use of evidence and instrumentation in the treatment of dysphagia
Contents
1. isometric dewetzel purdue edu Cost 100 00 p Swallowingexercises com Strengthening and Compensating Mendelsohn Maneuver Mendelsohn Effortful Swallow Can be used as strengthening skill training ROM OO TO or aS a maneuver Suprahyoid group Tongue base Load holding larynx in elevated position against constriction and UES retraction and resistance ava Pressure generatorn Using with bolus may increase salience load Mendelsohn Maneuver Increased activation of submental muscles Wheeler Hegland et al 2008 Increased vertical anterior duration amp extent of hyoid amp laryngeal movement Wheeler Hegland et al 2008 Increased A P diameter and duration of UES Opening Wheeler Hegland et al 2008 Improved coordination Improved timing Increased pressure BOT PPW Effortful Swallow Began as compensatory strategy Then considered strengthening Evolved to skill training Task oriented form of skill training with a strength component from greater muscular activation Potential for increased load resistance by increasing bolus viscosity Effortful Swallow Increased amplitude of submental activation Wheeler Hegland et al 2008 Reduced pharyngeal area pre swallow Fritz et al 2014 Increased pharyngeal closure during swallowing Fritz et al 2014 May consequently affect airway protection and UES activation gt earlier onset longer duration extent motion Increased duration of UES opening Wheeler2. Hegland et al 2008 Significantly higher mean esophageal peak pressure across all sensor locations striated gt smooth gt mixed Neki et al 2012 4 13 2015 Effects of MM on Measures of Swallowing Duration Post Stroke VFSS completed after each week regardless of whether patient had had treatment Improved measures after treatment weeks and not after no treatment weeks Increased improvement after 2 vs 1 treatment weeks Worsening of symptoms after 2 vs 1 week of no treatment Significant improvements in MDOHE and MDOHAE MUESO trending toward significance Improvements noted after 10 sessions Much better after 20 sessions McCullough et al 2012 Effortful Swallow Increased generation of oral pressure Increased linguapalatal pressure after 4 weeks of training Clark amp Shelton 2013 Increased BOT PPW motion with longer duration contact Increased pharyngeal pressure Increased hyoid vertical displacement wheeler Hegiand et al 2008 Increased duration of anterior excursion of hyoid Wheeler Hegland et al 2008 High Resolution Manometry of Pharyngeal Swallow Pressure in ES and MM MM decreased UES pressure MM increased duration VP pressure ES may promote increased VP pressure which can overcome decreased BOT pressure ES is a FOM rather than BOT event Both maneuvers increased minimum pressure at UES Hoffman et al 2012 4 13 2015 Effortful Swallow ES Mendelsohn Maneuver MM
3. to control group no biofeedback 13
4. 4 13 2015 USE OF EVIDENCE AND Disclosures INSTRUMENTATION IN THE TREATMENT OF DYSPHAGIA All of the speakers on the panel received an honorarium from ISHA for this talk Dee Dee Hammond MA CCC SLP University Hospital Jessica Huber PhD CCC SLP Purdue University Michele Parrish MA CCC SLP ENT Associates Dawn Wetzel MAT CCC SLP Purdue University GOALS CONTENT Name appropriate evidence based exercise s given Exercises disordered physiology Provide examples of instrumentation to facilitate learning of specific exercises Identify the instrumentation that is best suited to target specific physiologic deficits Rehabilitating the Swallow Specificity The exercise task should correspond with the Lingual Strengthening Mendelsohn Super Supraglottic Effortful Swallow Shaker Chin Tuck Against Resistance Intensity Instrumentation lIOPI Swallow Strong sEMG EMST IMST Endoscopy Rehabilitating the Swallow Percent maximum performance power pressure Number of repetitions Frequency of practice Duration of training over time desired outcome Strength training may work best when paired with task specific practice Overload Mechanical Feedback Resistive Accountability Rehabilitating the Swallow Transference Cross training and non specific strength training EVIDENCE AND INSTRUMENTATION LINGUAL STRENGTHENING SHAKER AND CHIN TUCK AGAINST RESISTANCE Dee Dee Hammond M A CCC SLP IU He
