Other contributing factors
Some common reasons a person may need to use a puréed diet include:
Most people only stay on a puréed diet until they can get therapy, recover and return to eating solid food. However, the diet can also be a long-term solution if you cannot tolerate or manage eating solid foods at all.
How do I know what is puree?
Pureed foods do not need chewing. They are completely smooth with no lumps, skins, strings or seeds. It is usually eaten with a spoon and holds its shape on the spoon. Make sure you have the right equipment to prepare food. A food processor works best to properly puree foods. If you don’t have one, use a good blender or hand mixer instead. Choose foods that puree easily and avoid foods that are stringy, like celery and onions; foods with nuts or seeds; and foods with tough outer skins. Take out any pits, bones, seeds, skins, or other tough inedible parts before you puree your food.
This handout includes a list of foods that puree very well, but some foods do not puree well. These include breads, cakes, cookies, muffins, biscuits, or other crumbly foods. Instead, they can be softened and thickened using a slurry mixture that helps food stick together. Gelatin can be used to slurry foods. You can use flavored or unflavored gelatins depending on what food you want to slurry.
Eating Out: Eat at restaurants that offer a variety of foods and that will cater to people on special diets.
Many places will purée or prepare foods for your needs. Call ahead and speak to a manager or chef. You may be surprised at how helpful they will be. You may also want to order sides of broth, gravy, or milk to moisten your foods.
Add more calories to your diet If you need to eat more calories, here are some easy tips:
Add calories with milk/half & half, margarine/butter, gravies, jellies, syrups, powdered milk or any other calorie and protein enhancers.
You can find a number of Puree cookbooks for people with dysphagia:
Dysphagia Diets carries a complete line of dysphagia friendly products that can be delivered directly to you home. www.Dysphagia-diets.com
]]>Characteristics - Provides meals with an even consistency and no combinations of solid and liquid foods in the same dish.
Why are ‘mixed consistency’ or ‘dual consistency’ foods not recommended for people with dysphagia?
By definition, mixed consistency foods include both solids and liquids. Some mixed consistency foods are easily recognized on the plate or in a bowl (e.g. vegetables in a soup broth). Other items that appear to be a single consistency on a plate may quickly separate into two consistencies in the mouth (e.g., watermelon).
]]>Why are ‘mixed consistency’ or ‘dual consistency’ foods not recommended for people with dysphagia?
By definition, mixed consistency foods include both solids and liquids. Some mixed consistency foods are easily recognized on the plate or in a bowl (e.g. vegetables in a soup broth). Other items that appear to be a single consistency on a plate may quickly separate into two consistencies in the mouth (e.g., watermelon). As a general rule, ‘mixed consistency’ foods are more challenging to swallow, because a person must have adequate abilities to handle both the solid and the liquid component of these items, which requires more advanced oral control and swallowing coordination abilities.
Examples of mixed consistencies
Common compensatory strategies:
Swallowing problems are associated with increased age, cancer treatment, and conditions such as Alzheimer’s disease, Parkinson’s disease, or stroke. The law requires that medicines should be given to the right person, at the right time, in the correct form, using the correct dose, via the correct route. The size, shape, and texture of pills can contribute to swallowing difficulties. Hard and soft gelatin capsules, oval pills, and oblong-shaped tablets are more likely than round pills or irregularly shaped tablets to cause swallowing difficulties. Crushing and mixing pills with juice, applesauce, or thickeners to ease swallowing are common. Understand the differences and the options available.
Pill Gels and Mouth Sprays
Pill swallowing gels are registered medical devices suitable for use in healthcare settings as well as by patients at home. Mouth sprays and pill coatings are best suited for at-home use. As integral members of the patient care team, speech-language pathologists should educate care providers on the implications of pill crushing and mixing and alternative methods of easing swallowing for patients.
Crush Meds
Crushing medications can destroys the release characteristics of controlled-release medications.
Avoid pill crushing as a general practice without consulting the prescriber and the pharmacist before altering dose forms. If you can crush a pill, use a recommended method like a pill crusher or a mortar and pestle to grind the pill to a fine powder. Always ask your doctor or pharmacist before you crush or take apart medication. “This method can dump too much of the drug into your system at once, or change the way the drug works. Ask your healthcare provider or pharmacist how you should take the powdered drug, including which foods or beverages they can be safely mixed with
Embedding Pills
Many people who have trouble swallowing pills like to embed them in applesauce or pudding. While mixing medications with applesauce, juice or thickeners may not pose a direct health risk such substances may well alter the dissolution rate and drug effect (i.e., bioavailability) of medications.
Water or juice or other
In general, it typically takes approximately 30 minutes for most medications to dissolve.
Pills should be swallowed with 4–8 ounces of water, and you should remain upright for at least 10 minutes after taking medications. People with underlying esophageal disease, such as diverticulosis or dysmotility disorders, should consider the use of liquid medication formulations or crushed pills instead of standard tablets and capsules., Taking pills with warmer water is more effective with helping them dissolve, than ice cold water.
Do not thicken your liquid medications with cornstarch-based or xanthan gum-based thickeners. Although thickened liquids provide an adequate profile for safe swallowing, administration with drugs may impact bioavailability.
1 pill at a time
It is safer to swallow 1 pill at a time than multiple at a time, to slow clearing through the throat or the esophagus
The more meds you take at one time, increase the risk of harmful interaction
Pill esophagitis
Pill esophagitis occurs when capsules or tablets get stuck in the esophagus (food pipe) and cause ulcers, inflammation, and other damage to the esophageal tissue. Common symptoms include pain or difficulty swallowing. People can also experience chest pain, back pain, and discomfort or difficulty swallowing solids or liquids. Gastrointestinal bleeding, manifested as bloody stools or vomit, can indicate a more serious condition, such as a pill penetrating through a blood vessel. Older people and people who use antihistamine medications (including Benadryl®) can have decreased saliva production or a dry mouth which can slow the passage of pills through the esophagus and increase the risk of pill esophagitis.
Globus sensation – “It feels stuck”
Possible Causes:
How can I assess my ability to take pills or see if it is traveling down my esophagus ok?
]]>Some common reasons a person may need to use a puréed diet include:
Most people only stay on a puréed diet until they can get therapy, recover and return to eating solid food. However, the diet can also be a long-term solution if you cannot tolerate or manage eating solid foods at all.
Pureed foods do not need chewing. They are completely smooth with no lumps, skins, strings or seeds. It is usually eaten with a spoon and holds its shape on the spoon. Make sure you have the right equipment to prepare food. A food processor works best to properly puree foods. If you don’t have one, use a good blender or hand mixer instead. Choose foods that puree easily and avoid foods that are stringy, like celery and onions; foods with nuts or seeds; and foods with tough outer skins. Take out any pits, bones, seeds, skins, or other tough inedible parts before you puree your food.
This handout includes a list of foods that puree very well, but some foods do not puree well. These include breads, cakes, cookies, muffins, biscuits, or other crumbly foods. Instead, they can be softened and thickened using a slurry mixture that helps food stick together. Gelatin can be used to slurry foods. You can use flavored or unflavored gelatins depending on what food you want to slurry.
Eat at restaurants that offer a variety of foods and that will cater to people on special diets.
Many places will purée or prepare foods for your needs. Call ahead and speak to a manager or chef. You may be surprised at how helpful they will be. You may also want to order sides of broth, gravy, or milk to moisten your foods.
If you need to eat more calories, here are some easy tips:
Garnishes to add color and taste:
Sell it!
Puree cookbooks - You can find a number of Puree cookbooks for people with dysphagia:
Purchasing pureed food
The COVID19 virus moves down the respiratory tract, through the mouth, nose, throat, and lungs. The lower airway has more ACE2 receptors than the rest of the respiratory tract, therefore COVID-19 is more likely to go deeper than more common viruses like the common cold. Speech-language pathologists who work with people with dysphagia need to be ready! We are entering a new era and increased area specialty of iatrogenic dysphagia. This is difficulty swallowing caused by a medical treatment or treatments, such as prolonged intubation and/or traumatic intubation.
]]>The COVID19 virus moves down the respiratory tract, through the mouth, nose, throat, and lungs. The lower airway has more ACE2 receptors than the rest of the respiratory tract, therefore COVID-19 is more likely to go deeper than more common viruses like the common cold. Speech-language pathologists who work with people with dysphagia need to be ready! We are entering a new era and increased area specialty of iatrogenic dysphagia. This is difficulty swallowing caused by a medical treatment or treatments, such as prolonged intubation and/or traumatic intubation.
On March 30, 2020, Bhatraju, et al. (2020) reported on 24 critically ill people in the Seattle area, showing that 75%* needed mechanical ventilation. The earliest that an individual was extubated (removal of the breathing tube) was 8 days. (We have heard anecdotal reports of people requiring up to 14 days). Bhatraju commented on how a typical indicator of age did not seem to matter, as the age range of those intubated was 18 to 88 years. A multivariable analysis in the Marvin, et al. (2018) study showed that age (>65) was significantly associated with SILENT aspiration. We must keep in mind that age may be a risk factor for post extubation dysphagia during the COVID recovery process and we should be more cautious regarding the risk for silent aspiration in those with COVID over 65? But doing dysphagia evaluations without a Modified Barium Swallow Study, how do you really know for sure?
There is not one standard protocol to resource for exactly how and when to evaluate this population of patients who were extubated after requiring intubation and ventilation for 48 hours or more. They are all different and it is dependent on the patient’s current and past medical history. The length of intubation can vary from 4 days to 4 weeks. This applies to all patients 18 to 88. One thing remains the same though, speech pathologists should be consulted on these patients after extubation. During the COVID crisis the CDC guidelines came out with the recommendations to avoid any endoscopic procedures and this included FEES due to the high risk of infection spread. It is our job to educate our physicians on post extubation dysphagia considerations, and to delay at least 24 - 48 hours before a bedside assessment, given the likelihood and enhanced risk for laryngeal sensory deficits and damage. NG tubes should remain in place upon extubation for proper access to adequate fluid intake and critical medications required for anyone with many comorbidities.
We must use critical thinking in the bedside evaluation, being keenly aware that this is subjective and we educate with nurses and physicians on these limitations. You may have to initiate modified diets and thickened liquids with these patients. The recent trend in dysphagia thinking the last few years............”If we can’t definitively rule out aspiration of thickened liquids, isn’t it safer to aspirate water?” We need to recognize the severity of this risk with COVID19 on the respiratory system. You may have to change your mindset and this is the time to be somewhat conservative with diet texture recommendations and consider the patient’s comorbidities (as you always should) and their overall current medical status.
