Session 21 Denise Dougherty - SC Speech Language Hearing

2/14/2014
Financial
The SLP Toolbox
• SCSHA honorarium
Denise Dougherty
MA, CCC-SLP
[email protected]
Denise Dougherty MA, CCC-SLP
•
•
•
•
Claims over $3,700 cap for total
PT/SLP services for pt. during
calendar yr. subject to review by
Medicare RAC (manual medical
review process (MMR).)
Service dates on or after April 1, ’13
Prepayment review
– CA, FL, IL, LA, MI, MO, NC, NY,
OH, NC, TX
All others do post-payment review.
Prepayment MMR review within 10
business days & Post-payment
review completed within 10
business days of receiving medical
record.
Talk Tools
Ark Therapeutics
E-Swallow
Vital-Stim
SpectraMed/Guardian
Ampcare
Atos Medical
Bionix Medical
IOPI
TheraSip
2
Skilled Level of Care
SO……….
REALLY need to be careful documentation
holds up
Shows need for skilled intervention of
SLP!
www.asha.org/slp/healthcare/documenta
tion/
– Documentation on ongoing treatment should
support need for skilled services
– Documentation reflective of routine, repetitive
observation or cuing may not qualify as skilled
rehab.
• Only observing meal, reporting on amount consumed, providing
verbal reminders in absence of other skilled assistance or
observations suggests NON SKILLED or maintenance level of care
– Establishment of maintenance program covered
for a brief period
• Usually included during final visits of professional (2)
Denise Dougherty MA, CCC-SLP
Skilled
3
Unskilled
www.asha.org/documentation-medicare/
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf
Skilled services must be
• Medically necessary
• Provided by
appropriately trained
professional
•
•
•
•
•
•
•
•
•
•
Denise Dougherty MA, CCC-SLP
1
ASHA HEADLINER – April 16, 2013
Medicare Part B claims
•
Nonfinancial
Unskilled services are
• Not medically
necessary
• Not appropriate to
condition or setting
• Provided by unqualified
personnel
Denise Dougherty MA, CCC-SLP
5
Denise Dougherty MA, CCC-SLP
Skilled
4
Unskilled
• Evals and re-evals
• Designing plan of care
• Ongoing assessment and
analysis
• Therapeutic services
• Compensatory skills training
• Device selection to replace
or augment a function
• Establishing maintenance
program & staff training
• Pt. and caregiver training
• Repetitive tasks w no
variation in complexity, level
of cueing or independence
• Observing pt.’s or
caregivers’ performance w
no feedback
• General activities to
promote overall fitness,
provide diversion or general
motivation
Denise Dougherty MA, CCC-SLP
6
1
2/14/2014
Your Documentation
MUST:
EVALUATION
Look at
• Disorders
– How swallow is affected
• Impact on phases of
swallow
• MEDS!!!!!!
• Muscle function
– Identify function through
tasks/scores
– Ability to show outcomes w
scores following therapeutic
exercise
– Helps develop plan of care
Standardized Evaluations:
• Frenchay Dysarthria
Assessment
• Mann Assessment of
Swallowing Ability
• Swallowing Ability and
Function Evaluation
• Bedside Evaluation of
Swallow
• Feeding and Swallowing
Disorders in Dementia++
• Clinical Observational
Dysphagia Assessment++
• PROVE Medical Necessity
• Can’t prove WHY on eval?…it’s
a NO GO.
• Skilled Services
• If payer isn’t convinced only
YOU can provide service, why
do they need YOU?
www.asha.org/slp/healthcare/d
ocumentation/
Denise Dougherty MA, CCC-SLP
7
•
•
•
•
•
•
•
•
Diet?
Liquid?
Swallowing precautions?
Swallowing strategies?
Independent feeding?
Supervision?
Feed?
Mouth care after meals?
Denise Dougherty MA, CCC-SLP
8
Coughing? Why??????????
CANNOT be ascertained at bedside!
Therapy Plan: Combination of….
• Medication side effect? 416 meds cause coughing
• RESEARCH EVIDENCE
ALONE IS NOT ENOUGH
• Post nasal drip? LPRD! 52 meds cause runny nose
• Retropulsion from esophagus? 30% of pts w oropharyngeal
dysphagia also have esophageal! Up to 25% of DISTAL esophageal
lesions present w oropharyngeal symptoms.
Evidence
Based
Practice
• Patient preference AND
SLP’s EXPERIENCE must
be considered!
• 30% w unexplained cough have reflux! SLP’s can’t fix acid!
• 38.1% w unexplained cough have esophageal cancer!
Pt.
Preference
SLP
Experience
DYSPHAGIA THERAPY/CHIN TUCK/THICKENED LIQUIDS
WON’T CHANGE THIS!!!!!
IF THESE ARE THE ONLY REASONS FOR THE COUGH, YOU WON’T
EVER SEE POSITIVE OUTCOMES FROM THERAPY!!!
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
9
10
ASHA.(2004).Guidelines for Speech-Language Pathologists Performing
Videofluoroscopic Swallowing Studies. ASHA Supplement 24, pp.77-92
So………………….What to Do?
Rationale for VFSS:
1. Identify normal/abnormal anatomy & physiology of swallow
Possible Combination of……..
• MBS/FEES if suspect pharyngeal dysphagia or is at risk
for pharyngeal dysphagia
• DON’T do MBS/FEES
– WHERE it is “broken”!
2, Evaluate integrity of airway protection before, during, after swallow
3. Evaluate effectiveness of postures, maneuvers, bolus modifications, sensory enhancements in
improving swallow safety/efficiency
– Will these make a difference or just WASTE our pt.’s energy?
– Test results won’t change how you clinically manage pt.
