue Mandible Hyoid bone Thyroid cartilages – NOTE: as the fibers of the inferior constrictors attach to the sides of the thyroid cartilage anteriorly, a space is formed between these fibers and the sides of the thyroid cartilages. These spaces are known as the pyriform sinuses. The pyriforms end at the cricopharyngeus muscle, the most inferior structure of the pharynx. • Cricoid cartilage Musculature of the Pharynx • Cricopharyngeus • Serves as the valve at the top of the esophagus • At rest, the CES is in tonic contraction to prevent air from entering the esophagus during respiration and to prevent reflux of material into the pharynx • At the appropriate moment during the swallow, the fibers relax to allow bolus passage into the esophagus. Anatomy of the Larynx • Epiglottis • Valleculae • Laryngeal Vestibule • Laryngeal Ventricle (space between the false and true vocal folds) Cartilages of the Larynx • Epiglottis • Cuniform cartilages (support and stiffen the aryepiglottic folds to maintain opening to larynx) • Hyoid Bone • Thyroid Cartilage • Cricoid Cartilage Intrinsic Muscles of the Larynx • Aryepiglottic Muscle– Sometimes credited with depressing epiglottis in initial stages of swallowing • Interarytenoids- Approximates arytenoid cartilages • Lateral Cricoarytenoids- adducts vocal folds • Thyroarytenoid- regulates longitudinal tension Extrinsic Muscles of the Larynx • Digastric – Raises the hyoid and may assist in depressing the mandible Extrinsic Muscles of the Larynx • Geniohyoid – Draws hyoid bone upward and forward Extrinsic Muscles of the Larynx • Mylohyoid– Elevates hyoid, floor of the mouth, tongue Extrinsic Muscles of the Larynx • Stylohyoid – Draws hyoid bone upward and backward Extrinsic Muscles of the Larynx • Posterior Belly of the digastric – Draws the hyoid upward and backward Extrinsic Muscles of Larynx • Thyrohyoid– Contraction elevates the thyroid cartilage and decreases distance between thyroid cartilage and hyoid bone Extrinsic Muscles of the Larynx • Sternohyoid • Sternothyroid • Omohyoid Physiology of the Pharyngeal Swallow • Bolus division at the level of the vallecula -1/2 flowing down either side of the pharynx (lateral channels) • Swallow reflex is triggered at anterior facial arches or at the level of vallecula • Brief period of apnea • Arytenoids medialize and tilt towards epiglottis, TVC are still open Physiology of the Pharyngeal Swallow • Tongue base retracts towards the posterior pharyngeal wall • Velopharyngeal port closes • Hyolaryngeal elevation with simultaneous pharyngeal squeezing and shortening occurs Physiology of the Pharyngeal Swallow • Epiglottis retroflexes during laryngeal elevation • TVC contract .63 seconds AFTER the arytenoids begin medialization • Airway closure is not complete at the level of the glottis until midway through the swallow Physiology of the Pharyngeal Swallow • Relaxation of the cricopharyngeus to allow passage of the bolus into the esophagus. • Without the triggering of the swallowing reflex, none of these physiologic activities can occur Anatomy of the Esophagus • Hollow muscular tube apprx. 23-25 cm long composed of skeletal and smooth muscle with a sphincter at each end (UES and LES) • Innervated by Vagus nerve • Begins at the 6th cervical vertebra inferior to the UES • Anterior border = cricoid cartilage; posterior and lateral borders = cricopharyngeus muscle Anatomy of the Esophagus • The proximal 5% of the esophagus is striated muscle, the middle 30-40% is mixed, and the distal 50-60% is entirely smooth muscle. • The esophagus has 3 layers: – Squamous epithelium – Lamina propia – Muscularis mucosa which has 2 layers of muscle (inner circular and outer longitudinal muscle layer) which act in peristaltic fashion to move bolus into stomach Physiology of the Esophagus • “Peristaltic wave” Concept A ring of contraction appears in the wall of the esophagus At the same time, the muscular wall just ahead of the ring relaxes in a phenomenon called “receptive relaxation” As the peristaltic wave moves along, it propels the contents of the bolus ahead of it Physiology of the Esophagus • Peristalsis begins once the bolus enters the esophagus and expands the