Evaluating and treating COVID19 patients is truly no different than treating other cases. We are still using clinical judgement, critical thinking skills, educating, advocating and communicating with medical teams- as we always have done. But in other ways- our practice has drastically changed to accommodate the COVID19 situation. We can rely heavily on our bedside skills or use the proper instrumental assessment during this time, MBSS. We will start seeing COVID patients being admitted to acute rehab and skilled nursing. We are still faced with the same challenges as we always have been: NPO vs pleasure feeds, trial feeds? Aspiration vs malnutrition/dehydration risk? Every patient is unique- we still make appropriate recommendations on a case by case basis. But there has NEVER been a more critical time to keep their respiratory status as strong and uncompromised as possible, considering the effect of COVID 19 if someone does becomes infected.
This has been a challenging experience so far for all in the healthcare field, from PPE to caseloads. In these COVID times, the challenge for clinicians is the word “objectively.” Thorough clinicians can make solid clinical judgments based on good chart reviews, detailed discussions with medical team/family, and bedside swallowing evaluations that include a cranial nerve exam. Yet as it has always been, a bedside exam cannot objectively and completely evaluate the oropharyngeal swallow or 100 % rule-out aspiration.
An MBSS is still a very important evaluation for dysphagia patients to have at this time. The instrumental evaluation provides direct lateral and AP viewing of cervical spine, soft tissue abnormalities, detection and visualization of the depth of aspiration, stage transition, and biomechanics of all stages of the swallow through the lower esophagus. The most comprehensive imaging of the swallow available. As a physician-based medical practice, DiagnosTEX is proud to stand with you in caring for patients during the COVID 19 outbreak. Although many hospitals are limiting appointments for non-urgent procedures, safe oral intake is never 'elective.' Evaluation of at-risk patients is required to maintain safe PO feeding and decreasing the risk of life-threatening situations (such as aspiration, pneumonia, dehydration and malnutrition). We want you to feel confident in our dedication to the quality, safety, and oversight of infection control during this COVID 19 event when these patients come to you for rehab.
During your visit with DiagnosTEX you were possibly recommended a modified diet due to dysphagia. This educational sheet may help you understand the various consistencies that were recommended to help you prepare your meals and beverages correctly.
Not all consistencies are safe on a dysphagia diet, please clarify with the treating SLP for recommended consistencies
]]>Not all consistencies are safe on a dysphagia diet, please clarify with the treating SLP for recommended consistencies
Education Form on the
Modified Barium Swallow Study
By: Ronda Polansky M.S. CCC-SLP
What is a Modified Barium Swallow Study (MBSS) – a form of real-time x-ray called fluoroscopy to evaluate the ability to swallow safely and effectively. The exam is typically well tolerated, noninvasive, and can help identify the consistencies of liquid and food that a patient can most safely consume.
The patient is observed swallowing various consistencies and textures, ranging from thin liquid barium to barium-coated cookies, in order to evaluate his or her ability to swallow safely and effectively. This exam is performed with a dysphagia specialty trained speech-language pathologist present.
Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging. Fluoroscopy allows imaging of anatomical structures in real-time and allows the interpreting physician to observe structure and limited function. An MBSS may be performed as an independent test to look at the swallowing mechanism, or together with a scan of the esophagus, which evaluates the structure and function of the esophagus to the level of the stomach. The names of these two exams are similar: Modified Barium Swallow Study and a Barium Swallow Study/Upper GI, which can sometimes cause confusion when the test is ordered. Therefore, be sure to clarify with your physician which exam your doctor intended to prescribe.
What are some common uses of the procedure?
The MBSS is performed on patients of all ages with dysphagia, the technical term for difficulty swallowing. It is used primarily for evaluating the swallowing function and any evidence of aspiration, which is liquid or food going into the airway (the trachea and lungs) instead of staying in the pharynx and advancing to the esophagus.
In order to help an individual swallow more safely and efficiently, speech-language pathologists may suggest different head positions, such as tucking or tilting the chin or turning the head while swallowing. The MBSS can be used to evaluate and observe the effectiveness of these swallowing strategies. The speech-language pathologist may also suggest thickening liquids or modifying other food consistencies to help prevent penetration or aspiration of the food/liquids into the airway.
The MBSS may be performed because of a known or suspected swallowing problem or because of the presence of conditions that are strongly associated with swallowing difficulty, such as:
What are the limitations of the Modified Barium Swallow Study?
The MBSS only evaluates the area from the back of the mouth through the pharynx (throat) to the top of the chest. In some cases, the dysphagia symptoms may be due to abnormalities in the esophagus, which is lower in the chest. An esophagram, also called an upper GI or a barium swallow exam, may be recommended if the problem is thought to be lower in the esophagus and into the stomach.
]]>Laryngectomy
By: Ronda Polansky M.S. CCC-SLP
Evaluation of the patient must take into account not only the structure and function of the swallowing mechanism, but also the side effects that the chosen medical interventions will impose. Assessment of unique patient characteristics, including medical history, nutritional status, cultural preferences, coping style, support systems, and communication and cognitive abilities, is crucial in developing a treatment plan.
Historically, the first total laryngectomy completed for cancer was performed by Dr. Billroth in 1873. Today, a laryngectomy typically is performed as a primary or secondary treatment for laryngeal carcinoma. When indicated for a primary, untreated tumor, it is usually for advanced disease that cannot be adequately managed in a more conservative manner.
It is important to understand that during the normal swallow, the vocal cords close, just after the initiation of an exhalation, trapping the air in nearly full lungs and providing what’s known as “subglottic pressurization” The physics of swallowing, therefore, are altered quite a bit as laryngectomees are no longer capable to maintaining this pressure. Before the laryngectomy, with every swallow, there was a typical degree of pressurization that assisted in driving the food through the pharynx and into the esophagus.
There are 2 types of Laryngectomies: 1) Supraglottic laryngectomy and 2) total laryngectomy
During a supraglottic laryngectomy (sooprah-GLOT-tik lair-un-JECT-uh-me), a surgeon removes the top part of your voice box (larynx), near your vocal cords. Your voice box (larynx) has two bands of muscle that form the vocal cords. The front of the voice box is made of cartilage and is sometimes called the Adam’s apple. Supraglottic laryngectomy can interfere with laryngeal elevation and sometimes vocal fold adduction. If a “laryngeal suspension procedure” is performed during reconstruction, laryngeal elevation is improved and swallowing is safety enhanced. If a supraglottic laryngectomy procedure encompasses more than the traditional procedure and includes portions of the hyoid bone, base of tongue, aryepiglottic folds, or false vocal folds, prognosis for swallowing recovery is more diminished.
A total laryngectomy requires separation of the airway from the esophagus. The trachea typically is brought forward below the level of the larynx and is sutured to the base of the neck just above the sternal notch, creating a permanent tracheostoma for breathing. Dysphagia after total in all likelihood, is underreported. Patients undergoing total laryngectomy have few swallowing problems following surgery due to the permanent separation of the trachea and esophagus. However, occasionally the laryngectomee may have problems propelling the bolus through the oral cavity and pharynx as a result of the loss of hyoid bone, which is the anchor for the tongue. Increased pressure in the pharyngoesophagus following laryngectomy requires the tongue to move with greater force. Stricture at the anastomosis may cause narrowing and reduced bolus flow through the pharynx. Pseudoepiglottis, a postsurgical fold of tissue from the pharynx at the level of the base of tongue, may serve as a mechanical barrier to efficient bolus flow and trap food in its pocket.
Tracheostomy – A patient will have a temporary tube placed in their throat/neck called a trachesostomy tube, which they will breathe through. A “Trach” is short for tracheostomy (TRAKE-e-os-toe-me) which is simply a surgical hole in your windpipe. A tracheostomy provides an air passage to help you breathe when the usual route for breathing is somehow obstructed or impaired. Breathing is done through the tracheostomy tube rather than through the nose and mouth. When a tracheostomy is no longer needed, it’s allowed to heal shut or is surgically closed. For some people, a tracheostomy is permanent.
Effects of Radiation on Swallowing – Radiation has both early and late side effects that can impact swallowing function.
Early effects include xerostomia (dry mouth), erythema superficial ulceration, bleeding, pain, and mucositis, which is a painful swelling of the mucous membranes lining the digestive tract. These usually result in oral pain that may cause only minimal diet alterations, require prescription of pain medications, or necessitate reliance on non-oral nutrition. Hypopharyngeal stricture (a narrowing of the pharyngeal structure as a side effect of the radiation) may require dilation or surgery. Xerostomia is a side effect of treatment that persists for years and may worsen over time.
Late effects may include osteoradionecrosis (a condition where irradiated bone and surrounding tissues lose their reserve repairative capacity and start to degenerate), trismus (lockjaw), reduced capillary flow, altered oral flora, dental caries, and altered taste sensation. The late effect of reduced blood supply to the muscle can result in fibrosis, reduced muscle size, and the need for replacement with collagen. This can dramatically affect swallowing years after treatment with a fixation of the hyolaryngeal complex, reduced tongue range of motion, reduced glottic closure, and cricopharyngeal/PES relaxation, resulting in potential for aspiration.
Goals of Swallowing Rehabilitation There are several goals in swallowing rehabilitation.
The primary goals are to prevent malnutrition and dehydration and reduce the risk of aspiration. Re-establishment of safe and efficient oral intake, prevention of dysphagia prior to medical treatment, and patient education regarding the specifics of their disorder are also important goals of intervention. Pretreatment counseling is beneficial in addressing the possibility that dysphagia may develop during or after the completion of the planned treatment. Poorly prepared patients may become frustrated when attempting to feed and thus may fail to ingest enough to maintain adequate nutrition and hydration. Individuals can be given strategies, recommendations, or exercises prophylactically to reduce the chances of developing a problem. Researchers are currently investigating the benefits of pre radiation exercise. Treatment for post-surgical cases usually begins once the surgeon indicates the patient has healed sufficiently, usually 5 to 10 days post-surgery
Diets
Diet alterations and food presentation strategies also can be use therapeutically to improve efficiency and safety of swallowing. Thickening liquids may slow the rate of bolus flow through the pharynx for patients with a delayed swallow. A puree diet can be used if surgical resection or trismus prevents chewing. Foods prepared with sauces and gravies may be useful for a xerostomic patient. Alternating solids and liquids can reduce pharyngeal stasis. Liquids can be presented by cup, straw, spoon, or syringe, depending on specific patient needs
References
Agrawal, N., & Goldenberg, D. (2008). Primary and salvage total laryngectomy. Otolaryngology Clinics of
North America, 41, 771-780.
Balfe, D. M., Koehler, R. E., Setzen, M., Weyman, P. J., Baron, R. L., & Ogura, J. H. (1982). Barium
examination of the esophagus after total laryngectomy. Radiology, 143, 501-508.
Bajaj, Y., Shayah, A., Sethi, N., Harris, A. T., Bhatti, I., Awobem, A., Loke, D., & Woodhead, C. J. (2009).
Clinical outcomes of total laryngectomy for laryngeal carcinoma. Kathmandu University Medical Journal,
7(3), 258-262.
Chu, E. A., & Kim, Y. J. (2008). Laryngeal cancer: Diagnosis and preoperative work-up. Otolaryngology
Clinics of North America, 41, 673-695.