– Pt. unable to cooperate at this time
•
•
•
•
4. Recommend optimum delivery of nutrition/hydration (oral/non-oral, delivery method,
positioning, therapeutic interventions)
– If cough disappears w nectar at bedside, doesn’t mean it is safe – you’ve slowed down
liquid but can still penetrate
Compensatory Strategies
Adaptive Equipment
Diet/Liquid Modifications
Therapeutic Exercise
Denise Dougherty MA, CCC-SLP
5. Appropriate therapeutic techniques for oral, pharyngeal, and/or laryngeal disorders
– Work on what’s “broken” – maximize efforts for better outcomes!
6, Obtain info to collaborate with/educate other team members, referral sources, caregivers, patients
regarding recommendations for optimum swallow safety and efficiency
11
Denise Dougherty MA, CCC-SLP
12
2
2/14/2014
Chin tuck?
STRATEGIES
chin tuck
• GOOD OR BAD IDEA????????
– Narrows laryngeal inlet
– Widens valleculae
– Increased lumen at
cricopharyngeal level
– Increased duration of UES
relaxation
– Premature spillage of bolus
– Delayed trigger of pharyngeal
swallow
– Reduced laryngeal vestibule
closure
– To protect airway
• How do you KNOW it works????? MBS!
• Three possibilities:
– Works and is effective
– Doesn’t work but doesn’t harm! Wastes energy!
– CREATES THE ASPIRATION!
Denise Dougherty MA, CCC-SLP
13
15
Indirect
may be contraindicated in
COPD/cardiac pts
– Improves glottic closure
– Take in breath, let out
little air
– Hold breath
– Food placed in oral
cavity
– Swallow, holding breath
until swallow completed
– Cough
– Swallow again to clear
material expelled
may be contraindicated in
COPD/cardiac patients
– Improves supraglottic and
glottic closure
– Same sequence
– Use additional force to
provide greater muscular
tension
Denise Dougherty MA, CCC-SLP
16
Documentation must indicate treatment designed
to ensure safe swallowing during oral feeds
Primary Emphasis and goal of treatment:
– Exercises
– Improve oral motor
control of bolus
– Voluntary stage of
swallow
Denise Dougherty MA, CCC-SLP
super-supraglottic
Safety
THERAPY
– Presentation of
food/liquid in controlled
amounts
– attempt to reinforce
appropriate behaviors
during swallow
14
SWALLOWING
• Mendelsohn
– Improve laryngeal
vertical and anterior
motion
– Increase width and
duration of UES opening
Direct
Denise Dougherty MA, CCC-SLP
supraglottic
• Head back
– Impaired tongue anteriorposterior motion to
facilitate bolus transfer
through oral cavity
Denise Dougherty MA, CCC-SLP
– Forces bolus down opposite
side
– Increased UES lumen
diameter
– Decreased UES pressure
– Helpful in unilateral weakness
– Helpful in asymmetric bolus
passage
– Unilateral pharyngeal
weakness
– Close off weaker side of
pharynx
ASHA.(2004).Guidelines for Speech-Language
Pathologists Performing Videofluoroscopic
Swallowing Studies. ASHA Supplement 24, pp.7792
ASHA.(2004).Guidelines for Speech-Language Pathologists Performing
Videofluoroscopic Swallowing Studies. ASHA Supplement 24, pp.77-92
• Head tilt
– Unilateral oral and/or
pharyngeal disorder to
channel bolus through
stronger side of oral cavity
and/or pharynx
• Effortful swallow
– Improve tongue base
posterior motion
head rotation
Improving safety/QOL by reduction or elimination of
alternative nutritional support systems/advancement of
dietary level w improved nutritional intake
Documentation must be consistent with goals and
indicate reasonableness and need for skilled
intervention (2)
17
Denise Dougherty MA, CCC-SLP
18
3
2/14/2014
SODA
•
Pellitier& Dhanaraj (2006):
– moderate sucrose, high salt & high citric acid elicited significantly
higher lingual swallowing pressure compared to pressure generated w
water.
•
Study from Sweden – Bulow & Ekberg – noted “significant difference
between thin liquid & carbonated thin liquid
•
Carbonated liquid reduce penetration to airways
•
Pharyngeal retention significantly reduced w carbonated thin liquid
compared to thickened liquid
•
•
•
•
• Carbonated liquids valuable
treatment option for pts with penetration/aspiration
(Acta Radiol. 2003 Jul; 44(4):366-72 – Burlow M, Olsson R,Ekberg O.)
Denise Dougherty MA, CCC-SLP
DIET LEVEL/LIQUID MODIFICATIONS
•
•
•
•
•
Regular diet
Mince/non-chew
Finely chopped
Soft diet
Mechanical soft-ground
meat
Mechanical soft
dysphagia
Puree
Blenderized
Fortified full liquid
Thin/regular
Nectar thick
Honey thick
Pudding thick
NPO
Therapeutic feeds
Recreational or
Pleasure feeds
20
Denise Dougherty MA, CCC-SLP
19
Increasing Calorie Intake
Increase Calorie Intake
• Premium ice cream
• Whipped or sour cream
as topping
• Butter
• Mayonnaise
• Evaporated milk or half
and half
• Eggs – cooked only
• Cottage cheese
•
•
•
•
•
•
•
• Blue cheese or ranch
dipping sauce
• Cheese sauce
• Peanut butter – ONLY if
appropriate to diet level
• Powdered milk
• Instant breakfast shake
• Yogurt - smooth
• 1 tablespoon
– Corn oil margarine
– Oil
– Mayonnaise
– Half and half*********
– Honey
– Brown sugar
– Jelly
– Corn syrup
– Supplement 1 calorie/cc
– Supplement 1.5 calorie/cc
calories
102
120
101
20
64
51
54
57
15.6
22
cost!!
