1. SDDA: Dysphagia intervention Sanna Jansson, cert SLP Kerstin Johansson, PhD, cert SLP March 24, 2016 SLP-course 33, T6

2. Schedule 09.00 –10.15 Theory 10.15 – 10.45Break 10.45 – 12.00Practice LUNCH 13.15 – 14.45Summarizing exercises, ethical considerations 2

3. Goals Airway protection Hydration Nutrition Quality of life 3

4. Main intervention options 4 Medical BehavioralSurgical

5. Medical options Medication o For underlying disease o To thin secretions o For reducing salivary flow o Antireflux medication Dietary modifications o Regulation of hydration and nutrition o Special diets Change of feeding route o NG tube feeding o TPN (total parenteral nutrition) o Gastrostomy/PEG (see also ”surgical”) 5

6. Surgical Gastrostomy/PEG (see also ”medical) Improving glottal closure o Medialization of vocal fold o Injection in vocal fold Botox o Reduction of spasticity o Reduction of salivation Dilatation, myotomy or Botox for improving PES opening Laryngo-tracheal separation/trachestomy/laryngeal suspension Other, for example o Fundoplication (prevents reflux) o Laryngectomy to prevent aspiration (extremely rare) How could one and each of these methods affect swallowing physiology? Suitable for which patients? 6

7. Oral hygiene! Improve sensory systems Reduces the risk of pneumonia o Reduction of oral pathogens ROAG (Andersson et al., 1984, rev 2000) Free water protocols 7

8. Free water - example GFSWP (Carlaw et al 2012) 8

9. Behavioral treatment options Food modification o Consistency o Volume o Temperature o Taste o Smell 9 Facilitates swallowingFood gets cold – effects on appetite and taste Effects on physiology Gravitation

10. Cont. Behavioral treatment options Modification of feeding activity, for example o Alternating food and liquid o Meal time behavior  Rate of feeding o Meal schedule o Surroundings (minimize distractions, music, …) o Placement of bolus o Feeding aids 10

11. Cont. Behavioral treatment options Patient modifications o Posture o Positioning (body, head) Mechanism modifications o Attempts to modify the swallowing mechanism  Motor exercises (Mendelsohn, effortful, EMST, LSVT)  Sensory stimulation (Thermal-tactile stimulation, NMES)  Prosthetic adjustments (lifts obturators) Swallow modifications o Altering the swallowing physiology of the attempted swallow  Compensatory swallowing moneuvers, multiple swallows  Mendelsohn maneuvre, supraglottic Oral /oropharyngeal hydration 11

12. Forceful exhalations against a resistance o Valve opens at a certain resistance o Training at 75-80% of maximum expiratory pressure (MEP) Intensive o 25 exhalations/session (appr. 15 min) o 4-7 days per week o 4-12 weeks After 4-weeks EMST (RCT) o Improved airway protection and stronger cough in patients with PD (Pitts et al., 2009 Troche et al, 2010) Expiratory Muscle Strength Training (EMST) Half-time seminar 16 dec, 2011 Kerstin Johansson12 PEPTT (Positive Expiratory Pressure Threshold Trainer) Respironics Resistance: 0 – 20 cm H 2 O EMST 150 Aspire Products Resistance: 0 – 150 cm H 2 O (Saleem et al., 2005)

13. Facilitating Facilitation of voluntary muscle activity sensory stimulation, electrical stimulation etc Exercise Motor exercises aiming at improving muscle function – range of motion, strength Shaker, tongue strengthening exercises etc Compensation Compensatory techniques that affect swallowing physiology while performing the technique - no permanent improvement. Head turn, chin tuck etc 13

14. PAUSE 14

15. Exercises –See separate presentation 15

16. Instructions Answer the following questions for each intervention. –How do you instruct the patient? Practice on each other. –What’s the aim of the intervention? –Do you classify the intervention as an exercise, a compensatory technique or a facilitating technique? –Under what conditions is the intervention inappropriate? –Are there any risks associated with the intervention ? 16

17. Mendelsohn maneuver 1.Put one hand on your larynx and swallow What happens? 2.Now, swallow again Feel your larynx rise, but do not let it drop down Hold i t up with your muscles for two seconds Release and let the larynx drop 3.Repeat (Kahrilas et al., 1991, Neumann et al 1995, Huckabee et al 1999) 17

18. Effortful swallow 1.Swallow harder!! 2.Some patients need extra instructions as: 1.Swallow hard, as if you were to swallow a large meatball/ a ball 2.Swallow very hard while squeezing the tongue hard against the palate. 3.Try this first with some water and then with water or food. Any difference? (Bülow 1999, Huckabee et al 2005, Hind et al., 2001) 18