5. 48 Participants found the sitting position of CTAR to be less strenuous Greater maximum sEMG values were noted during the CTAR isokinetic and isometric exercises than during the equivalent Shaker exercises CTAR isometric exercise showed significantly greater sEMG values than the Shaker isometric exercise With clinical trials the hopes are that this exercise is effective as exercising the suprahyoid muscles achieving therapeutic benefits comparable to the Shaker exercise with the potential for greater compliance 4 13 2015 JOAR Jaw Opening Against Resistance Rhythm Slim Chin Muscle Exercise Watts 2013 used SEMG to compare the Developed in Japan as Shaker exercise and the JOAR exercise an anti aging device that Participants were asked to open jaw for ao eh 10seconds against resistance Position under chin and oe push down for10 Suprahyoid muscle activation was found seconds do for 3 minutes to be greater with the jaw opening eu 00 exercise than the Shaker exercise Further clinical research is needed www japantrendshop com rhythm slim chin muscle exercise p 1292 html ISO Swallowing Exercise Device EVIDENCE AND INSTRUMENTATION CONVE MEG OY de MENDELSOHN MANEUVER and Jolie Parker an SLP L EFFORTFUL SWALLOW AND SEMG Flexible plastic device with padding to allow CTAR and JOAR Dawn Wetzel MAT CCC Instructions are for aE Clinical Associate Professor Purdue University isokinetic first and then 7
6. Logemann As you swallow squeeze hard with all When you swallow hold your Adam s apple up for your throat and neck muscles 2 3s by squeezing your throat and neck muscles Huckabee and Steele As you swallow push your Swallow normally and in the middle of the tongue really hard against the roof of the mouth swallow when you feel your Adam s Apple lift hold it up for 2 3s with your throat muscles before you finish your swallow sEMG sEMG http theprogrp com speech therapist Biofeedback Use of equipment to measure body functions that are not monitored consciously Steele 2004 SEMG Surface electromyography A visual or auditory display representing muscle activity A linear relationship between the force of muscle contraction and the amplitude of an EMG signal SEMG SEMG Potential Benefits One of the oldest evidence based practices in Objective feedback dysphagia rehabilitation Immediate feedback Haynes 1976 Relative information re amplitude and duration of muscle activity Teaches control and challenges effort Safe easy noninvasive Limitations Outcomes superior with biofeedback when No norms for submental sEMG activity compared with traditional therapy alone Does not provide information re specific muscle activity Sukthankar et al 1994 Crary 2004 Huckabee amp Cannito 1999 Steele 2004 Does not measure specific amount of muscle activity Cost 1395 00 1795 00 SEMG Hand held portabili
7. alth University Hospital Indianapolis IN dhammond iuhealth org Swallow STRONG Program Swallow STRengthening OropharyNgeal Gustatory Swallow STRONG program Project Developers Jo Anne Robbins Ph D Nicole Pulia Ph D Nasia Safdar M D Ph D and Jacqueline Hind M S Grant received by William S Middleton Memorial Veterans Hospital in Madison WI Intensive oropharyngeal strengthening program designed to decrease health related complications in veterans with dysphagia 4 13 2015 Interpretation of Video Identify primary physiologic deficits Plan of Care What treatment has evidence to support its use What instrumentation feedback could facilitate learning of the treatment technique SwallowSTRONG Swallow Solutions LLC 8 weeks of Isometric Progressive Resistance Oropharyngeal I PRO therapy using the Madison Oral Strengthening Therapeutic MOST device newer version SwallowSTRONG by Swallow Solutions Followed by a simple long term oropharyngeal strength maintenance program Main goal Improve swallowing and eating in veterans with dysphagia by providing strength training and biofeedback Pressure is measured by sensors at four different locations of the tongue Sensor locations remain the same given the custom molded mouthpiece Electronic interface shows patient performance and calculates therapy targets Swallow Solutions SwallowSTRONG software provides knowledge of performance and resu