$.02
$.06
$.03
$.013
$.036
$01125
$.04
$.04
$.054
$.0625
(2)
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
21
LIQUID DIETS
Liquid Diets
• Clear liquids
• Full liquids
• Foods liquid at body
temperature
• Leave little/no residue
• Easily absorbed with
minimal digestive
activity
– Liquid or becomes liquid
at body temperature
– Easily absorbed
nourishment with very
little stimulation to GI
tract
Denise Dougherty MA, CCC-SLP
22
23
CLEAR LIQUIDS
Water
Clear bouillon
Broth
Strained fruit/vegetable
juices
• Tea
• Coffee
• Popsicles
• Ices
• Flavored gelatin
•
•
•
•
•
•
•
•
•
•
•
•
•
•
FULL LIQUIDS
Milk
Milk based beverages
Custard
Tapioca
Plain ice cream
Cooked cereals
Eggnog
Strained cream soup
Pudding
Sherbet
Denise Dougherty MA, CCC-SLP
24
4
2/14/2014
DIETS
DIETS
• National Dysphagia Diet Task Force
• Regular diet
– Level 1
– No dietary restrictions
– Minimum 2000-2200 calories
– Minimum 1500cc fluids
unless otherwise restricted
• Dysphagia pureed
– Level 2
• Dysphagia mechanically altered
– Level 3
(14)
• Dysphagia advanced
– Level 4****
• Regular diet
Denise Dougherty MA, CCC-SLP
25
Dysphagia Advanced Diet – Level 3
26
Dysphagia Mechanically Altered – Level 2
– Difficulty chewing regular textured food
– Difficult foods chopped, ground, shredded,
cooked or altered
– Avoid hard, sticky, crunchy diet
– Mild oral/pharyngeal phase dysphagia
– Based on regular diet
– Only allowance made for ease of chewing &
swallowing
– Minimum 2000-2200 calories
– Minimum 1500 cc fluid unless otherwise
restricted (14)
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
– Transition from puree diet (level 1) to higher
texture
– Mild to moderate oral and/or pharyngeal
dysphagia
– Some chewing ability required
– Food soft/moist enough to form bolus
– Difficult foods chopped, ground, shredded,
cooked
– Same calories and fluid amounts as higher
levels (14)
27
Dysphagia Puree – Level 1
Denise Dougherty MA, CCC-SLP
28
Appetite Enhancers
Difficulty chewing/swallowing foods at higher
levels of dysphagia diet
Only have to move food to back of mouth
and swallow
Relieved of chewing phase
Pureed to consistency of pudding/mashed
potatoes
If pt. can tolerate bit of texture, may add it
and still have majority of items pureed
same calories/fluids as higher levels
• Helpful in increasing appetite – may take
several weeks to kick in
– Megace (megastrol)
• Megace ES
– Marinol (dronabinol)
– Beneprotein – protein powder
• Can act as thickener!
– Scandical – calorie booster/gluten free
(14)
Denise Dougherty MA, CCC-SLP
29
Denise Dougherty MA, CCC-SLP
30
5
2/14/2014
Gelatin Slurry
Slurries
• Use on biscuits, crackers, bread, cakes without
need to blenderize or puree foods
– Do not use with fruit or nut pieces
36
c + 2T
1½c
3c 4 ½ c
Hot water or juice
Milk or broth
6T 3/4c
1½c
3c 4 ½ c
Denise Dougherty MA, CCC-SLP
32
Foods Appropriate to slurry
• Cookie sheet lined w parchment paper
• Lay food on cookie sheet ½” apart
• Gelatin into bowl, add cold water, stir, add hot water and whip well
w whisk
• Use immediately to slurry and pre-gel
• No nuts, seeds, coconut, fruit
• Completely soak food item
• Pour slurry on one side of food and spread
• MUST COMPLETELY SOAK FOOD AND SLURRY MUST GEL BEFORE
SERVING
• Turn food over and repeat
• Let stand 15 minutes
• Refrigerate to gel (30-60 min)
• Larger portions, denser foods take longer to gel (15)
• Cake donut – no
frosting +
• Sugar donut – no glaze+
• Muffins+
• Biscuits+
• Cake like brownie – no
frosting
• Bagel+
• Cake or cupcakes +
33
THICKENERS
• Cornbread+
• Cookies
• Danish
• Coffee cake+
• French toast***
• Pancakes
• Waffles
+ = may need to split in
half to absorb slurry (15)
Denise Dougherty MA, CCC-SLP
34
Foods with high water content
90%
Asparagus
Lettuce
Bell peppers
Broccoli
Cabbage
Cantaloupe
Carrots
Grapes
Melons
Mushrooms
Oranges
Peaches
Strawberries
• Thik & Easy Clear
– Ice cubes
• AquaCareH2O
– ice cubes
• Simply Thick (gel)
– Ice cubes
– Keeps carbonation!
