KEY ITEMS IN DYSPHAGIA PROCESS Recognizing dysphagia features: * education of nurses, doctors, therapists about dysphagia * screening methods

Speech and Language Therapist´s Examination Assesses: * Motor of speech * Volitional and reflexive function of the muscles in the oral, pharyngeal, larynxgeal, and facial areas * Sensory of the oral, pharyngeal, and laryngeal areas Defines: * The deficit function Discerns: * Muscle group that will restore the deficit function * Motor lines that power the muscle group * Sensory pathways to motor line(s) Chooses: Appropriate DPNS-techniques Stimulates: 3-5 times/ week Proposes: Modified diet, PO/ NPO, VFG-study Documents: Systematically on weekly basis Informs: Patient, Family, Multiprofessional Team.

In Videofluorography study: Radiologist, SLT and Nurse SLT and Radiologist assess: Triggering point of swallow Palatal reflex competency rate Tongue base retraction reflex competency rate Pharyngeal peristalsis Epiglottal range of motion Cricopharyngeal reflex competency rate Sensory in oral, pharyngeal and laryngeal areas Aspiration risk ● Nurse: - Prepares the room and the equipment for VFG study. - Helps patient to get ready for VFG study

Multiprofessional Teamwork Doctor: Responsible for patients health Plan of Care (POC) SLT: Examination and rehabilitation of dysphagia Nurses: Medical care & daily nutrition/hydration intake Radiologist: VFG-study Dietician: Medical Nutrition assessments ENT: Medical & Structural assessments as appropriate OT: Hand to Mouth function/coordination for feeding PT: Balance/positioning assessments Institutional Employees: All aspects of the patient’s health POC Patient: Compliance with all Plan of Care treatments Family : Educated/trained on Patient’s condition & management techniques

Information and guidance Patient Education and training for patient, family and multiprofessional team: Dysphagia features/signs Understanding the symptoms Nutrition Rehabilitation Treatment strategies & Goals Additional examinations and POC modifications as appropriate Ongoing Patient Risk Determinations

Conclusions The model for rehabilitation of dysphagia patients has been in use since 2000 The results have been promising It has clarified the roles and responsibilities of the team The recognition of dysphagia has increased The role of SLT has become crucial to the success of the total Rehabilitation Team The examination, rehabilitation and documentation are done systematically -> cost effective therapy, short-term treatment schedule, patient satisfaction, and increased patient safety.

Suggestions Screening methods and educational protocols for the team have to be established Systematic documentation enables information transfer with patient -> subsequent rehab facilities This kind of model for dysphagia rehabilitation could be a basis for national guidelines

Case Male 56 yrs Large temporoparietal stroke verified in CT-scan Anarthric Severe dysphagia Weakness in motor lines of CN V, VII, X, XII Sensory deficiency in the sensory lines of CN V, VII, IX, X

1. VFG-study Sept. 2002 showed: Poor bolus management in oral cavity Tongue base retraction competency rate 8 % Palatal reflex competency rate 50 % Epiglottal range of movement 25 % Cricopharyngeal reflex competency rate 100 % (table 1) Silent aspiration occurs

1st Videofluorosgraphy evaluation

Treatment DPNS-treatment Goals: 1) to restore the motor function of the tongue muscles and the laryngeal musculature, 2) to increase sensory in the oral cavity and pharynx (specific functional goals can be read in the handout) 5 times per week Weekly documentation of progress (daily treatment response form)

REHABILITATION (1st week)

2. VFG-study Nov. 2002, after six weeks of treatment Tongue base retraction reflex competency rate 100% Palatal reflex competency rate 100 % Epiglottal range of movement 25-50 % Cricopharyngeal reflex competency rate 100 % Aspiration on liquids, but sensory was75 %

3rd Videofluorography evaluation

REHABILITATION (7th week)

Results The therapeutic feeding was started after seven weeks of treatment Patient was discharged from the hospital after ten weeks of treatment with diet of: pudding consistencies and nectar thick liquids The patient was able to communicate with speech characterized as mildly dysarthric