Crary, M. A., & Glowasky, A. L. (1996).Using botulinum toxin A to improve speech and swallowing
function following total laryngectomy. Archives of Otolaryngology-Head and Neck Surgery, 122, 760-763.
The Department of Veterans Affairs Laryngeal Cancer Study Group. (1991). Induction chemotherapy plus
radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The New
England Journal of Medicine, 324, 1685-1690.
Eibling D. E.; Gross R. D. “Subglottic air pressure : A key component of swallowing efficiency”; The Annals of otology, rhinology & laryngology ISSN 0003-4894.
-See more at: http://www.oralcancerfoundation.org
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Dysphagia Consultation
Including Modified Barium Swallow Study (MBSS) and Esophageal Assessment to the Stomach Versus Fiber optic Endoscopic Evaluation of Swallowing (FEES)
MBSS and FEES are complementary assessments BUT are NOT the same instrumental assessment. The MBSS is considered the GOLD STANDARD and remains the MOST COMPRESHENSIVE EVAULATION of oropharyngeal dysphagia.
The Major Advantages of a Dysphagia Consultation including MBSS and Esophageal Assessment to the Stomach with DiagnosTEX Compared to FEES are:
Since 2003, Proudly Serving DFW 800.514.MBS1 (6271) f 817.514.6278 www.dysphagiadiagnostex.com
Comparison of Actual Biomechanics and Swallowing Features Viewed during a Dysphagia Consultation with DiagnosTEX versus FEES
BIOMECHANICS and Swallow Parameters OBSERVED | Mobile Dysphagia Consult MBSS/Esophageal Assessment | FEES |
Lip Closure | Yes | |
Bolus Preparation/Mastication | Yes | |
Bolus Transport/Lingual Motion | Yes | |
Oral Residual | Yes | |
Soft Palate Elevation | Yes | |
Nasopharyngeal Reflux | Yes | |
Actual Pharyngeal swallow | Yes | White out during swallow |
Vocal Cord Movement | Yes | Yes |
Laryngeal Elevation | Yes | |
Anterior Hyoid Excursion | Yes | |
Epiglottic Movement | Yes | Partial viewing |
Laryngeal Vestibule Closure at Height of Swallow | Yes | |
Pharyngeal Stripping wave | Yes | |
Pharyngeal Contraction A-P View | Yes | |
Pharyngoesophageal Segment Opening During Swallow | Yes | |
Bolus Movement before and after the Swallow | Yes | Yes |
Bolus Movement during the Swallow | Yes | |
Pharyngeal Residuals | Yes | Yes |
Tongue Base Retraction | Yes | |
Aspiration before or after the swallow | Yes | Yes |
Aspiration During the Swallow | Yes | |
Esophageal Clearance/Motility | Yes | |
Esophageal Reflux | Yes | |
Soft Tissue Abnormalities / Masses | Yes | |
Cervical Osteophytes & Cervical Spine Abnormalities | Yes | |
Diverticulum | Yes | |
Esophageal Strictures | Yes |
Since 2003, Proudly Serving DFW 800.514.MBS1 (6271) f 817.514.6278 www.dysphagiadiagnostex.com
]]>Dysphagia occurs more frequently in advanced stages of MS, although it can occur at any time during the disease course. Its real prevalence can be estimated to be around 30%–40%. Dysphagia is life-threatening if not managed properly. In fact, its complications such as dehydration and aspiration pneumonia are a common cause of death and morbidity in late MS.
Multiple Sclerosis (MS) is an autoimmune disease of the central nervous system (CNS) in which the material that surrounds and protects nerve cells, the myelin sheath, is attacked resulting in subsequent decreased functioning. There is a wide variability in swallowing disorders in individuals with MS. This is because of the wide variability in central nervous system damage, the wide range of disease severity, and the patterns of exacerbation and remission.
Common signs and symptoms of Dysphagia:
1. Pharyngeal delay – may result in difficulty swallowing thin liquids, or frequently having a mouthful of saliva and sometimes choking on it. MS experience more difficulty swallowing liquids, particularly if there is a delay between the end of the oral stage of swallowing and the beginning of the pharyngeal stage. During the delay the airway remains open until the swallow is triggered. This delay increases the risk of the liquid penetrating into the airway and aspirating into lungs
2. Reduced Pharyengeal Contraction – food/liquid retention and residue can remain in the pharynx after the swallow. The residual food may progress or be inhaled into the open airway when the patient breathes after the swallow
3. Oral phase delay – the longer a thickened liquid is held in the mouth the viscosity will change starting at around 10 sec
4. Decreased hyolaryngeal excursion – which effects the anterior movement and laryngeal elevation
5. Poor coordination of laryngeal and UES function – tend to present early in the progression of the disease process., can result in pyriform sinus retention
6. Penetration and/or aspiration – become apparent in more severe cases and can be life threatening if not identified and managed appropriately.
.
Fatigue and Dysphagia in MS
All too often overlooked is the interaction between fatigue and dysphagia. A person with MS may have no swallowing difficulty at the beginning of a meal, but may develop swallowing problems during a long meal, especially one involving prolonged mastication/chewing. Solid foods require much more effort and lingual pressure to push backward through the mouth than liquids do, and generating this additional pressure demands greater muscle strength. This can result in muscle weakness, which can then increase dysphagia.
Recommendations
1. Frequent rest periods during meals or eating, smaller meals, for a shorter period of time. May be required for an MS patient and their continuedPOstatus. Frequent rest period during treatment as well.
2. Chewing exercises. Swallowing therapy often involves exercises to strengthen the muscles used in swallowing and to improve the muscle coordination during the swallowing process, along with learning safe swallowing strategies. But fatigue must be monitored during therapy.
3. Chopping food into small bites before eating can help significantly or it may be required to downgrade to a puree consistency.
4. Therapy treatment to improve the ability to coordinate breathing and swallowing. This will help protect the airway so no food or liquid enters the lungs.
5. Oral- motor exercises – Specific exercises to strengthen tongue and lip function to promote faster swallowing may also be utilized. Monitor for fatigue during treatment.
6. Dietary changes such as adding a thickening agent to liquids, or avoiding certain types of foods that may result in choking or aspiration.
7. Postural adjustments can also be beneficial.
8. In severe cases, feeding tubes may be necessary, if chosen as an option by the patient and/or family.
8. Saliva production – They may suck on a lozenge to stimulate saliva production, which will stimulate more swallowing. (A sour candy stimulates more swallows than a milder or less flavorful lozenge.) Make sure this is safe for them considering their level of dysphagia.
Dysphagia will gradually worsens over the course of the disease, whereas others experience temporary difficulty that gradually improves from time to time.
What can caregivers do?
Caregivers should be observant during mealtime to determine if swallowing and eating are slowing down or becoming more difficult. The caregiver can provide reminders about strategies that have been recommended by the SLP. Practice is needed with strategies as sometimes in the course of a meal, a person may forget the proper head position, the proper amount of food or liquid taken per swallow and the time between a successful and unsuccessful swallow. Once the SLP has recommended specific strategies, the caregiver can provide gentle reminders/cues for the person to use these strategies successfully.
Also, the caregiver should be familiar with the Heimlich maneuver,. Remember that if the person who is choking is able to talk or cry, the Heimlich maneuver is not appropriate. For more information on the Heimlich Maneuver, visit the American Heart Association website at www.amhrt.org. There is little published research about MS and dysphagia treatment.
]]>
Consultants in Dysphagia Evaluation and Management
817-514-MBS1 or 1-888-514-MBS1
Created by : Ronda Polansky M.S. CCC-SLP
Oral Motor Management
An examination of the patients anatomy is done during an Bedside Swallow Eval (BSE)
This usually begins with lip seal and tongue movement
Of importance is evaluation of oromandibular movement during mastication, with SLP noting symmetry of motion, labial closure, control of saliva during fixed expression and chewing.
Oral – motor functioning is the area of assessment which looks at normal and abnormal patterns of the lips, tongue, jaw, and cheeks for eating, drinking, facial expression and speech to determine which functional skills a client has to build on, and which abnormal patterns need to be inhibited or for which compensation is needed. Oral-motor disorders are diagnosed by the SLP directly observing the patient, doing what is called an “Oral-Motor Exam”. In this exam, the therapist asks the patient to do a variety of tasks (such as pursing lips, blowing, elevating tongue, etc), looks inside the mouth, observes the patient eating and listens to them talk. The therapist will also listen for the patient’s ability to produce rapid oral movements.
SIGNS/SYMPTOMS:
Facial asymmetry can be produced by structural abnormalities or by unilateral or asymmetrical weakness of the muscles of the face. Structural abnormalities are due to musculoskeletal deformations, soft tissue masses, and tumors
All types of Dysarthria affect articulation of consonants, causing slurring of speech.
Ideas for more interesting O-M exercises for adults and children that can be done at home:
Blowing Bubbles
This may seem a bit immature, but it is a great exercise for breath control as well as pursing the lips.
In our own experience the clients that we’ve worked with have all enjoyed this activity. Remember, you’re never too old to have some fun!
Blow a Harmonica
Here is another great oral motor exercise for breath control and lip pursing, but with this one you get to make some noise!
If breath control is weak then your goal might be to get “louder” sounds from the harmonica.
If your lip strength is weak you might focus on trying to play just one note at a time.
Harmonica’s are inexpensive (you can even use a plastic one), and all in all it’s another fun activity.
Peanut Butter on the Lips
Rub some peanut butter on your lips and do your best to lick it all off. Make sure you apply the peanut butter from one corner of the mouth to the other.
This will force the tongue to reach from side-to-side to lick that tasty spread. This should go without saying by now, but never use this with anyone experiencing feeding or swallowing difficulties.
Icing
Putting ice on the lips will certainly help “wake up” those muscles. You can use a plain ice cube for this exercise, but ice pops are easier to use and add some flavor as well. Run the ice from the middle of the lips outward to the corner. Do this on both sides and then ask the patient to smile. Repeat the icing movements and the smiling attempts several times.
Brushing
Using a toothbrush, brush the upper and lower lips. You can purchase toothbrushes with different levels of stiffness. Try to use different levels ranging from very soft to stiff (never use anything that may cause pain). You can also use the brushing technique on the muscles surrounding the mouth (including the jaw).
Using a Straw
Practicing with a straw will obviously work on sucking skills, however it also involves pursing those lips again.
“Thin” liquids like water or apple juice are good starters.
As you progress you might want to try a “thicker” liquid like a milk shake.
Do not use this exercise if your patient has feeding or swallowing difficulties.
References: Speechtherapyonvideo.com, Beckman Oral Motor patterns
]]>The cervical spine begins at the base of the skull. Seven vertebrae make up the cervical spine with eight pairs of cervical nerves. The individual cervical vertebrae are abbreviated C1, C2, C3, C4, C5, C6 and C7. The cervical nerves are also abbreviated; C1 through C8.