Denise Dougherty MA, CCC-SLP
3T 6T ¾ c1
Cold water, juice
Milk or broth
6T 3/4c
31
Gelatin Slurry
Thickit
Thickit 2 (concentrated)
Thicken Up
Thick & Easy
Thik & Clear
Aqua Thick
Resource Thicken up clear
1½T
Servings
6
12 24
*****1/4 c needed for 1 slice white bread (15)
Denise Dougherty MA, CCC-SLP
•
•
•
•
•
•
•
3
Unflavored gelatin
• Liquid mixed with thickener
• 4 fl. Ounces liquid and 1 tablespoon of
thickener
• Refrigeration time of 2 hours is required
• Use within 48 hours
Denise Dougherty MA, CCC-SLP
Ingredients
35
85%
Apples
Blueberries
Kiwi
Raspberries
Pineapples
Pears
Plums
Orange juice
Milk
65%
Kidney beans
Baked potatoes
Cooked pasta
Rice
Denise Dougherty MA, CCC-SLP
36
6
2/14/2014
XEROSTOMIA
FRAZIER WATER PROTOCOL
•
•
•
•
•
•
•
• Permits & encourages water between
meals
• Began in ‘84
– observed/suspected noncompliance
– with liquid restrictions
•
•
•
•
– Mouthwash
– Oral spray
Recommended by staff pulmonologist
Highly controversial
Thirst response diminished with age
Studies: 50% of elderly Medicare pts. die of
complications associated w dehydration within 1
yr. of admission to hospital/LTC facility
Denise Dougherty MA, CCC-SLP
•
•
Present small amounts
Multiple swallows
Alternate solids & liquids
Decrease rate of
presentation
• Control sip size
• No straw
• No talking
Gum
Mouthwash
Toothpaste
Gel
Oral balance spray
Denture Adhesive
Suction tip for mouth care
Soft bristled tooth brush
Denise Dougherty MA, CCC-SLP
37
38
MUSCLE
TYPES
• Liquids by spoon
• Moisten mouth prior to
meal
• Chin tuck
• Head rotation
• Head tilt
• Food placement
• External pressure to cheek
• Labial/chin support
Denise Dougherty MA, CCC-SLP
Biotene – over the counter
800-922-5856 or www.biotene.com
–
–
–
–
COMPENSATORY STRATEGIES
•
•
•
•
Dr. John’s lollipops – drjohns.com
Salese
Xylimelt
Thayer’s Slippery Elm Lozenges and Spray
Artificial saliva
Sage – sageproducts.com; mouth care kits, protocol, brochure
Oasis – over the counter
• Type One
–
–
–
–
–
postural
Slow contraction time
Resist fatigue
Low force
Aerobic activity
• Type Two
–
–
–
–
–
–
39
Powerful movements
Fast contraction time
Fast fatigue
Also have type IIa & IIb
Very high force
Anaerobic activity
•
•
•
•
•
•
Denise Dougherty MA, CCC-SLP
Most muscles mix of I & II
Neck muscles are Hybrid
– more II than I
Fibers innervated by motor
neuron
Motor neuron & muscle
fiber innervated make up
motor unit
Endurance exercises build
type I (slow) fibers
Resistance exercises build
type II (fast) fibers
40
Repetition
– Critical element
– Need repetitive performance even after skill
acquired
– Changes in cortical organization require continued
performance over time
– Key component of active resistance exercises
– Unclear number of repetitions required to build
strength in orofacial muscles
• Likely varies with age, underlying disease process
• American College of Sports Medicine: 8 -15 reps 1-3 times day
optimal to build strength in limb musculature (3)
Denise Dougherty MA, CCC-SLP
41
• Healthy older adults & chronic stroke pts had
statistically significant improvements in lingual
strength during non-swallowing isometric exercises w
spontaneous generalization to natural swallowing
tasks
• Stroke pts demonstrated reduced liquid aspiration &
pharyngeal residue
• After 8 wks. of exercise, continued improvements in
tongue strength suggest longer program of exercise
may yield even greater improvements (3)
Denise Dougherty MA, CCC-SLP
42
7
2/14/2014
Intensity
•
•
•
Possible Scenarios & Goals
Specificity
Load placed on motor system
must be progressively increased
over time to increase demands as
system adapts
Strength training
– Highest amount of force that
can be generated once
Endurance training
– Less force with increased
number of repetitions
– Swallowing sacrifices speed
that speech needs
– Utilizes higher lingual
contractile force to prepare
and propel bolus
– Sensory pathways for
swallowing involve
consistency, temperature and
taste input (3)
Anterior loss of food saliva
•
Improve jaw closure
•
Improve lip seal
•
Lip closure around object
•
Lip closure against resistance
•
Pucker lips
•
Puff cheeks/lips sealed
•
Tongue depressor between lips
•
Retract corners of lips w/out
showing teeth
•
Thermal stim of lips w cold
•
Improve oral sensation
(9)
Pt. will ……………………. on ___ of ____ trials
*eliminate loss of food/liquid from lips when SLP
provides jaw support
*open/close jaw against resistance provided by SLP
*achieve lip closure around lifesaver on string/ice
cube/popsicle, button etc.
*Achieve lip closure against resistance provided by
SLP
*Pucker lips
*Achieve lip closure while keeping jaw open
*Hold tongue depressor between closed lips
*Puff cheeks w lips tightly sealed
Denise Dougherty MA, CCC-SLP
43
Possible Scenarios & Goals
Decreased bolus formation
•
Improve oral sensation
•
Improve tongue movements
•
Improve cheek tone
•
External pressure on cheeks
•
Tongue
clockwise/counterclockwise
between teeth/closed lips
•
Protrude tongue = touch chin/nose
•
Click tongue on roof of mouth
•
Tongue tip out against tongue
depressor
•
Tongue upward against tongue
depressor
•
Tongue in cheek with/without
resistance
•
Oo-ee (9)
(9)
Possible Scenarios & Goals
Pt. will……………….on ______ of ______trials
*Click tongue on roof of mouth
*Push tongue tip against tongue depressor
*Push blade of tongue upward against tongue
depressor
*Push r/l lateral border of tongue against
tongue depressor
*Protrude tongue into r/l cheek
Decreased bolus propulsion
• Improve tongue
movement
• improve oral
coordination
• improve oral sensation
• Tongue sweep from front
to back touching
hard/soft palate
• Tongue pops/clicks
44
(9)
Pt. will ……. on ___ of
___trials
*Move swab between
tongue/hard palate from
front to back
*Pop tongue against hard
palate
*Walk tongue on hard
palate from front to back
*Clean buccal cavity w tongue during/after
meal w/without cues
*Pucker lips, move lips side to side
Denise Dougherty MA, CCC-SLP
Possible Scenarios & Goals
Aspiration before
swallow
• Improve tongue
control
• Hard /k/
• Aspiration during
swallow
• Improve laryngeal
elevation
• Mendelsohn (9)
Denise Dougherty MA, CCC-SLP
45
Possible Scenarios & Goals
(9)
Pt. will….on___ of
____trials
*Exert pressure w back of
tongue against tongue
depressor
*Produce forceful /k/ at
end of words
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
47
Aspiration after from
pyriform sinus residue
• Improve laryngeal
elevation
• Improve UES opening
• Shaker
• Mendelsohn
• ee then falsetto
46
(9)
Pt. will …..on ____ of ____
trials
*Produce ee moving from
low to falsetto
*Hyoid lift
Denise Dougherty MA, CCC-SLP
48
8
2/14/2014
Possible Scenarios & Goals
Aspiration after from
penetration into laryngeal
vestibule
• Improve laryngeal
elevation
• Low ee and falsetto (9)
Possible Scenarios & Goals
(9)
*Produce ee moving from
low to falsetto
*Hyoid lift
Denise Dougherty MA, CCC-SLP
Possible Scenarios & Goals
Residue in pyriform
sinuses lateral pharyngeal
wall w aspiration
• Increase movement of
pharyngeal wall
• Masako (9)
•
*Hyoid lift
•
*Perform ___ repetitive head lift
maneuvers
•
•
*Perform masako __ times
•
*Pretend to yawn/gargle
•
•
•
51
General Principles:
• 2-4 days/wk.
