Quiz 2

Soft Palate Elevation

Velum makes contact with the pharyngeal wall- you want no air or food/liquid between the two
**Stops bolus from entering the nasal cavity

Pharyngeal stripping wave

3 C-shaped muscles squeeze in sequence (from top to bottom)
-Length of the pharyngeal wall from nasopharynx to UES.

Pharyngeal Residue

Clinical sign of physiologic impairment
-food/liquid/contrast still in the pharynx
-can be anywhere in the pharynx

Liquid wash

wash down bites of food and pharyngeal residue
-sip of water after every bite, every 3 bites, etc.

Masako Maneuver

-place tongue in between teeth
-bite tongue lightly and hold it there
-swallow with tongue held
to make it harder...
-increase reps
-increase tongue protrusion

Masako Maneuver purpose

to increase anterior movement of the posterior pharyngeal wall

Consider Masako Maneuver if u see

reduced PPW (posterior pharyngeal wall) movement
controversial... promotes atypical swallow


difficulty sending nerve signals to the muscles to make them move

Parkinson's disease & Huntington Disease

involuntary muscle movements/tremors

Muscular dystrophy

Muscle weakening/atrophy

% of people with NM disease have dysphagia


Leading death in Parkinson's (70%) and in Hungtingtons (68-87%)

aspiration pneumonia

2 diff swallowing assessments

clinical swallowing assessments
instrumental swallowing assessments

Instrumental swallowing assessment

sees" the swallow
Assesses the penetration/aspiration
Uses some tool to objectively evaluate the swallow function

Clinical swallowing assessment

aka "bedside examination"
Assesses the likelihood of dysphagia
-Determines the need for an instrumental swallowing assessment
-Determine appropriate clinical interventions inc. diet recommendation

Clinical Swallow Exam CSE Steps

1. chart review
2. case history
3. patient observation
4. oral mech
5. swallow exam if appropriate

Recommend an instrumental exam if...

No outward signs of swallowing difficulty...
Suspicion for silent aspiration
-Occurs in 2-25% of acute stroke patients
*Medical history indicates possible recurrent aspiration
-CSE indicates signs of possible dysphagia


thin tube is fed from nose to esophagus
-Assesses pressures during & after swallowing


thin camera is passed through the nasal cavity into the pharynx
-Direct visualization of the pharynx before/after/during swallowing

Another word for epiglottic inversion...

Epiglottic deflection & epiglottic retroflection

During the swallow, we adduct (bring together) our vocal folds. When does this happen?

As we're breathing out

Substitute from shaker exercise

chin tuck against resistance

Your client's arms, legs, and torso move around continuously in an uncontrolled manner. The movements are slow and large. No matter how hard they try, they can't seem to stop the movements. They've even fallen off their chair a time or two.
What neuromusc


Since your patient came off the ventilator, she speaks in a severely breathy, quiet voice. You're concerned her vocal folds may have been damaged, and she may have difficulty adducting them. Which swallow evaluation would give you information about whethe


Which of the following exams requires the patient to swallow barium?


Which of the following exams allows you to determine whether or not your patient is aspirating?


Which of these describes a relapsing/remitting disease?

gets better and gets worse cyclically

Which of these is a relapsing/remitting disease?

Myasthenia gravis

We've discussed impulsivity as a common symptom following which disorder?


What does velar elevation do?

stops bolus from entering the nasal cavity

What does the Masako Maneuver do?

Increases anterior movement of the posterior pharyngeal wall

Compensatory strategies

sensory stimulation, viscosity changes, changes in bolus size or patient positioning, head tilt

Strengthening of paralyzed/paretic muscles

Lingual strengthening exercises

Swallowing exercises

Shaker/tuck with resistance
Effortful swallow

Compensatory strategies

Chin tuck
Liquid Wash
Head back
Head tilt
Supraglottic swallow
Effortful swallow

Myasthenia Gravis

autoimmune disease that weakens acetylcholine (neurotransmitter) receptors
-muscles get fatigued
-worse in evening than morning
-worse in longer meals
-compensatory strategies= shorter, more frequent meals, rest breaks

Multiple sclerosis

immune mediated" attack on CNS
-Immune system attacks myelin (sheath that surround nerves and makes them work quickly)
Damaged myelin scars over (sclerosis)
-Distorts/interrupts nerve impulses to/from the spinal cord and brain
-Exacerbations (pain, numbn

Tongue control during bolus hold

Stops bolus from flowing into the throat too early
Tongue seals soft palate, containing the liquid

Labial Seal

ability to have the bolus stay in the mouth and not dribble out of the lips.