Dysphagia following cervical spine intervention has been under-diagnosed and overlooked. Understanding the occurrence of post surgical dysphagia is essential in diagnosing and treating the condition. With increased awareness of the risks and proper identification treatment can be initiated promptly to avoid unnecessary complications during the hospital stay. Dysphagia research, as limited as it is, indicates anywhere from a 45-85% rate of dysphagia after surgery, with percentages of 10-15% suffering from persistent dysphagia over a 6 months period.
Three types of cervical fusion:
Left side anterior cervical fusion is preferred due to less risk of dysphagia as the recurrent laryngeal nerve runs laterally. But each surgeon has a preferred approach of his or her own. The recurrent laryngeal nerve is vulnerable anywhere between C1-T1.
The oropharyngeal structures correlate with the cervical spine (see attachment). Cervical Spine 1-5 as well as C6 and C7 correspond with many anatomic landmarks important to swallowing.
C-1 – Hard Palate, Soft Palate, Velum
C-2 – Base of tongue, valleculae
C-3 – Base of Tongue, Retropharyngeal space, valleculae, epiglottis
C-4 – Hyoid Bone, Pyriform Sinuses
C-5 – Vocal cords
C-6 – Vocal Cords, Pyriform Sinuses, Cricopharyngeal muscle
C-7 – Cricopharyngeal muscle
Cervical osteophytes and other hypertrophic changes of the cervical spine are found in approximately 20-30% of the elderly However, large osteophytes that protrude from the anterior edge of the cervical vertebrae can impinge on the pharynx or upper esophagus. Large osteophytes have been found to cause dysphagia, odynophagia, and globus symptoms. Resnick et al. coined the term “diffuse skeletal hyperostosis” to describe these large multisegmental bridging osteophytes of the cervical and lumbar spine. They found that dysphagia was fairly common in patients with diffuse skeletal hyperostosis. Retention and aspiration were more often seen with increased osteophyte size. However, even small osteophytes may cause clinically relevant pharyngeal residue and aspiration if they occur concomitantly with other clinical conditions. The presence of a cervical osteophyte in an elderly patient does not necessarily explain individual symptoms. Swallowing dysfunction is common in this age group and can be caused by a variety of diseases, including stroke, Parkinson’s disease, dementia, and esophageal carcinoma. Videofluoroscopy has been found to be the most sensitive method to detect swallowing abnormalities in patients suffering from dysphagia.
Treatment of cervical osteophyte—induced dysphagia should depend on the nature and severity of disease. Sedation, antiinflammatory drugs, and muscle relaxants with an appropriate soft diet have been used successfully . Surgical excision of a large anterior cervical osteophyte via an anterior extrapharyngeal approach was first described by Iglauer in 1938. In a review of the literature, Sobol and Rigual found 70-80 patients with osteophyte-induced dysphagia. Of these, 19 patients underwent surgery that successfully relieved the dysphagia in all but three patients. Vocal cord paralysis has been reported in 2-11% of patients as the most common complication, followed by fistula, hematoma, infection, and transient aspiration. One patients suffered from a hypoglossal nerve paralysis postoperatively, which, to our knowledge, has not been reported as a complication of osteophyte surgery. However, some studies have suggested that surgery should be reserved for patients with severe symptoms or for those patients for whom conservative treatment failed.
References
Resnick D, Shaul SR, Robins JM. Diffuse idiopathic skeletal hyperostosis (DISH): Forestier’s disease with extraspinal manifestations. Radiology 1975;115:513-524[Abstract]
Jones B, Donner M. Examination of the patients with dysphagia. Radiology 1988;167:319-326[Abstract/Free Full Text]
Deutsch EC, Schild JA, Mafee MF. Dysphagia and Forestier’s disease. Arch Otolaryngol 1985;111:400-402[Abstract/Free Full Text]
Umerah BC, Mukherjee BK, Ibekwe O. Cervical spondylosis and dysphagia. J Laryngol Otol 1981;95:1179-1183[Medline]
Iglauer S. A case of dysphagia due to an osteochondroma of the cervical spine-osteotomy-recovery. Ann Otol Rhinol Laryngol 1938;47:799-803
Heeneman H. Vocal cord paralysis following approaches to the anterior cervical spine. Laryngoscope 1973;83:17-21[Medline]
Komisar A, Tabaddor K. Extrapharyngeal (anterolateral) approach to the cervical spine. Head Neck Surg 1983;6:600-604[Medline]
Public Education Sheet
For over 75 years May has been designated as Better Hearing and Speech Month — a time to raise public awareness, knowledge, and understanding of the various forms of communication impairments to include those of hearing, speech, language, and voice. Communication impairments affect the most vulnerable in our society — the young, the aged, the disabled, and the poor.
Helen Keller once noted that of all her impairments, she was perhaps troubled most by her lack of speech and hearing. She elaborated, that while blindness separated her from things, her lack of speech and hearing separated her from people — the human connection of communication
· Speech-Language Pathology (Speech-Language Pathologists) and Audiology (Audiologists) are the professions concerned with the prevention, identification, and treatment of communication impairments. After earning a master’s degree (consisting of required coursework and practicum experiences), passing a national examination, and serving a year long clinical internship, these professionals are eligible for certification, in the form of the Certificate of Clinical Competence (CCC), from the American Speech-Language-Hearing Association. (Both of these professions were rated among the top 50 for job satisfaction in recent Jobs Rated Almanac.)
· Speech-language pathologists are the professionals who treat various aspects of all types of speech, language, voice, stuttering, hearing, swallowing and related disorders. They hold at least a master’s degree and are certified by the American Speech-Language-Hearing Association. Speech Pathologists work in schools, private practice, hospitals, clinics, and other health and education settings.
· In the United States it is estimated that between 6-15 million adults have some form of dysphagia (swallowing difficulties). This can be the result of a neurological disorder/event (stroke, disease, syndrome, brain injury), head and/or neck cancer, or unknown cause. Dysphagia can range from minor oral discoordination to severe aspiration (into the lungs) of foods and liquids. The entire spectrum affects the safety and effectiveness of nutrition and hydration.
· A videofluoroscopic swallow study, also called a Modified Barium Swallow Study (MBSS), may be ordered after a clinical swallow evaluation is completed if there is concern that a patient may be aspirating on food or liquids, has significant oral dysphagia that can not be seen clearly from the outside, or if patient has significant complaints of food “getting stuck” in the throat. This procedure is completed in a radiology suite at a hospital or on a mobile unit with a speech pathologist and physician present. The patient is given different consistencies and textures of food and drink laced with barium to swallow while under fluoroscopy. The patient’s swallow is evaluated by observing the contrast move through the mouth, throat, and esophagus.
· After completing a swallowing evaluation, therapy is often recommended. Swallowing therapy can include diet modification training, teaching of compensatory strategies, exercises, and neuromuscular electrical stimulation.
· Speech and language disorders take many forms such as speech, articulation, voice, stuttering, aphasia, oral language, or swallowing problems. They may be learning based, acquired, or the result of accidental injury or illness at any age. Speech and language disorders can limit academic achievement, social adjustment, and career advancement. Most people with speech and language problems can be helped. Even if a problem cannot be eliminated, Speech pathologists can teach people with speech, language, or swallowing problems strategies to help them cope. People may not fully develop or regain their capacity to speak, understand, or swallow but a Speech Pathologist can help them achieve an improved quality of life.
· The National Institute on Deafness and Other Communication Disorders reports that approximately 43,000,000 people in the United States suffer from a speech, voice, language, or hearing impairment.
· Find out more information at www.asha.org
For your Mobile Modified Barium Swallow Studies contact DiagnosTEX. For more information go to www.dysphagiadiagnostex.com
Phone: 817-514-MBS1 or 1-888-514-MBS1
Fax: 817-514-MBS8 or 1-877-514-MBS8
Speech Pathologist Reference Sheet
By. Ronda Polansky M.S. CCC-SLP
THE NERVE OF IT ALL!
CRANIAL NERVE REFERENCE SHEET
The cranial nerves innervate the muscles of the jaw, face, tongue, neck, pharynx, and larynx. Some of them are motor, some are sensory and some are mixed nerves, containing both sensory and motor fibers. Six of them are involved in speech and swallowing, and are therefore very important to the speech, language pathologist.
The Six Cranial Nerves Involved in Speech and Swallowing
CN V – – the trigeminal nerve
CN VII – – the facial nerve
CN IX – – the glossopharyngeal nerve
CN X – – the vagus nerve
CN XI – – the spinal accessory nerve
CN XII – – the hypoglossal nerve
CN V is the trigeminal nerve.
It provides motor innervation to the muscles that control the mandible (jaw), the tensor veli palatini muscle of the velum, and the tensor tympani muscle of the middle ear. It mediates sensation from the head, jaw, face, some of the sinuses and tactile sensation from the anterior two thirds of the tongue.
CN VII or the facial nerve
Its motor nucleus which is located in the junction of the pons and medulla innervates all of the muscles of facial expression including those in the forehead, cheeks, and lips, as well as the stapedius muscle of the middle ear. It also sends motor impulses to the rest of the ear; if you can wiggle your ears; this action is mediated by CN VII. The facial nerve mediates taste in the anterior two thirds of the tongue.
CN IX, or the glossopharyngeal nerve, is a mixed nerve.
Its motor aspect contributes to the action of the middle pharyngeal constrictor muscle and innervates the stylopharyngeus muscle. Its sensory aspect carries input from the posterior one third of the tongue, the velum, and the pharynx including the tonsils. The glossopharyngeal nerve is responsible for taste in the posterior one third of the tongue and for tactile sensation to the posterior part of the oral cavity, including the velum, tonsils, and walls of the oropharynx. It provides the feedback that is most important in the elicitation of the swallow.
Feedback from motor movements, especially tongue movements which are mediated by the hypoglossal nerve, also help to trigger the swallow. Input from both the cerebral cortex and the cerebellum is responsible for the coordination and timing of the motor movements involved in swallowing
CN X is the vagus nerve. This mixed nerve originates in the medulla.
One of the motor nuclei of the vagus innervates the majority of the viscera, including the heart, respiratory system, and digestive system. Another motor nucleus sends motor commands to the pharyngeal constrictor muscles and completely controls the intrinsic musculature of the larynx. The superior branch of the vagus innervates the cricothyroid muscle and so is involved in pitch changes. Its recurrent branch innervates all of the other intrinsic laryngeal musculature. The vagus also innervates the glossopalatine and levator veli palatine muscles, making it primarily responsible for palatal functioning.
CN XI is the spinal accessory nerve,
A motor nerve that originates in the medulla. It innervates the trapezius and sternocleidomastoid muscles of the neck. It also sends some motor messages to the uvula and the levator veli palatine (raises the velum).
CN XII, is the hypoglossal nerve,
Another motor nerve that originates in the medulla. It controls tongue movement, innervating both the intrinsic and extrinsic tongue muscles.