• 20-45 min
• 1-2 exercises per muscle group
• 10-15 reps
• 65-75% of maximum level
Resistance Exercise
– Strength gains w exercise
similar to results in younger
individuals
– Stimulates release of hormones
– Enhance benefit of nutritional
& hormonal interventions
Denise Dougherty MA, CCC-SLP
*Perform ___repetitive head lift
maneuvers
*Perform masako ___ times
*Pretend to yawn/gargle
Can begin at age 30 – affects 1 in 5
over age 60 (13)
Skeletal muscle loss
– 10-50% over age of 60
– 45-50% by age 75-85
– Over 55% lost by age 85
*Produce ee moving from low to
falsetto
(13)
– Increased oral & pharyngeal
transit times
– More pharyngeal residue
– More laryngeal penetration
*Hyoid lift
50
Sarcopenia
(9)
Prevent/Slow/Reverse Sarcopenia
• Decreased lingual strength by
age 60
• Reduced lingual thickness
associated w poor nutritional
status
• See
*Produce ee moving from low to
falsetto
Denise Dougherty MA, CCC-SLP
49
Pt. will ….. on___of ___trials
Denise Dougherty MA, CCC-SLP
Pt. will …… on ___ of ___ trials
Aspiration after from
vallecular residue
• Low ee and falsetto
• Improve tongue
movement
• Improve laryngeal
elevation
• Improve tongue base
retraction
• Masako
Pt. will…. on___ of
___trials
(9)
53
dysphagia
• Age related
deconditioning
5 Risk factors:
*Unintended weight loss (more than 10
pounds in past yr.)
*General feeling of exhaustion 3 or
more days per wk.
*Muscle weakness
*Slow walking speed
*Low levels of physical activity (10)
2/14/2014
sarcopenia
• Muscle
fiber type
!!
• Inability to
protect
airway
aspiration
Copyright Denise Dougherty, MA, CCC-SLP,
& CCE, 2012
52
Stroke Patients and Stage Duration
(11) Laryngeal closure duration (LCD)
Stage Transition duration (STD)
•
transition between oral & pharyngeal
stages of swallow & timely initiation
of pharyngeal swallow
•
Time difference between bolus head
passing ramus of mandible &
initiation of maximum hyoid
excursion.
•
Increases w age
•
Penetration from prolonged STD =
delayed response of pharyngeal
musculature
•
STD values correctly identified
presence of aspiration 75% of time
in post-stroke pts
•
duration of contact between
arytenoids and epiglottis
•
Reflects integrity of airway
protection mechanism to prevent
entry of bolus into airway during
swallow
•
Post-stroke pts exhibit significantly
shorter LCD’s than healthy
Denise Dougherty MA, CCC-SLP
54
9
2/14/2014
Parkinson's and Changes in Aging
Lips
pressure/strength
(12)
Weakness of muscles for cough
Coughing single most important defense mechanism
Sarcopenia contributes to inability to generate expiratory forces for cough
•
•
•
•
Early stages, motor control impaired and later stages, impaired motor & sensory
components of cough affected
Sensory loss at base of tongue – accounts for vallecular residue
IF decreased sensitivity in laryngopharynx - may not be able to respond to post
swallow residue & risk of aspiration increases
•
•
•
•
•
•
poor mobility (1)
Drooling
Habitual open mouth posture
Loss of liquid
Poor contact on spoon w bottom
lip
Open mouth chew
Poor lip seal on straw
Can’t blow bubbles
Can’t hold lips together
Poor p,b,m artic
Can’t hold tongue depressor with
lips
•
•
•
•
•
•
•
•
Lips open/pulled back in slight
smile
Lips open/triangular shape
No lip rounding
No lip retraction
Poor lip movement during speech
Sucks food off spoon rather than
bowl with top lip
Poor long vowel differentiation
Poor /w/ artic
Need to exercise expiratory muscles in Plan of Care.
2/14/2014
Copyright Denise Dougherty, MA, CCC-SLP,
& CCE, 2012
55
Lips
Poor lip differentiation (1)
• Lips/mouth move as
unit
• Min. lip movement
during eating/speech
• Unable to chew closed
mouth
• No lip rounding/lip
retraction with teeth
together
56
Lips
• Button Pull
Lip force gauge – 4.5 to
5 pounds of pressure
quarter size – nickel size
– dime size
• Can’t hold straw with
lips while teeth
together
• Papapa said w wide
mouth movement
• Unable to clear
top/bottom lip teeth
• Jug Lift
– Use old button pull
Numerous studies noted
improvements w lips & tongue
movements for swallow
• Improved lip closure
• Improved ROM of tongue
• Improved chewing(7) (8)
• Cross Bar
– 2 tongue depressors;
increase time sticks
touch
– Squeeze pop
www.candywarehouse.com
Denise Dougherty MA, CCC-SLP
• Tongue depressor – lip
press
• Tongue depressor –
dumbbells for lips
weighted (2, 4, 6, 8 cents)
• Paper plate hold
– Use flimsy plate and
work up to heavier
plate
Denise Dougherty MA, CCC-SLP
57
Lips
Denise Dougherty MA, CCC-SLP
58
Ora-light
distributors listed w bibliography
Lip stimulator
exercises orbicularis
oris, mentalis,
buccinator & levator
labii superioris
Lip force (LF) will strongly
influence swallowing
capacity (SC).
