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
stasis"
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
ALS
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
35%
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
Manometry
thin tube is fed from nose to esophagus
-Assesses pressures during & after swallowing
FEES
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
ALS
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
FEES
Which of the following exams requires the patient to swallow barium?
MBSS
Which of the following exams allows you to determine whether or not your patient is aspirating?
FEES & MBSS
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?
TBI
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
Masako
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
Exercises
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
-cerebellar
-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
Aspiration
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
Detraining
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
Training
Performance improvement
-strength
-speed
-coordination
Early changes
-coordination of motor unit recruitment
Later changes
-Muscle tissue itself
~5 weeks for hypertrophy
Specificity
the exercise needs to mimic the desired outcome as close as possible
Intensity
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
UES
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
Reflux
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)
Hearburn
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
NPO
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
-Release
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
PURPOSE
increase tongue base retraction
Increase submittal muscle strength
When to use the tongue pull back exercise...
reduced tongue base retraction
-maybe reduced hyoid movement
Cordectomy
removal of all/part of the vocal folds
Pharyngectomy
Removal of all/part of the pharynx
Larynx
connects the oro/nasal cavity to the lungs
-without the larynx, no connection
Tracheostomy
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
Stenosis=narrowing
Trismus
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
Neuroplasticity
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
sunaptogenesis
This synapse is refined and developed over time
Potentiation
Chains of neurons that are frequently used grow stronger
Action potentials have a larger effect on the target cell
Structural... Sprouting (going together)
Depression
Rarely used neuron/chains parts get weaker
Strength of information flowing reduces
Structural... Pruning (ripping apart)
Neurons that fire together
wire together
associations
aka pavlovs dog
Sunchornously linked neurons are often near each other in the brain... but not always
Necrosis
Cell death from injury
Different from pruning
-Could be cells that were active
Synaptic sprouting
after brain injury...
collateral
regenerative
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