esophageal lumen • Primary peristaltic waves- progressive contractions in the esophagus initiated by the swallow. Allows the bolus to be propelled at a velocity of 2-4 cm/sec • Secondary Peristaltic Waves- elicited at any level of the esophagus and is initiated by intraesophageal bolus distension to clear the esophagus without a secondary swallow. Helps with solid transport as primary wave may not fully propel the bolus to the stomach • Tertiary Contractions- simultaneous, non-peristaltic waves that are a physiologic response to esophageal distension. They are not sufficient in clearing the esophageal body. May arise separately of swallowing events as in gastroesophageal reflux and stress The Normal Swallow Disorders of Swallowing Penetration/Aspiration • Penetration= Any material penetrating the laryngeal vestibule but not passing the level of the true vocal folds • Aspiration= Any material penetrating the larynx and entering the trachea below the true vocal folds – Aspiration may occur before (before the swallow reflex has triggered, when the airway has not elevated or closed), during (laryngeal valves are not functioning adequately), or after (when the larynx lowers and opens for exhalation) the swallow Penetration-Aspiration Scale • • Created by Rosenbeck et. Al. (1996) Attempt to describe and provide reliable quantification of penetration/aspiration events • • Description of the Scale 8-point multi-dimensional scale (more than one behavior is being judged) Depth of the bolus invasion into the airway Patient’s response to the bolus The expulsion of the material A higher score in the scale assumes to be a more severe sign of dysphagia • • • • Penetration-Aspiration Scale • 1 = Material does not enter the airway • 2= Material enters the airway, remains above the vocal folds, and is • ejected from the airway • 3= Material enters the airway, remains above the vocal folds, and is not ejected from the airway • 4=Material enters the airway, contacts the vocal folds, and is ejected from the airway • 5=Material enters the airway, contacts the vocal folds, and is not ejected from the airway • 6= Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway • 7=Material enters the airway, passes below the vocal folds, and is not ejected form the trachea despite effort • 8= Material enters the airway, passes below the vocal folds, and no effort is made to eject Oral Stage Disorders • Reduced labial closure • Reduced lingual movement • Reduced range or coordination of lingual movement to hold bolus consistencies Oral Stage Disorders • • • • Reduced oral sensitivity Tongue thrust Reduced lingual elevation Reduced anterior-posterior (A-P) movement of the tongue • Disorganized A-P tongue movement • Tongue pumping Oral Stage Disorders • • • • • • Piecemeal deglutition Reduced ability to seal tongue to palate laterally Reduced buccal tension Reduced range of lateral mandibular movement Poor alignment of the mandible/maxilla Poor dentition, Ill-fitting dentures, edentulous Pharyngeal Stage Disorders • • • • • • Delayed swallow reflex Absent swallow reflex Inadequate velopharyngeal Reduced pharyngeal peristalsis Unilateral pharyngeal weakness Cervical osteophyte and cervical dislocations Pharyngeal Stage Disorders • Reduced laryngeal elevation • Reduced laryngeal closure • Cricopharyngeal dysfunction Compensatory Strategies Goals of Compensatory Strategies • • • Immediate but transient effect on efficiency or safety of swallowing. Changes the flow and gravitational direction of a bolus to allow safe passage into the stomach. Reimbursement for long-term intervention is typically not supported. Postural Strategies • Chin Tuck – – – – – Also called “chin flexion” or “chin down” First introduced by Logemann (1983) to treat observed delays in triggering the pharyngeal swallow, poor tongue control, reduced tongue base retraction, and/or reduced closure of the laryngeal vestibule and vocal cords as assessed by MBS Symptoms observed on MBS include pre-swallow vallecular pooling (secondary to a swallow delay) and/or aspiration during a swallow Contraindicated for patients with poor lip closure or poor oral control Patient is asked to place the chin to the