8. est between each breath on the trainer likely not long enough for people with motor disorders EVIDENCE AND INSTRUMENTATION IMST Patient Instructions SUPER SUPRAGLOTTIC SWALLOW Place the nose clips on your nose AND ENDOSCOPY AS Make sure your lips are completely sealed BIOFEEDBACK around the mouthpiece Completely exhale until there is no more air in your lungs Michele Parrish M A CCC SLP Breathe in as deeply as you can Ear Nose amp Throat Associates Exhale again Parkview Regional Medical Center Rest between each breath on the trainer mparrish entfw com 11 Physiology of Super Supraglottic Swallow Maneuver Improve closure ABOVE the glottis Arytenoids adduct and move more anteriorly Closure of the true and false vocal cords Reduce aspiration risk before during and after the swallow When to Utilize the Super Supraglottic Swallow Maneuver Decreased delayed TVC closure improve airway protection Delayed pharyngeal swallow expedite airway protection Difficulty coordinating the swallow respiratory cycle improve conscious awareness to normal swallow breathe pattern Silent aspiration improve airway protection despite reduced sensation Super Supraglottic Swallow Technique Contraindications Chaudhuri et al 2002 Increased stress on heart function during breath holding maneuvers History of stroke Cardiac arrhythmia CAD 4 13 2015 Omhae et al 1996 Glottic and supraglottic cl
9. for Mendelsohn SEMG Protocol for MM and ES Steele et al htto www intechopen com Participants completed repeat videoswallow studies Two primary measures used to assess improvement PASS Amount of residue 4 point scale Also looked at hyoid excursion and UES opening ESS appeared to increase swallowing safety ESS did not decrease post swallow residue MM resulted in varying changes amplitude and or durational changes in maneuver MM appeared to affect hyoid excursion and swallow efficiency with decreased post swallow residue EVIDENCE AND INSTRUMENTATION EXPIRATORY AND INSPIRATORY MUSCLE STRENGTH TRAINING Jessica E Huber Ph D Professor Purdue University jhuber purdue edu Inspiratory and Expiratory Muscle Trainers Individual breathes into a tube with nose clips on or into a mask On the end of the tube or mask is a resistance Resistance makes it difficult to breathe in or out Expiratory EMST 150 from Aspire Products Inspiratory PowerBreathe can buy on Amazon Basic Muscle Training Guidelines Specificity of training Train with the task you are trying to improve Muscle trainers do this to a point especially in expiratory muscle training You are training with a downstream resistance and speech is breathing with a downstream resistance larynx and articulators But do not use the trainers instead of speech therapy only in conjunction continue to work on speech Must overload the muscle Low res
10. h Group 3 Use of the IOPI for lingual strength Group 2 and 3 Exercised 5 days week for one month 10 reps 5x day targeting tongue lateralization propulsion and elevation Lazarus et al Folia Phoniatrica Logopaedica 55 4 199 2005 So what if my clinic has no money Use your thumb Anterior tongue press Place the thumb just behind the top teeth and press the anterior tongue against the thumb Pretend to say k Posterior tongue press Place the thumb against the hard palate where tongue meets the hard palate for the k sound Sustained Head Lifts Do this first Lie flat on your back with no pillow under your head Keep your shoulders flat against the bed or floor Lift your head only and look at your feet chin tuck Work up to 60 seconds Release and rest for one minute repeat x2 Complete 3 reps 3 times a day 4 13 2015 Repetitive Head Lifting Lie flat on your back Repetitively lift your head and look at your feet Let your head go back down slower speed greater strength Repeat this 30 times Rest for one minute Repeat two more times 90 total sit ups for your neck Do this exercise 3 x day for 6 weeks Problems with Compliance Elderly may need structured and gradually progressive program to achieve goals Isometric exercises Sustained head lifts were found to be harder than isokinetic exercises and therefore goals achieved less often Muscle disc
11. istance high repetition High resistance low repetition Must repeat the movements But do not go to the point of exhaustion When To Use Strength Training Is weakness present Does the weakness interfere with speech functioning Speech only requires 10 20 of the max force of the lips Are there contraindications for strengthening exercises Will the course of the disease make strengthening exercises futile Will the person fatigue to the point of not being able to complete everyday activities communication swallowing 4 13 2015 Inspiratory and Expiratory Muscle Trainers Can increase the amount of resistance as the individual becomes stronger Can help with breath support for anyone with weak respiratory muscles Also may help for professional voice users who need additional respiratory support Do not use with patients who get fatigued easily ALS Myasthenia Gravis or with those who problems do not involve muscle weakness Generally need an MD script for use Must follow basic muscle training guidelines Basic Muscle Training Guidelines Frequency Must train regularly 5 6 days per week Generally only use with individuals who can continue to train on their own outside of therapy During therapy you check progress Takes less to maintain strength than build Once strength is increased do not need to continue with strengthening exercises as often Can just do exercises a few times per week Cautions About Stre