• Saliva control & adequate
lip seal
• Develop lip closure, lip
rounding, & muscle
memory
Results support earlier
findings: LF training can be
used to treat dysphagia. (4)
Used w permission from Innovative Therapists Int'l,
Inc. TalkTools® is a registered trademark of
Innovative Therapists Int'l Inc.Talk Tools
Denise Dougherty MA, CCC-SLP
59
Tongue tip
stimulator
exercises
genioglossus
& intrinsic
tongue
muscles
Denise Dougherty MA, CCC-SLP
60
10
2/14/2014
Facial Flex
Ora-Light
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered trademark
of Innovative Therapists Int'l Inc.Talk Tools
Labial resistance
Pediatric -2, 4, 6 oz.
Horizontal - pucker, relax, smile
as often as can do in 1 min
Vertical – increased jaw
strength; place between
upper/lower teeth w closed
end outside of mouth – may
also work w trismus
Tongue shield
stimulator exercises
genioglossus &
intrinsic muscles of
the tongue
Tongue shield
stimulator exercises
Styloglossus,
palatoglossus,
hyoglossus,
genioglossus,
intrinsic muscles of
tongue
Denise Dougherty MA, CCC-SLP
61
Denise Dougherty MA, CCC-SLP
62
Horn Hierarchy
Talk Tools and Therapro
Adult Facial Flex
Horn hierarchy from Talk Tools
– Improve abdominal
airflow strength
– Drooling control
– Increase abdominal
demand in very small
increments
– Specific speech sound
teaching w phonemes
listed for each horn
• Facial Concepts, Inc.
P.O. Box 99
Blue Bell, PA 19422
Phone: (800) 469-FLEX
(610) 539-5869
Fax: (610) 539-9430
Email: [email protected]
Denise Dougherty MA, CCC-SLP
63
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered
trademark of Innovative Therapists Int'l Inc.Talk Tools
Lip closure Kit
• Includes horns that focus
on primary lip closure, lip
rounding, and airflow
patterns.
Complete hierarchy, specific
kits or individual horns
– Lip closure kit
– Lip protrusion kit
– Tongue retraction kit
Blow horn 25 times in rapid
repetitions using only lips and
good abdominal grading
Denise Dougherty MA, CCC-SLP
64
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered trademark of
Innovative Therapists Int'l Inc.Talk Tools
Tongue retraction kit
• increases lip protrusion,
tongue retraction, &
prolongation of
controlled oral airflow.
Lip protrusion kit
• Normalize oral
musculature
• promotes lower jaw
stability, lip protrusion, &
airflow control.
Denise Dougherty MA, CCC-SLP
65
Denise Dougherty MA, CCC-SLP
66
11
2/14/2014
Straw Hierarchy
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered
trademark of Innovative Therapists Int'l Inc.Talk Tools
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered
trademark of Innovative Therapists Int'l Inc.Talk Tools
•
•
•
•
•
Children & adults
Entire kit or separately
Achieve tongue retraction
Inhibits tongue thrust
Use lip block & exercises
to strengthen jaw,
increase jaw lip
dissociation (if bites on
straw to stabilize)
• Velopharyngeal
insufficiency?
lip blocks
• designed for pts. who
don’t want "cute" lip
block!
• FDA-approved material
for oral usage
• clean for use w multiple
pts.
• Fit Straws #2 & 3
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
67
68
Therasip
Ark Therapeutics - used with permission
used with permission
• Micro-resistant straws
• Also stainless steel set
• Increase difficulty of suck
against resistance
Lip blocks
– Increase ability to suck
– Stronger lip seal
– Improved velopharyngeal
closure
– Increased pharyngeal
contraction
Entire kit or just straws
Straws w valves
Denise Dougherty MA, CCC-SLP
69
•
•
Upper Lip Stretch
– Improves lip closure
Corner of Upper lip downward
stretch
– Strengthens lip closure –
reduce drooling
– Stretches /elongates upper lip –
sucking on straw
Pursed lip strengthener
– Reduces drooling
– Strengthens inner cheek/lip
musculature
– Spaghetti suck – weighted item
on floss/string
•
•
•
•
•
•
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered
trademark of Innovative Therapists Int'l Inc.Talk Tools
Kiss the lollipop
– Downgrade size to tootsie pop
to dum-dum to licorice
Lip roll
– index finger rotates on lip
under nose for stretch
Lip smack
Increase sensory input with sticky
substance
Puff up cheeks
– No air leakage
– 15 seconds
Puff up cheeks and attempt to pop
– No air leakage
– 15 seconds with gentle
resistance
Denise Dougherty MA, CCC-SLP
70
Vibrator with Toothette
Lip Exercises
•
Denise Dougherty MA, CCC-SLP
71
Watkins extracts for flavor – or make your own
Use for hypo/hyper sensitivity or tactile defensiveness in oral cavity
Promote awareness of oral cavity and relax "fixing.”
Tool for diagnosing oral sensitivity
Denise Dougherty MA, CCC-SLP
72
12
2/14/2014
Z-Vibe Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a
Ark Therapeutics used with permission
registered trademark of Innovative Therapists Int'l Inc.Talk Tools
• add vibration to
lollipops, Toothettes &
DentaSwabs in therapy
• Lip strength exercises
• Constructed of medical
grade materials
• FDA compliant &
contain no lead,
phthalates, PVC, BPA, or
latex.