chest during swallowing. Postural Strategies • Head Rotation – – – – Rotation, or turning, the head toward the weaker, hemiparetic side can direct the flow of the bolus toward the stronger more sensate side of the pharynx Size of the pharyngeal cavities on impaired side will be reduced, and thus the bolus will be directed toward the more functional side May benefit the patient who has diffuse weakness and residual Patient must be able to rotate head 90 degrees Postural Strategies • Head Tilt – – – Tilting the head toward the stronger side may help to direct the bolus to the stronger, potentially more sensate oral and pharyngeal side Increased sensation and motor strength/coordination on the unaffected side may facilitate improved oral control, bolus formation and propulsion with a stronger pharyngeal swallow. Pt. is instructed to tilt head toward the stronger nonimpaired side during PO intake. Postural Strategies • Side lying – – – Described by Logemann (1996) as an effective posture to compensate for reduced pharyngeal contraction that results in diffuse residue in the pharynx Rationale is that a lateral head/trunk position will reduce the gravitational force on any residue that is left in the pharynx after the swallow. Pt. is placed laterally in a bed or in a semi-reclined or fully reclined chair Postural Strategies • Neck extension – – – – The posture of leaning the head back utilizes gravity to propel a bolus into the pharynx and is primarily used when oral motor deficits inhibit efficient anterior to posterior transit of a bolus into the pharynx. Pt must have prompt, efficient swallow response Pts. are instructed to take a breath, hold it, then bring chin up and allow gravity to move the bolus back towards the pharynx. Contraindications – can decrease the patient’s ability to close laryngeal vestibule effectively. Also, decreases UES’s ability to relax – directly related to the degree of extension. May increase aspiration risk in neurogenic dysphagia pt’s who may be forced into this position unintentionally. Bolus Control Strategies • Lingual sweep – – – Most practical and “normalized technique” Goal is to actively use the tongue to clear residue from oral cavity and redirect to the tongue blade for bolus development Patient is cued to use the tongue purposefully to sweep the entire oral cavity with special focus to the area of weakness. Bolus Control Strategies • Cyclic ingestion (alternating solids/liquids) – Indicated for patients with bolus manipulation deficits, especially those who exhibit post swallow residue – Patient is instructed to alternate solids and fluids to clear the oral cavity of residue unable to be managed with lingual sweeping Bolus Control Strategies • Dry swallows (multiple swallow) – – Can be used with a patient who exhibits post swallow residue somewhere within the digestive tract (oral residue, vallecular residue, pyriform sinus residue) Pt. is instructed to dry swallow after every bolus swallow – as many times as indicated by instrumental assessment Bolus Control Strategies • Bolus placement – Position the bolus in the more sensate, unimpaired side of the oral cavity for preparation – Patient is instructed to angle utensil toward the unimpaired side. Bolus Control Strategies • Modification of bolus size – Smaller boluses may allow for greater control and less scatter of the bolus to oral recesses – In some patients with decreased sensitivity, larger bolus can provide increased sensory input – especially with heavier bolus with variable texture – allows for better oral awareness (dementia) Bolus Control Strategies • Adaptations in the rate of intake – – Slower rate may give pt. with neurologic deficits more time to manage the bolus External controls may need to be employed may be required to slow rate of TBI or right CVA pt. (Impulsivity) Volitional Airway Protection Strategies • Supraglottic Swallow – – – Provides volitional airway protection when patient is a silent aspirator or has delayed reflexive airway protection Pt. is instructed to take a deep breath and hold it firmly while swallowing the bolus. On completion of the swallow, patient is instructed to cough prior to inhalation. The patient swallows and coughs for a second time. Caution: Cardiac patients- Chaudhuri et al. (2002) – fitted stroke patients with holster monitors to measure the cardiovascular impact of supraglottic and super-supraglottic swallow. 