12. lts for both the patient and clinician Provides information regarding accuracy of movement and overall performance Positive feedback encourages increased motivation Progressive resistance training can increase strength and structural volume thus decreasing penetration decreasing oropharyngeal residue and improving quality of life Cost Device and one mouthpiece 3 995 00 PNA 1 7 000 lowa Oral Performance Instrument System consists of carrying case 1 connecting tube 10 tongue bulbs and user manual IOPI Medical LLC 1100 00 4 13 2015 Strengthening Protocol I PRO therapy with SwallowSTRONG Involves active application of pressure by the tongue against stable resistance in the mouth targets anterior posterior left right middle and whole tongue PROTOCOL 10 lingual presses per sensor 3 times a day 3 days a week 8 weeks Swallow STRONG Clinical Demonstration Project Results from first 40 patients enrolled were presented at DRS conference in Nashville TN by Nicole Pulia Ph D Penetration Aspiration Scale decreased for thin liquids Isometric pressures increased at front and back sensors Quality of life subscale scores improved as well as Functional Oral Intake Scale Several patients progressed from feeding tube dependency to full oral intake Number of pneumonia diagnoses decreased by 88 and hospital admissions decreased by 79 Single air filled plastic bulb attaches to a hand held pres
13. ngth Training Do not delay other interventions until you are done strengthening the muscles Only use with individuals who will do drills at home daily Do not use EMST with patients who are not safe to perform a Valsalva maneuver 10 4 13 2015 a EMST Improves P A Score but not in all EMST Improves Cough Dynamics in PD patients 33 of treatment group 0 4 0 35 n o w Post EMST i ia 7 al Duration seconds O u oO Sz ine oO o 2 o1 oO Compression Phase Expiratory Rise Time Duration Treatment Pitts Bolster Rosenbek Troche Okun and Sapienza 2009 n 10 EMST Program Sapienza and EMST Patient Instructions colleagues 5 sets of 5 breaths completed 5 days per week Sagi oie a a m Cae l Completely inhale until you cannot breathe any more air Do the training in the seated position at the same time of in your lungs day l Make sure your lips are completely sealed around the Set muscle trainer to 75 of the patients maximum mouthpiece expiratory pressure MEP Obtain by asking patient to breathe to top of VC and then blow hard Hold your cheeks with one hand and fast into pressure meter Breathe out as hard as you can Or set the device to the highest level the patient can manage Remove the trainer from your mouth Can follow a similar protocol with inspiratory training Inhale again Sapienza recommends training for 4 weeks but that is R
14. omfort and time constraints were also reported Head lifts were found to be too demanding for patients with chronic conditions Resistance for Shaker lifting head against gravity Instructions Sit up comfortably in chair Keep shoulders still Place an inflatable rubber ball 12cm under the chin A hand may be used to hold it in place Tuck the chin as hard as possible against the ball Hold for 10seconds Next squeeze the ball as hard as possible by tucking the chin against it 10 successive times 4 13 2015 Exercise was found to increase the duration and width of the UES in the normal elderly population Shaker et al in 2002 noted significant change in functional swallow measures Shaker et al 1997 Easterling et al in 2005 and Logemann et al in 2009 noted improved laryngeal elevation and UES dilation Logemann et al in 2009 noted significantly less postswallow aspiration after 6 weeks of using Shaker exercise in tube fed population with severe oropharyngeal dysphagia due to abnormal UES opening Chin Tuck Against Resistance Enhances Sup anyole Muscle Activity opening UES using a Shaker like exercise Used for patients with dy Pan due to upper esophageal sphincter dysfunction Aim of study determine if the CTAR exercise was as effective as the Shaker exercise in raising the sEMG activation levels of the suprahyoid muscles during both isometric and isokinetic tasks Yoon et al Dysphagia 2014 29 243 2