Mnemonic for the Cranial Nerves
On |
(olfactory) |
Some |
(sensory) |
Old |
(optic) |
Say |
(sensory) |
Olympus’s |
(oculomotor) |
Marry |
(motor) |
Towering |
(trochlear) |
Money |
(motor) |
Top |
(trigeminal) |
But |
(both) |
A |
(abducens) |
My |
(motor) |
Finn |
(facial) |
Mother* |
(motor) |
And |
(auditory) |
Says |
(sensory) |
German |
(glossopharyngeal) |
Bad |
(both) |
Vended |
(vagus) |
Business |
(both) |
At |
(accessory) |
Marry |
(motor) |
Hopps |
(hypoglossal) |
Money |
(motor) |
The facial nerve could also be classified as both sensory (taste for anterior two thirds of tongue) and motor, in which case the word in this part of the rhyme would change to “brother.” It is usually classified as a motor nerve. CSU, Chico, Patrick McCaffrey, Ph.D.
]]>
Phone: 817-514-MBS1 or 1-888-514-MBS1
Fax: 817-514-MBS8 or 1-877-514-MBS8
www.dysphagiadiagnostex.com
By: Ronda Polansky M.S. CCC-SLP
Dysphagia during the Holidays
If you really think about it, our lives revolve around food and eating. We do business over lunch, romance over dinner, celebrate with food, and eating together solidifies families. We know PO feeding becomes important on many levels to many of patients around the holidays. Modified diets are often not popular during the season that we gather around food with family and friends. Over fifteen million people suffer from Dysphagia in the United States alone and dysphagia does not respect the holidays. Many may be surprised to learn that many of their favorite foods can be apart of their modified diet. Most soft foods are naturally the preferred choice for a dysphagia diet, but with some simple preparation many foods can be pureed to a consistency that is safe.
There are also many foods that can be used in their regular form and consumed without modification or added thickeners. Consider the following:
Cereals
Dairy
Fruits
Vegetables
Soups
Condiments
Easy to Puree Foods
Liquids
Egg Nog – some very close to nectar, but thickener can be added to ensure this, without changing consistency much. Adding alcohol will thin the consistency.
Warm Apple Cider – this is a thin liquid
You can also find a list of suggested dysphagia recipe books on our website in the Clinical Cafe
Consultants in Dysphagia Evaluation and Management
817-514-MBS1 or 1-888-514-MBS1
By: Ronda Polansky M.S. CCC-SLP
TASTE REFERENCE SHEET
Now That’s Tasty!
DELICIOUS, Scrumptious, delectable, BLAND, unpalatable, Stale, awful, YUMMY,
Just a few of many words to describe taste, but they also describe smell and the two are often linked together.
4 BASIC TASTES ARE:
SWEET, SOUR, SALTY, BITTER
Actually there is a 5th basic taste called “Umami” which has recently been discovered. Umami is a taste that occurs when foods with glutamate (like MSG) are eaten.
Umami is a Japanese word meaning savory, a “deliciousness” factor deriving specifically from detection of the natural amino acid, glutamic acid, or glutamates common in meats, cheese, broth, stock, and other protein-heavy foods. The action of umami receptors explains why foods treated with monosodium glutamate (MSG) often taste “heartier”.Umami is hard to translate, to judge by the number of English words that have been suggested as equivalents, such as savoury, essence, pungent, deliciousness, and meaty. It’s sometimes associated with a feeling of perfect quality in a taste, or of some special emotional circumstance in which a taste is experienced. At the beginning of the twentieth century, Professor Kikunae Ikeda of Tokyo Imperial University was thinking about the taste of food: “There is a taste which is common to asparagus, tomatoes, cheese and meat but which is not one of the four well-known tastes of sweet, sour, bitter and salty.”
TASTE BUD
For food to have taste it must dissolve in water. Different parts of the tongue can detect all different types of taste. The actual organ of taste is called a “taste bud”
Each taste bud ( and there are approximately 10,000 taste buds in humans) is made up of many receptor cells ( 50-150). They only love for 1-2 weeks and are replaced by new receptor cells. Taste buds are small structures on the upper surface of the tongue, soft palate, and epiglottis that provide information about the taste of food being eaten. The majority of taste buds on the tongue sit on raised protrusions of the tongue surface called papillae.
As you get older you tend to lose taste buds and your sense of taste is weakened. Taste buds can be dulled or even damaged if they are irritated by extreme heat or cold, infections, a dry mouth, smoking, spicy foods, extremely sour foods, and some medications. Some people are sensitive to a particular food, such as walnuts, which may cause soreness in their mouth.
Definitions
Ageusia – complete inability to taste. This is rare.
Hypogeusia – reduced ability to taste. Found in the elderly
Hypergeusia – Enhanced ability to taste
Taste disorders can be caused by drugs used to treat epilepsy, Parkinson’s Disease, diabetes and high blood pressure. Damage to the areas of the brain such as the brain stem, thalamus, and cerebral cortex may also cause taste problems. This may be why your patients do not want to eat and intake has declined.
CRANIAL NERVES
Two cranial nerves that intervate the tongue and are used for taste are:
1. Facial nerve (CN V11)
2. Glossopharyngeal nerve (CN IX).
3. Another cranial nerve, Vagus (CN X) carries taste information from the back part of the mouth.
The Trigeminal Nerve (CN V) carries information related t o touch, pressure, temperature, and pain.
TRY THE TASTE TEST:
Materials:
What to do:
The smell of food is part of its taste, so if we can’t smell a food, we can’t taste it properly.
Sense-sational Facts:
Consultants in Dysphagia Evaluation and Management
817-514-MBS1 or 1-888-514-MBS1
www.dysphagiadiagnostex.com
By: Ronda Polansky M.S. CCC-SLP
REFLUX
Heartburn is a common problem in the United States and in the Western world. Approximately 7% of the population experience symptoms of heartburn daily. An abnormal esophageal exposure to gastric juice is probably present in 20-40% of this population, meaning 20-40% of the people who experience heartburn do indeed have GERD. In the remaining population, heartburn is probably due to other causes. Because many individuals control symptoms with over-the-counter medications and without consulting a medical professional, the condition is likely underreported.
GERD – Gastroesophageal Reflux is defined as the retrograde movement of gastric contents from the stomach through the lower esophageal sphincter and into the esophagus. The most common symptom is “heart burn”.
Persons with GERD frequently complain of:
1. Non cardiac chest pain, heartburn
2. Dysphagia,
3. Waterbrash (stimulated salivary secretions by esophageal acid),
4. Odynophagia (pain when swallowing),
5. Acid regurgitation
6. Globus sensation
GERD occurs through one of three mechanisms
1. Inappropriate or transient lower esophageal sphincter relaxation
2. Increased abdominal pressure or stressed induced reflux
3. Incompetent or reduced lower esophageal sphincter pressures or spontaneous free reflux.
Lower esophageal sphincter competence is the most important barrier to esophageal reflux.
LPR – Laryngopharyngeal Reflux is an inflammatory disease of the larynx but it originates in the stomach like other reflux disorders. Acid from the stomach rises up to the level of the laryngopharynx and targets the laryngeal tissues to cause a number of disorders.
Difference between GERD and LPR – Persons with LPR frequently complain of:
1. Occurs when a person is upright
2. Occurs during the daytime
3. Presents with the symptoms of dysphagia,
4. Odynophagia,
5. Pharyngitis
6. Globus sensation
7. Shortness of breath
8. Air hunger
9. Hoarseness
10. Pulmonary aspiration
11. Coughing, but usually without the specific complaint of heartburn.
RSI – Reflux Symptom Index
Within the last MONTH how did the following affect you?
1. Hoarseness or voice changes 0 1 2 3 4 5
2. Clearing your throat 0 1 2 3 4 5
3. Excess throat mucus or postnasal drip 0 1 2 3 4 5
4. Difficulty swallowing foods, liquids, or pills 0 1 2 3 4 5
5. Coughing after you ate or after lying down 0 1 2 3 4 5
6. Breathing difficulties or choking episodes 0 1 2 3 4 5
7. Troublesome or annoying cough 0 1 2 3 4 5
8. Something sticking in throat or lump in throat 0 1 2 3 4 5
9. Heartburn, chest pain, indigestion 0 1 2 3 4 5
A score greater than 10 strongly suggests that the patient has laryngopharyngeal reflux (LPR).
Lifestyle Changes
1. Stop smoking
2. Avoid foods and beverages that worsen symptoms.
3. Avoiding alcohol, chocolate, citrus juice, and tomato-based products
4. Lose weight if needed.
5. Eat small, frequent meals.
6. Wear loose-fitting clothes.
7. Avoid lying down for 3 hours after a meal.
8. Raise the head of your bed 6 to 8 inches by securing wood blocks under the bedposts. Just using extra pillows will not help.
Medications: A health care provider may recommend over-the-counter antacids or medications that stop acid production or help the muscles that empty your stomach. Many of these medications can be obtained without a prescription.
1. Antacids, such as Alka-Seltzer, Maalox, Mylanta, Rolaids, and Riopan, are usually the first drugs recommended to relieve heartburn and other mild GERD symptoms. Antacids, however, can have side effects. Magnesium salt can lead to diarrhea, and aluminum salt may cause constipation. Aluminum and magnesium salts are often combined in a single product to balance these effects. Calcium carbonate antacids, such as Tums, Titralac, and Alka-2, can also be a supplemental source of calcium. They can cause constipation as well.
2. Foaming agents, such as Gaviscon, work by covering your stomach contents with foam to prevent reflux.
3. H2 blockers, such as cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR), and ranitidine (Zantac 75), decrease acid production. They are available in prescription strength and over-the-counter strength. These drugs provide short-term relief and are effective for about half of those who have GERD symptoms.
4. Proton pump inhibitors include omeprazole (Prilosec, Zegerid), lansoprazole (Prevacid), pantoprazole (Protonix), rabeprazole (Aciphex), and esomeprazole (Nexium), which are available by prescription. Prilosec is also available in over-the-counter strength. Proton pump inhibitors are more effective than H2 blockers and can relieve symptoms and heal the esophageal lining in almost everyone who has GERD.
5. Prokinetics help strengthen the LES and make the stomach empty faster. This group includes bethanechol (Urecholine) and metoclopramide (Reglan). Metoclopramide also improves muscle action in the digestive tract. Prokinetics have frequent side effects that limit their usefulness—fatigue, sleepiness, depression, anxiety, and problems with physical movement.
Because drugs work in different ways, combinations of medications may help control symptoms. People who get heartburn after eating may take both antacids and H2 blockers. The antacids work first to neutralize the acid in the stomach, and then the H2 blockers act on acid production. By the time the antacid stops working, the H2 blocker will have stopped acid production. Your health care provider is the best source of information about how to use medications for GERD.