86.6% (13/15 patients) showed abnormal cardiac readings (arrhythmias) during the maneuvers. Volitional Airway Protection Strategies • Super-supraglottic swallow – Patient is instructed to take a deep breath and tightly hold, then swallow “hard” or with greater effort than usual. Following swallow. Pt. should follow with a cough prior to inhalation – See supraglottic swallow for cardiac precautions Sensory Strategies • Thermal stimulation – Used as antecedent to the bolus – Apply stimulation cyclically throughout the meal Sensory Strategies • Vocal quality checks – Pt. is instructed to monitor vocal quality during oral intake – If “wet”, dysphonic, aphonic pt. should cough or clear throat and swallow. Vocal quality should be reassess until clear vocal quality is achieved – Warms et al. (2000) – Dietary Modifications • Dysphagia Diet Project, 1999 – Task force initiated by dieticians in 1996 secondary to frustrations over lack of standardization for solids and liquids – Task force members included: clinical and consulting dieticians, clinical and research SLP, food scientists, food industry representatives Dietary Modifications • Food Textures – NDD Level 1 - puree – NDD Level 2 – mechanically altered, cohesive, moist, semi-solids, no bread – NDD Level 3 – soft-solid – Regular Dietary Modifications • Liquids – Thin – Nectar-like – Honey-like – Spoon-thick Clinical Evaluation of Swallowing Clinical Evaluation of SwallowingPurpose • a.k.a. “the bedside swallowing evaluation” • Evaluate patients for the likelihood and seriousness of a swallowing impairment • Information gathering opportunity prior to objective instrumental assessment Clinical Evaluation of SwallowingInformation Gathering • Must have physician consult prior to evaluation • Chart review – – – – – – – – – – – – H&P (history and physical) Onset of the problem Reason for hospitalization ROS (review of systems) Respiratory status PMH or PSH Behavior Level of responsiveness Current method of nutrition Medications Review of previous eval reports/tx. notes from previous level of care Nursing notes/observations • Pt/family interview Clinical Evaluation of SwallowingSupplies • • • • • • • • • • Textures/consistencies representative of possible diet levels Cups Several spoons Tongue depressors Cotton Tip Applicators Thickener Stethoscope (elective) Flashlight/Penlight Laryngeal mirror (elective) Protective equipment (gloves) – note latex allergies or isolation precautions • Evaluation forms Clinical Evaluation of SwallowingProcedure • Style variability depending on clinician, patient, circumstances • Make sure that an order has been specifically written for swallow eval prior to the evaluation – clarify order if questions • Check with RN first before performing the evaluation • Eval at meals when possible • Pt. Interview • Oral-peripheral exam • Laryngeal examination • Behavioral observations • Presentation of consistencies Clinical Evaluation of SwallowingOral Stage Observations • Oral Preparation – – – Clearing of bolus from utensil/apparatus (lip closure) Anterior loss of bolus Mastication • Style – rotary vs. “munching” & Duration – Bolus formation • Oral transit – – – Tongue pumping Oral stasis Cough before swallow Clinical Evaluation of SwallowingPharyngeal Observations • • • • • • Somewhat limited at bedside – looking for any clinical signs of aspiration Swallow initiation Laryngeal elevation Cough responses – note 40% of aspirations are silent! Changes in vocal quality Subjective complaint of stasis Clinical Evaluation of SwallowingModifications During Evaluation • Will depend on response of the patient – Texture modification – Postural modification Clinical Evaluation of SwallowingDetermining Next Options • • • • No clinical signs of aspiration – proceed with/continue/advance diet Continue NPO or recommend NPO until further evaluation Need more objective data – MBS, FEES Other referrals – ENT, GE Clinical Evaluation of SwallowingDocumentation • • • • • • • • • • • • • • • • • • • • Medicare requires several pieces of info in report Medical w/up (MD) Dysphagia criteria LOA Motivation Cognition One of these conditions – h/o aspiration, OM d/o, structural lesions, neuromuscular disturbance, post sx. Reaction, weight loss Assessment History Current nutritional status Clinical observation Definitive diagnosis Id of the swallow phase affected Recommendations/tx. Plan Care planning Goals Type of care planned Reasonable expectation of improvement Safety issues Need for skilled rehab Clinical Evaluation of SwallowingDocumentation • May be able to give severity level to oral stage • Will not be able to give severity level to pharyngeal stage because not enough info • EXAMPLE: Pt. Exhibits moderate oral stage dysphagia characterized by orofacial and lingual weakness resulting in anterior loss of bolus, ineffective bolus preparation, and oral stasis. • EXAMPLE: Pt. Appears to exhibit pharyngeal dysphagia (or pharyngeal dysphagia suspected) as evidenced by delayed swallow initiation, reduced laryngeal elevation, multiple cough responses during evaluation placing the patient at risk for aspiration. Recommend MBS for further objective measures to determine pt’s ability to protect the airway prior to the initiation of p.o. intake Clinical Evaluation of SwallowingDetermining Severity • 3rd party payers are challenging SLP to prove validity and reliability of dysphagia assessments and treatment • Clinical bedside eval. and MBS have come under much scrutiny because of the subjective nature and lack of inter and intrajudge reliability • Dysphagia Outcome and Severity Scale (DOSS) • Developed by O’Neil et. Al., 1999 to create a reliable and uniform measure of dysphagia severity • Takes 4 factors into account – Level of independence, level of nutrition, diet levels and diet modifications, and swallowing impairments Dysphagia Outcome and Severity Scale Rehabilitation Techniques Goals of Rehabilitation • Restore to a condition of health or useful and constructive activity. • Improve anatomy/physiology permanently so that the significance of the disorder is minimized or eliminated • Rehabilitation techniques may improve the swallow function to such a level that compensatory strategies may be applied Rehabilitation-Premises of Treatment • Effective rehabilitation relies on an accurate diagnosis and individualization of the treatment plan and to the specific physiology • Symptoms are usually easy to observe (e.g., pooling or residue, premature spillage) • Underlying etiology that leads to symptoms requires a more critical eye • Rehabilitation approaches will be different depending on the etiology • Inappropriate treatment due to inaccurate diagnosis of physiology is not efficacious, not cost effective, and may be contra-indicated. Rehabilitation- Oral Motor Inefficiency • OM inefficiency may result in various dysphagic symptoms – – – – – • Anterior loss of bolus Posterior loss of control of bolus Incomplete development of a cohesive bolus Decreased mastication effectiveness Decreased ability for lingual sweep to clear stasis from buccal, sublingual or general oral cavity Efficacy data of OM exercises is increasing in literature as of late Rehabilitation- Lips • Increased or decreased labial tone may result in difficulty removing bolus from utensil, inability to maintain bolus in oral cavity, may inhibit bolus acceptance all together (especially in the case of abnormal reflexes) • • These exercises may help with bolus control, decreased anterior loss of bolus If hypertonic – slow, progressive stretching in effort to relieve spasm. Provide firm directed pressure to lips and move laterally and superior/inferior positions • If hypotonic – pursing, retracting lips either in rote ROM or against resistance – Facial Muscle Exercise Program (FMEP) – Tongue Depressor “Exerciser” – Oral Motor Exercises Rehabilitation-Tongue • Deficits of lingual control can result in premature spillage or bolus formation difficulties • These exercises may help with lingual strength or ROM • Hypertonic – Gloved hand, gauze pad – light stretching. • Hypotonic – ROM x all planes with resistance against tongue