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Transcript of TREATMENT. Treatment Modalities Compensatory Strategies Postural changes Diet modification Direct...
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TREATMENT
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Treatment Modalities Compensatory Strategies
Postural changes Diet modification
Direct Treatment/intervention Working directly on swallow using food and liquid
Indirect treatment/intervention Manipulation of structures involved with swallowing
Education Patient Medical staff Family/visitors
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Compensatory Strategies
Chin down/tuck: Indications: pharyngeal swallow delay;
reduced tongue base retraction; laryngeal dysfunction
Rationale: widens valleculae; narrows airway; pushes epiglottis and tongue base posteriorly
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Compensatory Strategies Chin-up/head back:
Indications: reduced A-P bolus transit Rationale: uses gravity to help move bolus
posteriorly.
Head rotation/turn: Indications: unilateral laryngeal and pharyngeal
dysfunction; cricopharyngeal dysfunction Rationale: closes off weak side; airway
protection; reduces cricopharyngeal tension.
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Compensatory Strategies
Head tilt: Indications: unilateral oral and pharyngeal
dysfunction Rationale: direct bolus to stronger side
Lying down: Indications: reduced pharyngeal
contraction or reduced laryngeal elevation Rationale: keeps residue on pharyngeal
wall.
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Diet Modification Liquids:
Thin: Water, apple juice, Kool-Aid, etc…
Nectar thick: Eggnog, V8, etc…
Honey thick: Artificial maple syrup, honey, molasses, etc…
Frozen or congealed liquids should still be considered thin. Example: ice cream, jello, popsicles, etc…
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Diet Modification Solids
Regular: Steak, boiled potatoes, chicken, cereal, etc…
Mechanical Soft: Well-done vegetables, chopped meat with gravy, etc…
Pureed: Applesauce, mashed potatoes, blenderized meats, etc…
Some facilities will provide a mixed consistency diet. Need to talk with dietician/food service coordinator to
determine appropriate consistency meals.
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Indirect Treatment
Typically involves exercises with three primary purposes: Increase oral motor control of the
bolus/voluntary stage of the swallow Stimulation of the swallowing reflex Increase airway protection through
adduction exercises
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Oral Motor Exercises
Necessary tongue movements Lateralization Elevation to the hard palate Creating a single, cohesive bolus Elevation to hold the bolus Range of anterior to posterior propulsion Organized anterior to posterior
propulsion
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Oral Motor Exercises Range of Motion (ROM)
Protrusion Elevation Lateralization
Resistance Isometric exercise
Pushing against a tongue blade, sucker, spoon, etc.
Difficult to measure, only through behavioral means
Quantitative measures available IOPI
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Oral Motor Exercises Bolus Manipulation
Gross manipulation Large manipulable
Clinician controlled Licorice whip Sucker
Consider excess saliva Hold a cohesive bolus
Hold a bolus, manipulate, expectorate Examine for signs of poor containment
Propulsion Gauze soaked in juice
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Stimulate the Swallow Reflex
Thermal Stimulation Laryngeal mirror
#00 or #0 Ice water Stimulation to the base of the anterior
faucial arches 5-10x Pipette ice water
If tolerated Can be carbonated
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Oral-Pharyngeal Sensation Thermal-tactile stimulation:
Indication: Reduced oral-pharyngeal sensation; delayed pharyngeal swallow trigger
Rationale: To increase sensation and swallow trigger
Electrical stimulation: Indication: Reduced oral-pharyngeal sensation;
delayed pharyngeal swallow trigger Rationale: To increase sensation and swallow
trigger
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Oral-Pharyngeal Sensation
Deep Pharyngeal Thermal Stimulation: Indication: decreased oral-pharyngeal
stimulation? Rationale: Maximal sensory input to elicit
pharyngeal swallow trigger?
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Adduction Exercises
Hold breath Pushing or pulling on a chair
Both hands, 5 seconds
Pushing or pulling One hand while producing clear voice
Following 5 rep of the sequence “AH” with hard glottal attack. Supraglottic swallow
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Direct Treatment/Intervention
Involves administration of a bolus and incorporating instructions/compensations
Small bolus sizes/volumes should be initiated
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Swallowing Maneuvers
Supraglottic swallow: Indication: reduced vocal fold closure;
delayed pharyngeal swallow Rationale: closes vocal folds before and
during swallow
Super-supraglottic swallow: Indication: decreased airway closure Rationale: tilts arytenoids and closes
laryngeal vestibule
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Swallowing Maneuvers
Effortful swallow: Indication: reduced tongue base retraction Rationale: increase tongue base retraction
Mendolsohn maneuver: Indication: reduced laryngeal elevation;
uncoordinated swallow; delayed cricopharyngeal relaxation
Rationale: opens UES and prolongs opening
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Swallowing Maneuvers
Masako maneuver: Indication: reduced tongue base
retraction Rationale: increase anterior movement
of post. pharyngeal wall.
Shaker maneuver: Indication: cricopharyngeal dysfunction Rationale: Increase laryngeal elevation
and increase opening of UES.
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Therapeutic Strategies for Specific Disorders
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Oral Preparatory Phase of the Swallow Reduced lip seal
Lip exercises Pocketing/buccal
Posture change External pressure Exercises
Reduced tongue movement Exercises Manipulate bolus placement Posture
Reduced oral Sensitivity
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Oral Transit Phase of the Swallow Tongue thrust
Bolus positioning Reduced tongue movement
Exercises Postural changes Bolus positioning
Delayed Reflex Thermal stimulation Posture
Tilt head forward Diet/hydration manipulation
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Pharyngeal Phase Reduced pharyngeal peristalsis
Alternate solid-liquid swallows Chin press Mendelsohn maneuver Effortful swallow Shaker exercises Electrical neuromuscular stimulation
Reduced laryngeal elevation Supraglottic swallow Super supraglottic swallow Electrical neuromuscular stimulation
Delayed cricopharyngeal opening
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Pharyngeal Phase Pharyngeal hemiparesis
Posture Tilt toward stronger side Turn toward weaker side
Reduced laryngeal closure/elevation Supraglottic swallow Adduction exercises Electrical stimulation
Cricopharyngeal dysfunction Hypertonicity
Myotomy Mendelsohn maneuver Dilatation Shaker maneuver
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Esophageal Disorders
May be suspected by SLP; typically diagnosed by GI physician
Typically treated medically
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Medical Management of Dysphagia Tongue scarring
Surgical release Positioning of food
Cervical osteophyte Surgical removal Diet modification
Scar tissue Removal Posture
T-E fistula Surgical closure
Diverticulum Surgical repair
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Dietary: Hydration Management Manipulating consistencies to alleviate
symptoms Oral phase
Liquids/solids Thinner Thicker
Pharyngeal Phase Liquids/solids
Thinner Thicker
Esophageal Phase Liquids/solids
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Specific Diagnoses
Mysasthenia gravis Amyotrophic lateral sclerosis (ALS) Huntington’s Chorea Parkinson’s Disease Cognitive impairment
Alzheimer’s dementia
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Adaptive Equipment Glossectomy
Spoons Syringes
Cut-out cups Assures chin tuck position
Food processors Manipulate food consistency
Non-slip surface disks Plate guards, lipped dish Built up utensils
Splints Arm rests
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Oral vs. Non-oral Feedings Oral Feedings:
Risk of aspiration Rate of deglutition Weight considerations Body requirements
Meeting requirements? Calorie counts Full time dietary staff support
Non-oral feedings NG tube (small-bore; Dobbhoff): nasogastric G-tube (PEG): gastric J-tube (PEJ): intestinal Orogastric