References:
Murray, Thomas, Carrau, Ricardo, Clinical, management of Swallowing Disorders, Second Edition, 2006
www.niddk.nih.gov.com
Consultants in Dysphagia Evaluation and Management
817-514-MBS1 or 1-888-514-MBS1
By: Ronda Polansky M.S. CCC-SLP
TASTE REFERENCE SHEET
Now That’s Tasty!
DELICIOUS, Scrumptious, delectable, BLAND, unpalatable, Stale, awful, YUMMY,
Just a few of many words to describe taste, but they also describe smell and the two are often linked together.
4 BASIC TASTES ARE:
SWEET, SOUR, SALTY, BITTER
Actually there is a 5th basic taste called “Umami” which has recently been discovered. Umami is a taste that occurs when foods with glutamate (like MSG) are eaten.
Umami is a Japanese word meaning savory, a “deliciousness” factor deriving specifically from detection of the natural amino acid, glutamic acid, or glutamates common in meats, cheese, broth, stock, and other protein-heavy foods. The action of umami receptors explains why foods treated with monosodium glutamate (MSG) often taste “heartier”.Umami is hard to translate, to judge by the number of English words that have been suggested as equivalents, such as savoury, essence, pungent, deliciousness, and meaty. It’s sometimes associated with a feeling of perfect quality in a taste, or of some special emotional circumstance in which a taste is experienced. At the beginning of the twentieth century, Professor Kikunae Ikeda of Tokyo Imperial University was thinking about the taste of food: “There is a taste which is common to asparagus, tomatoes, cheese and meat but which is not one of the four well-known tastes of sweet, sour, bitter and salty.”
TASTE BUD
For food to have taste it must dissolve in water. Different parts of the tongue can detect all different types of taste. The actual organ of taste is called a “taste bud”
Each taste bud ( and there are approximately 10,000 taste buds in humans) is made up of many receptor cells ( 50-150). They only love for 1-2 weeks and are replaced by new receptor cells. Taste buds are small structures on the upper surface of the tongue, soft palate, and epiglottis that provide information about the taste of food being eaten. The majority of taste buds on the tongue sit on raised protrusions of the tongue surface called papillae.
As you get older you tend to lose taste buds and your sense of taste is weakened. Taste buds can be dulled or even damaged if they are irritated by extreme heat or cold, infections, a dry mouth, smoking, spicy foods, extremely sour foods, and some medications. Some people are sensitive to a particular food, such as walnuts, which may cause soreness in their mouth.
Definitions
Ageusia – complete inability to taste. This is rare.
Hypogeusia – reduced ability to taste. Found in the elderly
Hypergeusia – Enhanced ability to taste
Taste disorders can be caused by drugs used to treat epilepsy, Parkinson’s Disease, diabetes and high blood pressure. Damage to the areas of the brain such as the brain stem, thalamus, and cerebral cortex may also cause taste problems. This may be why your patients do not want to eat and intake has declined.
CRANIAL NERVES
Two cranial nerves that intervate the tongue and are used for taste are:
1. Facial nerve (CN V11)
2. Glossopharyngeal nerve (CN IX).
3. Another cranial nerve, Vagus (CN X) carries taste information from the back part of the mouth.
The Trigeminal Nerve (CN V) carries information related t o touch, pressure, temperature, and pain.
TRY THE TASTE TEST:
Materials:
What to do:
The smell of food is part of its taste, so if we can’t smell a food, we can’t taste it properly.
Sense-sational Facts:
Consultants in Dysphagia Evaluation and Management
www.dysphagiadiagnostex.com
817-514-MBS1 or 1-888-514-MBS1
2921 Brown Trail # 110
Bedford, Texas 76021
Modified Barium Swallow Study Notification for NURSING
is scheduled for a Modified Barium Swallow Study (MBSS) on________/________/_______
at _____:_____ am/pm
In order for the procedure to run smoothly for our patient, your help is needed:
1. Please take the VITAL SIGNS prior to the test
2. Please make sure the patient is sitting UP, in a WHEEL CHAIR, and ready for the test
3. Have the CHART ready and available for the physician on board to review
4. Remove any necklaces/earrings as they may interfere with the x-ray
5. Assist in inserting dentures or other dental items necessary for PO
Thank you very much!
The MBSS will be performed at this facility, requiring the patient to board a mobile clinic.
BP _______ PULSE _______RESP ______ TEMP ______
Speech Therapy Department_____________________________
Phone: 817-514-MBS1 or 1-888-514-MBS1
Fax: 817-514-MBS8 or 1-877-514-MBS8
Speech Pathologist Reference Sheet
By: Ronda Polansky M.S. CCC-SLP
STRATEGIES in Head and Neck Cancer
For those patients who have undergone surgical resection or organ preservation protocols for head and neck cancer and who are unable to resume functional swallowing, several treatment options are available. Treatment strategies should be introduced during the MBSS to determine the effectiveness of the strategy prior to implementation.
Several categories of interventions exist: including postural changes, sensory procedures, maneuvers, diet changes, physiologic exercise, and orofacial prosthetics. Used alone or in combination, these options can be extremely successful in returning a patient to safe and efficient oral intake.
Postural strategies are simple techniques designed to alter the bolus flow.
· A chin down posture improves base of tongue contact to the posterior pharyngeal wall, opens the vallecular space, and puts the larynx in a more protected position.[44]
· Head rotation to the damaged side closes off a weakened pharynx and allows bolus passage down the intact contralateral side.[45]
· Head tilt to the intact side provides gravity assist in bolus flow through the oral cavity and pharynx. A sidelying position may be useful in a delayed swallow or with poor airway protection as it slows the flow of the bolus through the pharynx. Combinations of these strategies can be used with an additive effect.
Sensory procedures provide altered sensory feedback or sensory enhancement during swallowing.
· Alterations in bolus volume, taste, and temperature can be used to affect changes in swallowing physiology. For example, cold and added pressure (thermal-tactile stimulation) have been shown to increase the speed of initiation of the swallow response.[46]
· Added pressure on the tongue by a utensil also increases sensory feedback. Since chewing sends sensory information to the pharynx, a soft masticated diet should be utilized when possible.
· Finally, the sensory motor integration achieved during self-feeding helps to normalize swallow patterns. Therefore, patients should feed themselves whenever possible.
Extensive data exist regarding the efficacy of swallowing maneuvers in the head and neck population. They are designed to alter the physiology of the swallow.
· The supraglottic swallow maneuver closes the vocal folds before and during the swallow.[23] The effortful swallow improves tongue base retraction and pressure generation.[22]
· The Mendelsohn maneuver enhances and prolongs laryngeal elevation and anterior movement to improve laryngeal elevation and extent and duration of cricopharyngeal opening.[22]
· The tongue-holding maneuver improves the tongue base to posterior pharyngeal wall contact and exercises the glossopharyngeal muscle.[21]
· Dry or repeated swallows reduce pharyngeal residues.
Diet alterations and food presentation strategies also can be use therapeutically to improve efficiency and safety of swallowing.
· Thickening liquids may slow the rate of bolus flow through the pharynx for patients with a delayed swallow.
· A puree diet can be used if surgical resection or trismus prevents chewing.
· Foods prepared with sauces and gravies may be useful for a xerostomic patient.
· Alternating solids and liquids can reduce pharyngeal stasis.
· Liquids can be presented by cup, straw, spoon, or syringe, depending on specific patient needs.
· Chopsticks or an iced teaspoon can place foods in the posterior oral cavity.
· A glossectomy spoon is specially designed to push food into the pharynx, bypassing the oral phase of swallow.
Food placement on the surgically unaffected side can increase efficiency and safety as well. All of these dietary changes can be used in combination with postural alterations and swallow maneuvers at mealtime.
Oral prosthetics can offer structural support and compensation to oropharyngeal structures that were lost or altered postsurgery.
· Palatal lowering prostheses recontour or lower the palate to allow the remaining portion of the resected tongue to contact the palate when swallowing.[47]
· Obturators can fill a palatal defect, preventing food leakage into the nasal cavity and establishing more normal intraoral pressure.
Use of these devices can significantly reduce oral residue. The speech pathologist collaborates with the maxillofacial prosthodontist to provide feedback on the configuration, use, and benefits of the prosthesis.
Reference: H. Lee Moffitt Cancer Center & Research Institute, 12902 Magnolia Drive, Tampa, FL
21. Fujiu M, Logemann JA. Effect of a tongue holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech-Lang Pathol. 1996;5:23-30.
22. Lazarus C, Logemann JA, Gibbons P. Effects of maneuvers on swallowing function in a dysphagic oral cancer patient. Head Neck. 1993;15:419-424.
23. Logemann JA, Pauloski BR, Rademaker AW, et al. Super supraglottic swallow in irradiated head and neck cancer patients. Head Neck. 1997;19:535-540.
45. Logemann JA,Kahrilas PJ, Kobara M, et al. The benefit of head rotation on pharyngoesophageal dysphagia. Arch Phys Med Rehabil. 1989;70:767-771.
46. Lazarra GDL, Lazarus C, Logemann JA. Impact of thermal stimulation on the triggering of the swallow reflex. Dysphagia. 1986;1:73-77.
47. Davis JW, Lazarus C, Logemann J, et al. Effect of a maxillary glossectomy prosthesis on articulation and swallowing. Prosthet Dent. 1987;57:715-719.
Family Education Sheet
ASPIRATION
Aspiration – Aspiration occurs when material such as gastric contents, saliva, food, nasopharyngeal secretions are inhaled into the airway or upper respiratory tract. In a healthy population, micro aspiration is common and pulmonary secretions seldom occur. In the unhealthy population risk for pneumonia is higher due to levels of consciousness, altered airway defenses, and depressed immune function. Aspiration may be silent or with overt symptoms. How much is too much aspiration??
Not enough research exists to definitively answer this question. Until more research is available, the SLP should use clinical judgment and assume that the least amount of aspiration is safest for the patient (Hardy & Robinson, 1999). The amount of aspiration will also depend on the patient’s current medical condition and varying diagnoses involved.
Aspiration Pneumonia –Pneumonia occurs when bacteria that normally exist in the oral, nasopharyngeal and gastrointestinal tract or food and/or liquid are aspirate into the lungs. A chest X-ray that may show infiltrates or pneumonia confirms diagnosis of pneumonia, most consistently in the right lower lobe. A bronchoscopy can give a definitive diagnosis.