blade. Resistance can be progressively increased. – Life saver on a string – manipulate in all planes in oral cavity – Tongue Depressor “Exerciser” – Robbins, J et. Al (2005). Studied effects of lingual strength training in normal elderly adults and elderly stroke patients. Rehabilitation- Jaw • Decreased strength in masseter, temporalis, pterygoids can result in decreased ability to masticate – Gum on a string – tie a piece of gum on to a piece of dental floss. Have patient chew the gum focusing on keeping the gum in a “ball” form. – Tongue Depressor “Exerciser” Rehabilitation- Velum • • Data to support palatal strengthening are scant Exercises which may help with palatal strengthening – – – – Straw suck – Have patient suck through a straw while occluding the other end with fingertip DPNS (evidence unavailable) Use of CPAP (Liss, Kuehn, & Hinkle, 1994)- Patient wears CPAP while producing various phonemes against positive airway pressure Velopharyngeal Closure Test (VCT) (Hagg, 2004)- Patients asked to inhale deeply, then exhale through a straw at a constant pace for as long as possible against 12 cm water pressure. Generally accepted lower normal limit is to exhale against 5 cm of water pressure for at least 5 seconds. Straw should be 1 cm in diameter. Straw must be at the bottom of the container. Repeat 3 times. Increase the amount of water for challenge. Rehabilitation- Swallow Delay • • • Delayed pharyngeal swallow occurs when patient volitionally transfers bolus posteriorly out of oral cavity and pharyngeal response fails to occur in a timely manner This represents a deficit of the neurosensory system in which inadequate sensory feedback mechanisms fail to communicate with the oncoming bolus Rehabilitation techniques – Thermal gustatory stimulation – DPNS Rehabilitation- Laryngeal Elevation • • • Mendelson Maneuver Shaker exercises Expiratory Muscle Strength Training Rehabilitation- Tongue Base • • • Masako Maneuver Valsalva Maneuver (Effortful Swallow) DPNS Rehabilitation- Laryngeal Valving • Vocal adduction exercises • Vocal Function Exercises (Stemple, 1993) Rehabilitation- UES • Mendelson maneuver • Shaker exercises Correspondence • • • • • • Angela S. Dubis-Bohn M.A., CCC/SLP, BRS-S Dodd Rehabilitation Hospital 480 Medical Center Dr. Room 1145 Columbus, Ohio 43210 (614) 293-5275 [email protected] References • References- Anatomy & Physiology • Bartoshuk, L.M., Duffy, V.B, Leder, S.B., &Snyder, D.J. (2003). “Oral Sensation: genetic and pathological sources of variation”. Perspectives on swallowing and swallowing disorders. 12:4. 3-9. Berkovitz, B, Kirsch, C., et. Al. (2003). Interactive head and neck CD-ROM. London: Primal Pictures. Butler, S.G., Psstima, G.N., Fischer, E. (2004). “Effects of viscosity, taste, and bolus volume on swallowing apnea duration of normal adults”. Otolaryngology- Head and neck surgery. 131:6, 860-863. Corbin-Lewis, K., Liss, J.M., Sciortino, K.L. (2004). Clinical anatomy and physiology of the swallow mechanism. Clifton Park: Thompson/Delmar Learning. Crary, M. (2003). Old and new strategies for assessing and treating adult dysphagia. Cathy Chester Memorial Seminar: Columbus. Crary, M.A., & Groher, M.E. (2003). Introduction to adult swallowing disorders. St. Louis, MO: Butterworth-Heinemann. Easterling, C.S. (2003). “Getting acquainted with the esophagus”. Perspectives on bean swallowing and swallowing disorders. 12:2. 3-7. Kaplan, M.D. & Baum, B.J. (1993). “The functions of saliva.” Dysphagia. 8:225-229. Langmore, S. (2004). FEES and fluoroscopy. ASHA Health Care Convention 2004: Orlando. • • • • • • • • • • • References • References- Anatomy and Physiology (Cont) • Leopold, N.A., Kagel, M.C. (1997). “Dysphagia- ingestion or deglutition? A proposed paradigm”. Dysphagia. 12: 202-206. Logemann: J.A. (1998). Evaluation and Treatment of Swallowing Disorders (2nd Ed.). Austin, TX:Pro-Ed. Miller, R.M. & Groher, M.E. (1993). “Speech-language pathology and dysphagia: a brief historical perspective.” Dysphagia. 8:3, 180. Morgan, A. et. Al. (2004). “Clinical characteristics of acute dysphagia in pediatric patients following traumatic brain injury”. 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