Lingual Stripping Wave

tongue pushes up to hard palate in a wave-like motion
-Pushes bolus posteriorly as the tongue moves posteriorly

oral residue/oral stasis

a clinical sign of physiologic impairment.
Any food/liquid/contrast still in the oral cavity.

Compensatory strategies

postural or behavioral modifications to help swallowing
e.g. chin tuck, bolus hold


Strengthen muscles or improve range of motion for swallowing
e.g. effortful swallow, tongue press

ETT Endotracheal tube

for short term purposes, delivers ventilator breaths to the lungs.
-Tube from mouth to trachea
-Inflated cuff stops air from leaking out mouth/nose
-Tube passes through the vocal folds

Effects on swallowing of the ETT

-Vocal fold damage
--Reduced glottal adduction
--Difficulty creating sub glottal pressure/closed system
-Odynophagia=swallowing pain
-Deconditioning- lose 1-3% of muscle strength per day.
--Unable to swallow= you use it or lose it

Feed-forward processing

Sensory prediction
-planning the next movement before the next movement has begun
-Grocery bag analogy

Tracheostomy tube

a small plastic/metal tube that connects the trachea to the ventilator/outside through a stoma in the throat

Why do ppl have trachs?

Prolonged ventilator needs
-difficulty weanong
-expectation to be on a ventilator long-term
-Typically considered after 7-10 days of oral intubation
-May also be an emergency decision
-- difficulty orally intubating
--choking/blockage of the upper airway

Trach benefits

-More comfortable
-Patient may not need sedation...
--reduced deconditioning
-May talk with cuff deflation
-Can swallow in some circumstances

Clinical complications of trachs

Reduced sensation..
-Airflow past the tongue=how we feel oral cavity
-If we dont feel saliva, we dont swallow it... if we don't swallow it, we aspirate it
Reduced taste
-Reduced saliva production
-Dry mouth (xerostomia)

Can you talk and swallow with cuff inflated?

You can talk.. but its bad for your airway cuz it puts pressure on the tracheoesophageal wall
You can swallow... but silent aspiration is rampant


material passes below the level of the vocal folds

Digital occlusion

Tool to talk with a trach

One-way valve

lets air in but doesn't let it out
-Closes for expiration
-Cuff MUST be deflated
-Easier than digital occlusion
-Faster than digital occlusion
-Automatically occludes 100% of swallows


After 4-6 weeks of bedrest..
-Muscle strength decreases up to 40%
-Muscle atrophy
-Fiber-type shift to type II
Includes throat muscles b/c of their role in neck stability
-Much easier to detrain than to train


Performance improvement
Early changes
-coordination of motor unit recruitment
Later changes
-Muscle tissue itself
~5 weeks for hypertrophy


the exercise needs to mimic the desired outcome as close as possible


Exercise efforts that do not force the neuromuscular system beyond the level of usual activity will not elicit adaptations
-Muscle must be exercised to the point of fatigue
-Load must be increased as muscles get stronger

You can only strengthen what you can control..

To exercise something, you HAVE to be able to move it on purpose... NOT chorea


Gets pulled open by hyoid movement
-UES also needs to relax

How much and how long it relaxes is related to..

bolus size
bolus texture
bolus weight
bolus thickness


Stomach contents/reflux move back up through the LES

Gastroesophageal reflux GE

Stomach contents/acid move from stomach to esophagus

Gastroesophageal Reflux Disease GERD

GE is frequent (>2x.a week)

Laryngopharyngeal Reflux LPR

It goes all the way through the UES into the pharynx

Reflux symptoms

Reflux laryngitis
Sore throat
Odynophagia (pain swallowing)
Globus sensation
Can reduce UES opening/increase tightness

Globus sensation

feeling of something "stuck" or a "lump

Reflux treatment...