Lip awareness
Lip strength
Lip seal
Lip
extension/strength
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
73
Jaw Stability
poor stability may result in:
Exercises with little direction
• Dumdum lollipop/toothette swab
– Sensory input – twirling/rotating plus taste
– Sucking
– Lateralization
– Tongue protrusion
– Lip rounding
• Horn hierarchy
• Z-Vibe, myomunchie
• Candy sprays
– Pressure from spray
– High taste – sweet, hot, spicy, sour
– Make with extracts – spray bottle
Denise Dougherty MA, CCC-SLP
74
• Full jaw opening during
speech
• Weak bite on solid
foods
• Unable to bite thru
solids w/o pulling &
tearing
• Munching chew instead
of rotary
• Bites on cup when
drinking
• Unable to open mouth
in midrange
(1)
Denise Dougherty MA, CCC-SLP
75
76
Jaw
Mastication
Therabite
– Atos Medical
– 7 stretches 7 x a day – hold 7
seconds
– Sustainable gain 1-1.5 mm per
wk. w exercise
– Gentle stretching of connective
tissue
– Strengthens weakened muscles
– Mobilizes joints
– Reduces joint inflammation
– Reduces muscle pain
– For restrictive jaw opening from
trismus
• Limited jaw mobility =
inflammation/pain = disuse
atrophy and/or joint
degeneration
• Myomunchie
– Orofacial myofunctional exercise devise
– Helps bruxism, tongue thrust
– Salivation increases 30% w chewing & increases swallow
frequency
– Exercises orofacial muscles, improves jaw stability, labial
competence, increases strength and endurance of bite/chew
– Sensory integration
– Helps position larynx in forward elevated position & may
improve airway closure
– Decreases open mouth posture
– http://www.teethperfect.com/products.htm
OPEN Swallow exercise
– Puts force on suprahyoid
groups
– At least 25-50% jaw opening
– 50% is optimal
– NEED tongue tip up
– Lori Burkhead study
Denise Dougherty MA, CCC-SLP
77
Denise Dougherty MA, CCC-SLP
78
13
2/14/2014
Jaw
Jaw Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a
Used with permission from Innovative Therapists Int'l, Inc.
TalkTools® is a registered trademark of Innovative
Therapists Int'l Inc.
registered trademark of Innovative Therapists Int'l Inc
Jaw Grading Bite Blocks
– Promote symmetrical jaw
strength, stability, grading by
varying jaw height
– Traditional (red) & softer
(purple)
– Teach jaw position & muscle
memory for standard speech
sound production. Excellent for
apraxic/dyspraxic pts.
• Jaw closure tubes
– Unable to go from open mouth posture to closed
mouth posture
– Six graduated bite tubes to teach jaw closure
– Cerebral palsy, TBI
– Helps w straw drinking
– Have pt. try to close jaw – measure distance from
upper to lower central incisors when pt. is stuck in
fixed position
– Pick size tube that corresponds
– Progress w hierarchy
Denise Dougherty MA, CCC-SLP
79
Denise Dougherty MA, CCC-SLP
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered trademark of Innovative
Therapists Int'l Inc.
•
• Bubble gum hierarchy
– Roll soft bubble gum into log and have patient bite
down – create tooth imprint
– Talk Tools hierarchy
– No gum if pt. won’t give it back!
Chewy tube – NOT recommended for TMJ
– Provide resilient, non-food, chewable surface for practicing biting &
chewing skills, & inhibit teeth grinding.
– 3 size-specific colors (colors FDA approved): red/large, yellow/small, &
blue/extra-large.
– Medical tubing or aquarium tubing
– May tie dental floss/string through tubing for handle
Denise Dougherty MA, CCC-SLP
81
82
Jaw
Chewy Tube
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a
registered trademark of Innovative Therapists Int'l Inc.
Used with permission from Innovative Therapists Int'l, Inc.
TalkTools® is a registered trademark of Innovative Therapists Int'l Inc.
• ARK grabber
– Improve jaw strength
– Reduce grinding/clenching,
biting, suckling
– Reduce pacifier usage, thumb sucking
– Children w weak jaw musculature
(hypotonicity/hyposensitivity) rely on oral habits to
provide stimulation to TMJ & help calm child
– Need to provide suitable substitute before it can be
reduced/eliminated – hard to go cold turkey!
– Purple is softer; green harder
– Scented – chocolate, grape, lemon, vanilla
• 2x diameter of red
version
• For pts. w excessive
mouthing or biting
• Not intended for jaw
exercise
• Alternative to negative
oral habits.
Denise Dougherty MA, CCC-SLP
80
Chewy Tube
Jaw
Denise Dougherty MA, CCC-SLP
Jaw Exercisers or Cross Bar
• Should complete jaw
grading bite blocks and
jaw closure tubes prior to
jaw exercisers if following
hierarchy
• Bite down gradually for
1 second until ends meet –
Hold 1 second then gradually
release – 1 second
83
Denise Dougherty MA, CCC-SLP
84
14
2/14/2014
Ark Therapeutics used with permission
Denise Dougherty MA, CCC-SLP
85
•
•
•
•
•
•
Poor Tongue differentiation
•
•
•
•
•
Denise Dougherty MA, CCC-SLP
jaw moves when tongue movements
made
Difficulty with r, l
Poor sequencing tongue movements
from front to back for back to front –
t-k and g-d
Imprecise artic (1)
•
•
•
•
•
•
•
•
No food lateralization w chew
Chew on 1 side of mouth
Can’t clear pocketed food
Can’t clear food from lips, tongue
Can’t perform tongue movements
Minimal movement in speech
Tongue blade tip down for /t/, /d/
Difficulty sequencing sounds in multi-syllabic
words (1)
Denise Dougherty MA, CCC-SLP
87
• Increased tongue strength
• Increased lingual volume
• Improved swallow
pressures
• Increased swallow
pressure & reduced
airway invasion
• Improved bolus control
on MBS
• Improved functional
dietary intake by mouth
Denise Dougherty MA, CCC-SLP
Tongue tip elevation/depression
•
•
•
•
Lateralization
Corner to corner
Honey, maple syrup, peanut
butter
Tongue depressor
Ora-Light
•
• Tongue Tip Lateralization
Push against tongue depressor
Strengthen/widen tongue
Resistance exercise
If patient dislikes taste, wrap
tongue depressor w fruit
rollup
•
Tool between upper & lower teeth
Bite down gently & hold 10 seconds
Bite down - touch bead
Bite down, move bead to middle of wire w
tongue tip
Bite down, move bead to top of wire w
tongue tip
Movement without tool
– Place on surface of lower back molars and bite gently –
hold for 10 seconds – keep jaw still
– Same placement & touch bead w tongue
– Move bead to middle of wire
– Move bead from top to bottom of wire
– Movements without lateralization tool
**Lingual strengthening must
involve resistance & overload
which traditional exercises lack
Denise Dougherty MA, CCC-SLP
88
Used with permission from Innovative Therapists Int'l, Inc.
