SWALLOWING AND SPEECH IN ATAXIA:

A TEAM APPROACH

Laura Gregory, MA CCC-SLPRehab Without Walls - San Antonio, TX

DISCLAIMER The information provided by speakers in any presentation

made as part of the 2012 NAF Annual Membership Meeting is for informational use only.

NAF encourages all attendees to consult with their primary care provider, neurologist, or other health care provider about any advice, exercise, therapies, medication, treatment, nutritional supplement, or regimen that may have been mentioned as part of any presentation.

Products or services mentioned during these presentations does not imply endorsement by NAF.

PRESENTER DISCLOSURES Laura Gregory, MA CCC-SLP The following personal financial

relationships with commercial interests relevant to this presentation existed during the past 12 months:

No relationships to disclose or list

OUTLINE OF PRESENTATION Overview of the swallowing process Overview of speech The team approach Specific treatments and compensatory

strategies

SWALLOWING TERMINOLOGY Dysphagia – the clinical term for a

disorder of swallowing Speech Language Pathologist (SLP) aka

speech therapist – diagnoses and treats dysphagia

Dysphagia is typically diagnosed through a videofluoroscopic or videoendoscopic swallow examination.

VIDEO OF A NORMAL SWALLOW

EFFECTS OF ATAXIA ON THE SWALLOW Decreased coordination and oral

control Delayed swallow initiation Decreased pressure gradient to propel

the bolus Impaired timing of reflexes for airway

protection Pure cerebellar ataxia does not cause

decreased strength or sensation

WHAT ARE THE SIGNS AND SYMPTOMS?

Coughing, especially with liquids and mixed or crumbly textures Penetration: food/liquid enters the airway

but does not pass below the larynx Aspiration: food/liquid enters the airway

and passes to the lungs – can lead to pneumonia

Food feeling stuck in throat Liquids going into nasal cavity

EFFECTS OF ATAXIA ON SPEECHArticulation of speech sounds is a complex process of movements of oral structures coordinated with respiration and voicing.

Ataxia affects speech in the areas of Timing Coordination

SPEECH DIFFICULTIES INCLUDE: Slurring of sounds “Scanning speech” with equal emphasis on

each syllable Difficulty modulating volume of voice Difficulty controlling force or direction of

oral movements (overshoot, undershoot) Inadequate or poorly coordinated breath

support These are referred to as Ataxic Dysarthria

RESULT Difficulty communicating with family

and friends Fatigue

SO WHAT CAN I DO?

Educate yourself and othersBe aware of early signs of difficulty

with swallowing and speechSeek help before swallowing and

speech difficulties become a major issue

Recruit a support network

IT TAKES A TEAM

WHO ARE THE PLAYERS? YOU! Caregivers/family Friends Physicians Speech pathologist Occupational therapist Physical therapist Social worker/therapist Dietitian

BECAUSE YOU ARE NOT JUST A MOUTH

VS

ROLES OF THE PLAYERS YOU!

You know yourself best, so you are in the best position to make decisions regarding your healthcare in partnership with the team. The team approach won’t work without YOUR motivation and participation

CAREGIVERS, FAMILY, AND FRIENDSEating is a social activity!

Communication goes two ways.

PHYSICIAN Discusses signs and symptoms with

you Makes appropriate referrals Communicates with the team along the

way

THERAPISTS Speech Pathologist

Evaluation and treatment of the oral/pharyngeal and respiratory components of swallowing

Physical Therapist Evaluation and treatment of postural and head

control as they relate to speech and swallowing. Can also address respiration.

Occupational Therapist Similar to physical therapist plus adaptive

equipment

OTHER POTENTIAL TEAM MEMBERS Social Worker/Therapist

Emotional support for adjustment to disability. Assistance in finding compensatory strategies to decrease frustration when communicating with friends and family.

Dietitian If changes to the diet are needed for

swallowing safety, a dietitian can assist in maintaining adequate nutrition

SWALLOWING: COMPENSATORY STRATEGIES

Universal Sit upright at 90 degrees with good

postural support Stay upright for 30 minutes after meals Take small bites and sips Reduce distractions, including talking Eat several small meals if fatigue is a

factor Avoid problematic consistencies

SWALLOWING: COMPENSATORY STRATEGIES

An SLP may recommend other strategies based on individual needs. Chin tuck Swallowing maneuvers designed to protect

the airway Diet modifications

Soft or pureed foodSolids chopped into smaller piecesThickened liquids

ADAPTIVE EQUIPMENT Provale cup:

delivers 1 tsp per sip

Bionix safe straw: 1 tsp

ADAPTIVE EQUIPMENT Less measured but

less expensive ways to control the flow of liquid : Squeeze the

straw Use a cup with a

lid

ADAPTIVE EQUIPMENT Scooper bowl Weighted utensils Dycem

SWALLOWING: POTENTIAL TREATMENTS Oral-motor exercises may be of some

benefit to improve timing, coordination, and awareness.

Neuro-muscular electrical stimulation (NMES), also referred to as Vitalstim, is not effective for ataxia alone but may be beneficial when there is accompanying weakness.

ALTERNATE METHOD OF NUTRITION Naso-gastric tube- can be used for a short

period of time when eating by mouth is not safe.

Gastric tube or less commonly a jejunal tube can be surgically placed for long term supplemental or alternate nutrition.

Choosing an alternate method of nutrition is a difficult decision that should involve the entire team and support network.

SPEECH: COMPENSATORY STRATEGIES Speak face to face without distractions Educate unfamiliar listeners Break sentences into shorter phrases

when you are not understood Introduce the topic using a single word Take your time

SPEECH: POTENTIAL TREATMENTS Overarticulation Pacing/rhythmic training Speech agility exercises Lee Silverman Voice Therapy (LSVT) –

Would be beneficial for Ataxia when a patient has difficulty speaking at a consistent volume or coordinating respiration with speech. Evidence base for multisystem atrophy.

ADDITIONAL ACTIVITIES Yoga Music therapy

AUGMENTATIVE/ALTERNATIVE COMMUNICATION

Low tech: Alphabet board, picture board, etc. Voice output device (or ipad)

Picture to speech Text to speech

Access Hand Switch Switch/scanning Eye gaze

AUGMENTATIVE/ALTERNATIVE COMMUNICATION

Funding in Texas Specialized Telecommunications Assistance

Program (STAP) http://stap.puc.state.tx.us Review of ipad apps

http://www.spectronicsinoz.com/article/iphoneipad-apps-for-aac

GO TEAM!!!