Medication (proton pump inhibitor)
Surgery (Nissen fundoplication)
Lifestyle changes
-Reduction in acidic foods
-Raised head of bed
-Smaller, more frequent meals
-Stopping 2 hrs before bed


No food or drink by mouth
If severe dysphagia=patient at high risk of aspiration (and compromise)
-Provide assessment
-Discuss with patient, family, and physician
-Physician may recommend no oral means of nutrition (NPO)

Alertnative means of nutrition/hydration

Short-term: few days-weeks
-Nasogastric (NG) tube: tube from nose to stomach
-TPN (total perenteral nutrition)- nutrition in the vein
Long-term: Gastric tube (G tube)
-PEG/JG tube
-Directly into stomach/jejunum
-Bypasses nose/throat
-Surgically placed

Pharyngoesophageal Segment Opening PES

How far & how long the UES/PES opens
-It has to be open long enough for all of the bolus to get into the esophagus
-It also has to be open far enough for the bolus to pass easily

Pharyngeal Contraction

Pharyngeal squeeze (side to side) and shortening (up and down)

Esophageal Clearance

Does the esophagus clear? (from UES to PES)

Mendelnson Maneuver

Swallow your saliva while touching your throat
-Feel where your Adams apple lift, note where it reaches its highest peak
-Mid-swallow, hold you Adam's apple up at its highest. Dont let it drop. hold for 2 seconds
PURPOSE: to increase laryngeal el

Use Mendelson maneuver when...

Pharyngeal stasis
Reduced UES opening
Reduced/slowed epiglottic deflection

Tongue Pull back exercise

Hold the tongue with a piece of sterile gauze
-Keep the mouth wide open during the exercise
-Use the tongue muscle to pull the tongue back into the mouth
-Provide some resistance
increase tongue base retraction
Increase submittal muscle strength

When to use the tongue pull back exercise...

reduced tongue base retraction
-maybe reduced hyoid movement


removal of all/part of the vocal folds


Removal of all/part of the pharynx


connects the oro/nasal cavity to the lungs
-without the larynx, no connection


hole (stoma) from throat goes directly to the trachea (breathing)
-Mouth now only connected to pharynx

Cons of radiation

Xerostomia (Dry mouth)
Odynophagia (pain when swallowing)
change/loss of taste
Fibrosis= scarring


tightly closed jaw muscles
-Spasm vs anything restricting oral opening
-"Lock jaw" with tetanus
Difficulty opening mouth
Can be unilateral
-Can result from facial/labial fibrosis

Surgery vs radiation

Surgery has become more popular bcuz radiation has risks of stenosis and fibrosis over years and loss of speech

Cancer patients who have been NPO > 2 weeks...=

worse swallow outcome at 12 months post radiation
-preserve function- use it or lose it

SLPs services

may not improve swallow function but DO improve diet texture/QOL
-likely compensatory strategies
-may be less conservative than doctors, less likely to recommend PEG-only

Prophylactic PEG

PEG at the beginning of treatment,
"its there if we need it"
Protects against weightless during XRT

Therapeutic PEG

Placed later in treatment if the patient is losing weight/malnutrition
-May get rid of PEG sooner than prophylactic PEG

Oral feeders

Do not lose more weight after XRT
-Attain better diet levels at 6 months and 12 months
And swallow better

Exercises after cancer treatment

might not matter
Stretching MAY help with ROM
-constantly fighting against increasing fibrosis

Compensatory strategies after cancer treatment

Postural changes (chin tuck, head turn)
-useful due to bypassing structural changes
Liquid wash
-useful because xerostomia
Artificial saliva
-Biotene, Xylimelts, Oasis, Aquaoral etc
Other strategies appropriate for the symptoms


the brains ability to reorganizes itself by forming new neuron connections throughout life
Highest during development but remains throughout life

When neuritis reach their target cells, a new synapse forms

This synapse is refined and developed over time


Chains of neurons that are frequently used grow stronger
Action potentials have a larger effect on the target cell
Structural... Sprouting (going together)


Rarely used neuron/chains parts get weaker
Strength of information flowing reduces
Structural... Pruning (ripping apart)

Neurons that fire together

wire together
aka pavlovs dog
Sunchornously linked neurons are often near each other in the brain... but not always


Cell death from injury
Different from pruning
-Could be cells that were active

Synaptic sprouting

after brain injury...

Effects of rehab on plasticity

intensity-- higher reps =reorganziation of motor maps
Early rehab is key-- take advantage of sprouting
-LARGEST improvement 30 days after CVA
Task specific training
-Induces a more normal pattern of activation
-Treat swallowing with swallowing

Sensory feedback loops

1. plan the action
2. do the action
3. feel & analyze
4. change the motor plan if it didnt