15. osure before the swallow Change in extent of vertical laryngeal position before swallow CP opened earlier Prolonged duration of pharyngeal swallow Bulow et al 1999 reported Overall improved pharyngeal clearance secondary to prolonged laryngeal excursion resulting in longer period of PES opening and relaxation Super Supraglottic Swallow Technique Hold your breath Bear down with your stomach push your stomach muscles into your back Swallow Cough Re swallow Defining Biofeedback Crary et al 2004 External means to provide feedback to patient with the goal to increase rate of motor learning Result improved efficiency of therapeutic process In short enhance new learning 12 Biofeedback and EBP Denk and Kaider 1997 33 HNC patients Control group conventional therapy Experimental group conventional therapy with biofeedback What if you do not have access to instrumentation Endoscopic Evaluation and Treatment of Swallowing Disorders Langmore 2001 Hum Hold Breath squeeze neck muscles suspend vocalization Patient did not fully occlude airway if vocalization or audible air leakage is noted Establish a protocol with local diagnostician Accompany patient to diagnostic testing 4 13 2015 Biofeedback and EBP Results showed biofeedback group exhibited Reduced occurrence of aspiration Reduced pharyngeal residue Improved pharyngeal wall movement Faster return to oral feeding compared
16. sure transducer that measures pressure generated when the tongue is pressed against the hard palate Objectively measures tongue and lip strength and endurance PEAK function allows measurement of maximum pressure LIGHTS function provides biofeedback for exercise and endurance TIMER function allows measurement of time helpful for endurance Typical Training Protocol Elevation at 50 Pmax max pressure 3 sets 10 reps 3 times a day Total 8 weeks Squeeze bulb until top green light is on After 4 weeks results revealed significantly greater change in maximum tongue strength with both exercise groups No statistical difference was found between the exercise group using tongue depressors or the group using the IOPI The Shaker Exercise Created by Dr Reza Shaker gastroenterologist at the Medical College of Wisconsin Designed to treat pharyngeal dysphagia involving incomplete relaxation of the upper esophageal sphincter Targets strengthening the Sa on muscles thyrohyoid mylohyoid geniohyoid and anterior belly of the digastric as these muscles contribute to the upward and forward movement of the larynx T bone which results in relaxation of the Shaker et al Am J Physiol 1997 272 Tongue Depressors as an Alternative In a study by Cathy Lazarus et al in 2003 three groups all healthy adults between 20 29 years were targeted Group 1 No exercise Group 2 Use of tongue depressors for lingual strengt
17. ty 9V Battery Easy to operate USB communication to PC Automatic data storage Continuous operation or work rest prompts Session number Locked unlocked mode Functional electrical stimulator interface Goal types include Above Tone Below Tone Above Stim Below Stim Maximum Display with Marker A B Ratio for Dual Channel Systems SEMG Protocol for MM and ES Steele et al htto www intechopen com Attach electrodes under the chin Ensure signal quality and appropriate graded amplitude response Record baseline series of 5 regular effort saliva swallows RESS 1 30 seconds Determine RESS reference range Practice RESS with target set at 100 of RESS reference range series of 3 5 x5 swallows Practice effortful saliva swallows ESS with target set at 100 of RESS reference range and increase by increments of 10 20 series of 3 5 x5 swallows Practice MM at lower threshold 30 of reference range Goal is to prolong contraction for 2 3 seconds above this level So You Don t Have sSEMG Mirrors Imagery Palpation Auscultation 4 13 2015 SEMG Protocol for MM and ES Protocols developed at Swallowing Rehabilitation Research Laboratory Toronto Rehabilitation Institute Software developed Biofeedback Foundation of Europe Practice approximately 60 saliva swallows session Participate in 20 24 treatment sessions 2x week Focus is target amplitude practice for effortful swallow and prolonged muscle contraction
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