19. The head-lift exercise (Shaker) 3 long head-lifts 1.Lie flat on your back. Do not use a pillow under your head. 2.Raise your head as though you were trying to fixate your gaze on your toes. Try to press your chin against your chest. Make sure not to raise your shoulders. Hold your head sustained for one minute or as long as you can. Rest for one minute. 3.Repeat three times with rest in between. 4.30 fast head-lifts a.Complete 30 fast head-lifts without sustaining in the lifted position. b.Complete the program three times/day for six weeks (Shaker et al., 2002; Easterling et al., 2005) 19

20. Supraglottic and Super-supraglottic swallow Supraglottic swallow 1.Inhale 2.Hold your breath 3.Swallow 4.Cough Super- supraglottic swallow 1.Inhale 2.Hold your breath and bear down. 3.Swallow 4.Cough (Martin et al., 1993; Ohmae et al., 1996; Bülow et al., 2001, Boden et al 2006) 20

21. Neuroprep 1 2 3 Swallow! 21

22. Head postural adjustments Chintuck (chin down) Head turn/rotation toward weak side Head tilt toward strong side Head extension (raise chin) How do these head postures affect swallowing? Lean towards strong side Turn towards weak side Weak side, paresis

23. Trial meal Try the different concistencies How does the different concistencies affect the swallow physiology? o In the oral, pharyngeal and esophageal phase? o Speed? Required force/strength? Need for oral preparation of bolus? How does a small vs a large bolus affect the swallow physiology? o In the oral, pharyngeal and esophageal phase? o Speed? Required force/strength? Need for oral preparation of bolus? o Read the litterature.

24. If you have the time… Reflect on how the body position affects the swallow physiology 1.Swallow while being in a reclined position 1.Swallow while lying supine 2.Swallow side-lying 24

25. References –Kahrilas PJ, Logemann JA, Krugler C, Flanagan E. Volitional augmentation of upper esophageal sphinkter opening during swallowing. Am J Physiol 260(3 Pt 1): G450-G456, 1991 –Hind J, Nicosia M, Roecker E, Carnes M, Robbins J. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys med Rehabil 82:1661-1665, 2001 –Fujiu M, Logeamann J. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol 5:23-30, 1996 –Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S et al.: Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 122(5):1314-1321, 2002 –Easterling C, Grande B, Kern M, Sears K, Shaker R: Attaining and maintaining isometric and isokinetic goals of the Shaker exercise. Dysphagia 20:133-138, 2005 –Martin BJW, Logemann JA, Shaker R, Dodds WJ. Normal laryngeal valving patterns during three breath hold maneuvers; a pilot investigation. Dysphagia 8:11-20 –Ohmae Y, Logemann JA, Kaiser P, Hanson BG, Kahrilas PJ. Effects of two breath holding maneuvers on oropharyngeal swallow. Ann Otol Rhinol Laryngol, 105(2):123-131 –Bülow M, Olsson R, Ekberg O. Videomanometric analyses of supraglottic swallow, effortful swallow and chin tuck in patients with pharyngeal dysfunction. Dysphagia. Summer;16(3):190-5, 2001 –See also Groher Crary (2016, 2010) for additional references.

26. Lunch 26

27. Discussion –What’s the aim of the intervention? –Under what conditions is the intervention inappropriate? –Are there any risks associated with the intervention? 27

28. Ethical issues –Tube feeding o Benefits and risks? –Food modifications, for example thickened liquids o Benefits and risks? –Patient autonomy o How do we know whether a patient with reduced autonomy is motivated for a specific treatment or other decisions o How can we increase the patient’s empowerment? –Ethical decisions o SLP vs Team-based  Physician: ”So, should we give this patient a PEG?”  SLP: ”….” 28

29. One clinical finding – several possible causes – different treatment options Aspiration Cause? Reduced opening of PES? Dilatation? Impaired oral control of bolus? Chintuck ? Reduced laryngeal elevation? Shaker? Requires knowledge of the swallowing physiology 29

30. Discussion Possible interventions for the patient with reduced oral bolus preparation/transportation? o Mechanism modification – exercises (improved function) o Food modifications – choose best consistency, temperature, taste… o Patient modifications – posture, … o Modification of feeding activity 30

31. Cont. discussion How could you improve a patient’s laryngeal function during swallowing? o Surgical o Exercise - LSVT o Compensatory - supraglottic 31

32. Cont. discussion Intervention considerations for the patient with a progressive disorder and dysphagia? o Mild stage  function restoration, compensation – avoidance of difficult foods o Moderate stage  training compensatory maneuvers, plan/introduce alternative nutrition, dietary intervention o Severe stage  QoL, issues regarding taste stimulation, free water, oral care etc 32

33. The End – THANK YOU! 33

34. Improved ORAL function 34

35. Therabite Trismus Prevent trismus in patients undergoing/post radiotherapy 35