High Risk Diagnosis
Dysphagia Indicators, Signs and Symptoms
Swallowing difficulty – influenced by solids or liquids
Associated Symptoms
1. Coughing, choking, and or excessive throat clearing
2. Excessive sneezing
3. Runny nose and/or watery eyes – equivalent to a cough in the elderly
4. Multiple swallows during any PO
5. Pain in swallowing
6. Feeling as if something is “stuck” in the throat. Referred to as s globus sensation
7. Pulmonary Status change
8. Complaints of fullness in the neck
9. Pocketing food
10. Wet -gurgly phonation/voice or respirations
11. Excessive secretions, drooling
12. Audible swallow
13. Mouth odor
14. Nasal regurgitation
15. Heartburn or chest pain during and or after PO
Ancillary Symptoms
1. Weight loss – malnutrition and/or dehydration
2. Change in eating habits or appetite
3. Voice changes
4. Decreased sleep
5. Taste changes
6. Dry mouth or saliva consistency changes
Medical History
1. Medical or psychiatric history – anorexia, bulimia, globus hystericus
2. Medications
3. Radiation treatment for CA
4. General health and current status
5. Recurrent Pneumonia
Clinical Observation
1. Nutritional and hydration status
2. Mental status and behavior, cognition. Feeding difficulties
3. Posture
4. Trach or open stoma
5. Nasal gastric tubes
Clinical Examination
1. Oral Mucosa
2. Dentures
3. Sensation
4. Reflexes
5. Oral anatomy
Normal Changes in Advance Age:
· Decreased salivation
· Decreased taste
· Decreased smell
· Decreased pliability of the epiglottis
· Decreased elasticity and strength of lung muscles
· Decreased muscle tone of the laryngeal & pharyngeal muscles
· Increased threshold for a cough reflex
· Increased threshold for a swallow reflex
· Incidence of esophageal disease and reflux
· Increased chest wall stiffness
· Changes in ossification of cartilages
· Degeneration of bony structures
· Changes in dentition
· Larynx lowers to level of 6-7 of the cervical spine
· Fatigue
· 10% reduction in brain weight
· 30% decline in the speed of action
TUBE FEEDING What one person considers “quality of life”, someone else may think differently. Artificial supplied nutrition and hydration are a medical treatment to be considered in the same light as other technological procedures and not considered life support in the medical field. Literature supports PEG placement in patients recovering from a traumatic accident or expected to make a recovery process. It is considered a medical intervention, not obligatory care. Tube feeding is an art and a science that is increasingly used in our aging society as more people become physically incapacitated or have dementia. Properly used it can be helpful.
Types of Nonoral Feeding
Phone: 817-514-MBS1 or 1-888-514-MBS1
Fax: 817-514-MBS8 or 1-877-514-MBS8
By: Ronda Polansky M.S. CCC-SLP
PUREE Pizzazz
Jazz it up tips!
The puree diet is recommended as an alternative for those unable to tolerate regular or mechanical soft foods. A puree diet is generally a cohesive mashed potato or pudding like consistency. A food processor is generally used to achieve this smooth, easier to swallow consistency. This type of diet poses a real challenge to make it appear and taste like the real food in its solid consistency. We also have to keep in mind adequate calories, protein and fluids to maintain good health and healing.
Make it Jazzy!
PIZZAZZ!
1. Quality – freshness
2. Flavor – garnishes, sauces, syrups, etc.
3. Nutritious
a. Add calories with mild, half & half, margarine, butter, gravies, jellies, syrups, powdered milk or any other calorie and protein enhancers.
4. Appropriate recommended texture – as recommended to on MBSS
5. Appearance
a. Use a spatula to flatten puree meat to look like a patty or pipe for sausage
b. Utilize smaller scoops to look more like meatballs
c. Use sauces and gravies to garnish
d. Sprinkle fruits and desserts with colored gelatin powder, cinnamon/sugar or use a whipped cream topping.
e. Use a slurry mixture to prepare bread products so it will look like the regular product. Top with margarine or jellies
f. Layer puree pasta with puree meat to give a more lasagna- like appearance
g. Use pastry bags to create special effects such as mixing colored vegetables and piping them onto the plate
h. Vary shapes using molds, soufflés, mousse and gelled bread products.
i. Garnish vegetables with cheese sauce or powder, butter, or margarine
Garnishes to add color, and taste
1. Paprika
2. Whipped cream
3. Cinnamon sugar mixture
4. Jelly
5. Honey
6. Maple syrup
7. Parmesan cheese
8. Hollandaise sauce
9. Chocolate syrup
10. Butterscotch syrup
11. Carmel syrup
12. Brown sugar
13. Bar BQ sauce
14. Cranberry sauce can be piped through a pastry bag to use as a garnish
15. Fruit sauces or salad dressings
16. Gravy, catsup, mustard, mayonnaise, and/or cheese sauce
Resources : Commercially Available Pureed Foods
Brand Company
Cliffdale Farms Cliffdale farms
800-887-1553
Menu Magic Diamond Crystal Specialty Foods
800-225-0592
Menu Direct Menu Direct
1-888-MENU123
Puree Plus Diamond Crystal Specialty Foods
800-225-0592
Sources for home food processors
1. Gourmet Kitchen – 800-304-2922, www.gourmetkitchenstore.com
2. www.cooking.com – Black & Decker, Cuisinart. Kitchen Aid, Krups
3. Goodman’s – 888-333-4660, www.goodmans.net
4. Robot Coupe – 800-543-7549
Sources for professional food processors
Reference: Dorner, B, Its Tough to Swallow, 2002
It is very important to understand WHY the dysphagia is occurring before initiating treatment for it.
There are no documented standards to date that tell us what is considered a mild, moderate or severe, delay. FYI – Perlman et.al, 1994 suggest that a delay of less than 2 sec is mild and a delay greater than 5 sec is severe.
References: Perlman, A. L., Booth, B. M., & Grayhack, J. P. (1994). Videofluoroscopic predictors of aspiration in patients with oropharyngeal dysphagia. Dysphagia, 9, 90–95
]]>Feeding and Alzheimer’s Disease
Intervention and useful strategies with AD during meals (Brush, J., Slominiski T., Boczko F., 2006)
Mealtimes can be a challenge on dementia units in long-term care facilities. The ability of someone with advancing dementia to maintain adequate nutrition and hydration by mouth can become quite compromised as the patient approaches end stage. Their eyes see food, but their brain may not know what to do with it. At this point the speech-language pathologist often is asked to get involved and do something to get the person to eat. The usual approaches well known among clinicians are reducing extraneous stimuli; alternating tastes, textures and temperatures; talking calmly and quietly to patients; and placing a cup or utensil in their hand. Other methods that complement these general strategies can be taught easily to and used by the nursing assistants who do the feeding. If a person you are feeding becomes agitated and resistant, stop!
Back off for a minute, give them time to re-orient to the meal in front of them, and then continue feeding. Patients with dementia can be highly distractible, which isn’t always bad. Sometimes a moment or two away from the task and their agitation and a gradual coming back may be all they need.
The Show and Tell method keeps patients involved in your presentation and approach as you feed them. As you get a bite ready, tell them what they need to do: “Okay, let’s take another bite” or “Try some vegetables; here you go.” Don’t ask them if they want the next bite; they’ll probably respond negatively. Hold it up in front of them so they can see and identify it, and don’t rush them. Give them a verbal cue as you approach them with it so they know the goal and can start forming a motor plan to manage the bolus, then verbally reinforce their acceptance. One thing I’ve learned in dementia unit dining rooms is that many of these folks don’t like surprises, so show them and tell them.
The Hide and Seek method is based on the concern that patients who see a bite of food coming toward them may become more agitated and vehemently resist because of their decreased ability to correctly interpret what the clinician is doing. This approach involves sitting quietly next to patients with a bite of food ready where they can’t see it. When their mouth opens, as frequently happens with an agitated patient, plug ’em!
Touch and Go is a helpful technique for patients who either don’t open their eyes or don’t open their mouths to accept the bite of food they see. Simply touching their lips with a utensil, cup or straw can work as a tactile cue for them to open up. If they have a prolonged oral phase or persistent chew, just presenting the next bite sometimes can facilitate the completion of the previous one.
Finally, de-stimulation is a method that can be tried with patients who don’t initiate the eating task and respond poorly to verbal entreaties. Dining rooms in large nursing homes can be busy, noisy places. Patients are often over-stimulated before they’re even served their meal. The last thing they need is more stimulation. You should clear the table in front of them, hold the dish in your hand, and quietly feed them. Admittedly, this is nothing new in the approach to feeding patients with dementia, but it’s surprising how little it’s actually practiced unless we’re vigilant in our training of nursing assistants. Because meals may take a bit longer using these methods, start with the highest-calorie items first. If necessary, consult with the facility dietitian about increasing the caloric density of what the patient can get down successfully. As clinicians, we must train staff members to utilize the most effective methods of presentation, approach and delivery to facilitate maximum PO intake with these patients. Any strategy we use depends on the patient’s level of dementia and presenting behaviors. We also have to be able to adjust our method to the patient’s response, from meal to meal or during a meal. Working with patients who have dementia requires patience and the ability and willingness to connect with them to help maintain their quality of life by enjoying one of the last pleasures they may have — eating a good meal. Dan Sherwood Jewish Home and Care Ctr, WI
Alzhiemer’s/Dementia and Tongue Strength
When evaluating and treating a special population is necessary that we determine how stable a patient is and we can begin by considering their location in a facility: ICU, floor of acute care hospital, skilled unit, rehab, or home.
Alzhiemers/Dementia – Alzhiemers/Dementia patients often times can not follow directions, but neither can NICU infants. To find some new treatment approaches consider infant oral motor treatment and learned techniques from occupational and physical therapists, especially in the treatment of muscle tone. Tongue strength is one of the most common underlying problems in dysphagia in the dementia population. Since SLP’s are not trained to work with muscle tone, the standard oral motor exercises do not always target the right areas. Tongue strength is important because the ability of the tongue to tolerate weight of a bolus is important to the swallow process.
TX Consideration: To build tongue strength the therapist must provide resistance to the tongue/muscle. One method is to use a tongue blade or spoon to push down on the tongue while trying to have the person protrude or lift the tongue, often this might be reflexive.
Guideline for Feeding Assistants in LTC In March 2002, CMS proposed a rule to allow Medicare and Medicaid program to use paid feeding assistants. The federal guidelines dictate a minimum of 8 hours of training in eight specific areas: feeding techniques, assistance with feeding and hydration, communication and interpersonal skills, appropriate responses to resident behavior, safety, and emergency procedures, infection control, resident rights, recognition of changes in residents that are inconsistent with their normal behavior, ands the importance of reporting those changes to the supervisory nurse. Janet Brown M.S. CCC-SLP, director of Health Care Services in Speech Language Pathology says that ASHA has recommended that Speech Pathologists be identified as a resource to the supervisors of the feeding assistants and to participate is designing state approved training courses. The national no profit consumer advocacy organization for nursing home resident favors more extensive training for certified nursing assistant and registered nurses. ASHA does not plan to take further action on the rule unless members express concern about how it is being implemented. ASHA urges clinicians to find out if feeding assistants are being used in their buildings and offer to consult on their training, and also monitor whether their referrals for dysphagia change as a result of having feeding assistants. Keep ASHA informed.
Banotai, A., New Guidelines for Feeding Assistance in Long-Term Care, Speech-language pathologists have a role in training, ADVANCE, March 8, 2004.
Strategy |
Why? |
How to do |
What it does |
Head Back | Poor oral control Must have normal pharyngeal phase |
Tilt head back during swallow | Uses gravity, duration of UES relaxation decreases with increased head extension |
Chin Tuck | Premature loss Reduced airway closure |
Touching chin to chest before & during swallow | widens valleculae narrows airway Pushes tongue base to pharyngeal wall |
Head rotation | Unilateral pharyngeal Paralysis, reduced PES |
Turn head to weak side before & during swallow | Direct bolus to stronger side Increases VC closure Reduce pyriform retention |
Head Tilt | Unilateral pharyngeal Paralysis |
Tilt head to stronger side before & during the swallow | Directs to stronger side with use of gravity |
Thermal Stim or Cold Bolus | Delayed swallow Reduced sensory recognition |
Cold laryngeal mirror & rub anterior facial arches | Decrease delay |
Supraglottic Swallow | Reduced or late VC closure Delayed swallow |
Inhale, hold breath, swallow, cough, swallow | Protect airway improves coordination |
Effortful Swallow | Reduced tongue base Retraction (vallecular retention) |
Swallow hard, push & squeeze all muscles in mouth and throat | Effort increases posterior tongue base mvmt. |
Mendelsohn | Reduced laryngeal elev. Reduced PES |
As you swallow, hold it in mid opening swallow for several secs. | Increases duration & width of PES, strengthens & retrains muscles of laryngeal elev. |
Shaker | Reduced PES opening | Lay flat on back, raise head high to see toes without raising shoulders. Hold 1 min, rest 1 min 30X |
Strengthens Suprahyoid musculature Decreasing pressure above UES |
E-Stim | Reduced laryngeal elevation | Stim of submandibular area | Retrains laryngeal musculature for laryngeal elevation |
Thick liquids | Delayed swallow Decreased laryngeal elev. Reduced VC closure |
Thickener | Thinner liquids penetrate more easily & are more difficult to control orally |
Puree Diets | Delayed swallow Reduced closure Reduced elevation Reduced mastication |
Foods blended Does not require chewing |
Do not flow as quickly as thin Easier to control |
Mechanical Soft | Reduced mastication | Ground meats; fruits Soft cooked vegetables |
Soft enough to be chewed easily |
Any alteration to the neurological system has the potential to cause dysphagia. It is important for the SLP to explore the neuroanatomical level of the disease process by conducting an MBSS. This will determine the motor and sensory etiologies and signs and symptoms of the presenting dysphagia. The results of the MBS will guide the choice of treatment strategies that are chosen according to the anatomic/physiologic rationale. An MBSS will allow you to evaluate ALL phases of the swallow: Oral Phase, Pharyngeal Phase, and Esophageal Phase.
]]>
Problem |
Probable Cause |
Phase |
Anterior loss of food or liquids | Decreased lip, jaw strength | Oral |
Can not suck through straw | Decreased lip, jaw strength Decreased lip sensation |
Oral |
Pocketing | Decreased tongue strength and sensation | Oral |
Reduced mastication | Decreased tongue strength | Oral |
Oral hold | Decreased tongue strength & sensation | Oral |
Loses food prematurely over back of tongue | Decreased base of tongue control | Oral |
Penetration BEFORE the swallow | Decreased base of tongue control | Oral |
Penetration DURING the swallow | Delayed reflex | Pharyngeal |
Penetration AFTER the swallow from retention in the pyriforms | Decreased laryngeal elevation | Pharyngeal |
Penetration from retention in the valleculae | Decreased base of tongue or laryngeal pressure | Pharyngeal |
Treatment Objectives for Short Term Goals
Anterior loss – Patient will be able to keep PO in the mouth while eating without losing bolus anteriorly.
Treatment objectives
Bolus Propulsion – Patient will move bolus to back of mouth in coordinated fashion to be able to propel PO safely through hypopharynx and reduced risk of it falling into the airway.
Premature Loss – Pt will be able to keep food from falling over the back of the tongue into the airway.
Laryngeal Closure – Patient will achieve closure of larynx during the swallow sufficient to keep PO from entering the airway
Laryngeal Elevation – Pt will reduced change of penetration by increasing laryngeal elevation and reducing retention in the pyriforms
Tracheotomy – Between 43-80% of the patients with tracheotomy tubes will manifest signs of aspiration or aspiration pneumonia. Dysphagia is produced by physiological changes associated with opening the trachea to atmospheric pressure, not merely the presence of the tube in the neck ( Murray, T, Carrau, R, 2006)
Physiciologic changes following a Tracheotomy
(Murray, T, Carrau, R, 2006)
Expiratory Valve – Most use a Passy-Muir Valve (PMV) –This is a removable one-way valve that opens to permit inhalation, but closes during expiration to divert the airflow through the larynx.
Advantages: (Gross RD, Eibling DE, Carrau R, Murray T, 2006)
· Patient can communicate verbally
· Airflow provides proprioceptive cues during swallowing exercises and learning maneuvers
· True VC adduction exercises will be maximized because of the subglottic air pressure build up
· Improved pressure to aid in bolus propulsion
Contraindication for Valve:
Signs and Symptoms of difficulty tolerating the Valve
Dysphagia Evaluation – For clinicians unfamiliar with inflating and deflating cuffed tracheotomies, with suctioning, and with medical emergency techniques, the eval should be complete with nursing or approp medical personnel.
Dysphagia Treatment – PMV’s can improve swallowing and can be used during assessment and treatment phase of dysphagia management.
A patients ability to perform compensatory strategies and facilitative techniques that promote increased airway protection during PO (i.e. Supraglottic swallow, Super supraglottic swallow, Mendelsohn maneuver) and swallowing exercises that focus on muscle retraining to improve laryngeal elevation and vocal cord function (i.e. falsetto/pitch exercises, vocal cord adduction exercises, Mendelsohn maneuver, E-Stim) should be enhanced when the PMV is in place.
ENG biofeedback techniques used in dysphagia intervention (Buchholz, 1994) can be applied effectively with trachs while wearing the PMV.
]]>Dysphagia Cups
· Sip-Tip – reduced amount of air ingested, less coughing and choking on some individuals
· Pre-Set drinking cup – preset measured cup delivers 1 tsp of liquid per sip. Holds 7 oz.
· Flexi-cut cups – cutout rims, various sizes
AliMed Dysphagia Catalog 800-225-2610
Pre – Thickened Beverages
Resource
Nutra/Balance
AliMed is a resource for adults and kids –
1-800-225-2610
Magic Cups – 4 flavors (vanilla, chocolate, orange and wild berry) 1-800-633-3438
Thickeners
Diafoods Thick-it – 1-800-333-0003
Simplythick – 1-800-205-7115
Thick-it – 1-800-828-1376
Thik & Clear – 1- 800-225-2610
Hormel Thick and Easy – 1-800-866-7757
Any pharmacy can special order thick-it.
Easy Mixer – 1-800-225-1610
Dysphagia Cookbooks
Good looking, Easy Swallowing – By: Janet Martin and Jane Backhouse
Non-chew Cookbook – By: J. Randy Wilson
Easy-to-Swallow, Easy-to-Chew Cookbook – By: Donna L. Weinhofen, Joanne Robbins, and Paula A. Sullivan
Dysphagia Cookbook – By: Elaine Achilles
It’s Tough to Swallow: Nutrition and Dining for Dysphagia – By: Becky Dorner and Assoc.
Puree Food with Substance and Style – By: J. William Richman and Maria Seppi Ferraco
So What If You Can’t Chew! Eat Hearty! Recipes and a Guide for Healthy and Happy Eating of Soft and Puree Foods By: Phyllis Z. Goldberg
Associations
National Parkinson’s Association
800-327-4554 www.parkinsons.org
National Stroke Association
1-800-STROKES www.info.stroke.org
American Stroke Association
1-888-4-STROKE www.strokeassociation.org
National Aphasia Association
1-800-922-4622 www.aphasia.org
National Rehabilitation Information
1-800-346-2742 www.naric.com
National Caregivers Association
1-800-896-3650 www.nfcacares.org
International Huntington’s Association
1-212-242-1968 www.hdsa.org
ALS Association
1-800-782-4747 www.alsa.org
National Alzheimer’s Association
1-800-272-3900 www.alz.org
American Cancer Society
1-800-ACS-2345 www.cancer.org
National Spasmodic Dysphonia Assoc.
1-800-795-NSDA www.dysphonia.org
Texas Laryngectomee Association
1-325-942-9404 www.texasastla.com
Dysphagia Resource for Patients
www.nidcd.nih.gov/health/voice/dysph.asp
Books by Stroke Survivors and M.D.’s
Reading a book by a stroke survivor or caregiver can give valuable insight into a patient’s recovery process or as a role of a caregiver. It also lets them know they are not alone.
These books have been endorsed by the American Stroke Association
Other Resources
Medline Plus Drug Information Listing
1-888-FIND-NLM
www.nlm.nih.gov/medlineplus/druginformation.html
This is an A-Z listing of prescriptions and OTC meds
National Council on Patient Education
301-656-8565
www.bemedwise.org and www.talkaboutrx.org
The councils TalkAboutRX. Org website helps consumers make wise decisions about prescription meds. A companion site, BeMedWise.org, does the same for OTC medications.
Oley Foundation
1-800-776-OLEY www.ley.org
This national organization provides research, support and information to people dependent on intravenous or tube feeding delivered nutrition. It provides free service to more than 6.500 members.
Keeping on Top of it ALL
ADVANCE for SLP and Aud – Free Subscription
1- 610-278-1400 www.advanceweb.com
ASHA Leader – free to ASHA members
1-301-897-0039 www.asha.org
Stroke Connection (ASA) – discount to SLP
1-888-4STROKE www.strokeassociation.org
Stroke Smart (NSA)
1-800-STROKES www.stroke.org
National Parkinson’s Report – Free
1-800-327-4545
Communicologist
1-888-SAY-TSHA www.txsha.org
]]>The following exercises should be performed 10 times each 2-3 times a day.
Lips – reduced lip sensation, strength, and ROM may result in drooling, lip biting and pocketing, as well as anterior loss.
Cheeks –reduced cheek sensation, strength, and range of motion may result in pocketing of food or biting cheek.
Before beginning exercises, observe patients facial asymmetry. Check buccal musculature by:
Tongue – reduced tongue sensation, strength, and ROM can result in the inability to manipulate bolus in oral cavity, it can also result in residue on hard palate and pocketing.
Soft Palate – reduced sensation, strength, and ROM can result in reduced gag reflex, hypernasal speech, nasal reflux, and premature spillage
Velar Exercises
Jaw strength and ROM – Necessary for rotary movements involved in mastication. Can be used with patients exhibiting reduced oral ROM or masseter weakness.
Mandible – mastication/ side-to-side and rotary action is required for cohesive boluses
Patients who have Parkinson’s disease or ALS often have reduced Mandibular ROM due to general muscle weakness.
Pharyngeal Exercises and Strategies
Esophagus
Esophageal Phase training