TalkTools® is a registered trademark of Innovative Therapists Int'l Inc.
Lick tongue depressor
Sticky substance on depressor
– use tongue tip
Myomunchie
Can SHOW outcomes with
• IOPI
• Tongue Press
• MOST
Tongue tip elevation/depression tool
Tongue Movements
Protrusion
Tongue to inner lip rim
Tongue to outer lip
Licking lollipop
86
(13)
Mobility
Tongue held forward, depressed
Drooling
Food loss
Limited vertical movement
Poor long vowel production
Poor /t/,/d/,/n/,/k/,/g/
used with permission
Lingual Strengthening Outcomes?
Tongue Movements
Poor strength
Ark Z-Grabber
• For pts. craving vibration &
sensory stimulation from
DnZ-Vibe®,
• Biting & chewing skills w
textured tip & chewable
loop.
• Transition from Grabber® to
Z-Grabber™ for added
sensory input & transition
to tips of DnZ-Vibe® for
speech & feeding skills.
• Loop used as handle
89
Denise Dougherty MA, CCC-SLP
90
15
2/14/2014
Tongue Movements
Tongue Movements
• Pencil/chopstick with tongue elevation
– Tongue under chopstick, elevate and pull back
•
• Fruit rollup, fruit by the foot, balloon, bubble gum
– Resistance for tongue tip
Tongue in cheek
– Cheek provides resistance
• Dumdum lollipop, lifesaver, gummy bear
– Lateralize
– Wrap lollipop with gauze
– Dental floss on lifesaver and gummy bear
• Tongue in cheek with outside resistance
– Cheek and outside pressure provide increased resistance
• Circle outside, inside lips
– Sticky substance on lips – honey, maple syrup, squeeze pop,
goo
– Crush cheerios etc. & mix with sticky – provides texture as
well
Denise Dougherty MA, CCC-SLP
91
Denise Dougherty MA, CCC-SLP
Z-Vibe - Used with permission from Innovative Therapists Int'l, Inc.
TalkTools® is a registered trademark of Innovative Therapists Int'l Inc.
Tongue Movements
• Diadokokinetic exercises – d, t, p٨t٨k٨
Tongue tip elevation, strength, ROM
Lateralization, food retrieval
Retraction/protrusion
Mid-tongue awareness &
strength
Tongue bowl
– Puh/tuh – 5.8 to 6.9 syllables per sec average for normal adult
– Kuh – 5.2 – 6.2 syllables per sec average for normal adult (16)
• Candy Sprays
– make your own!
• Tongue tip elevation
– Crossbar
– Lifesaver
– Cheerio
– Orthodontic rubber band
93
– From back to front
– Elongates & relaxes
• Tongue click
– Tongue widening
– Increase bolus
retention/transit
• Taco tongue
– Dum-dum lollipop
– Helps form bolus
Tippers
• 80% of population
• Bolus held between
tongue and anterior
portion of the hard palate
Dippers
• 20% of population
• Bolus held on floor of
mouth in front of tongue
prior to initiation of oral
stage
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
94
Tongue Base Retraction – movement
of posterior wall
Tongue Movements
• Stroking
Thermal tip
Spoon
Fine tip
Denise Dougherty MA, CCC-SLP
92
95
–
–
–
–
Pretend to gargle
Pretend to yawn
Effortful swallow
Super-supraglottic
swallow
• Take breath – let a
little out
• Hold breath –
swallow – squeeze
• Cough - swallow
– Masako
– Horn therapy
Masako (tongue hold or anterior
tongue anchor)
• Increased UES relaxation
pressures in older adults
• Increased lingual/pharyngeal
muscle activity (13)
– Affects anterior bulging of
posterior pharyngeal wall inhibits tongue base
retraction
– Exercise NOT a swallowing
maneuver
– Protrude tongue maximally
– hold between central
incisors and swallow (5)
Denise Dougherty MA, CCC-SLP
96
16
2/14/2014
surface EMG
Laryngeal Elevation
• Mendelsohn maneuver
• Technically ROM or
endurance exercise w no
added resistance (13)
• Prolongs UES opening
– Keep larynx at highest point
– Swallow w fingers lightly on
larynx
– Hold when its at highest
point – push tongue hard
against roof of mouth
– Base of tongue attached to
hyoid bone attached to
larynx – pushing up tongue
keeps larynx up
• Falsetto - Low e then high e
• Hyoid Lift – use drinking
straw to suck up 1” paper
square and deposit into cup
Denise Dougherty MA, CCC-SLP
97
•
Teaches control
•
NO harm to patient
•
Do with eating
•
Record “normal” swallow then compare with effortful swallow
•
Prometheus Group unit - $1500 to $5000
– Audio signal w laptop
Denise Dougherty MA, CCC-SLP
98
• Horn hierarchy
• Blow out candle – birthday candles you can’t
blow out
• Blow cotton balls across table – increase size of
cotton ball
• Bubble hierarchy
• REMEDIES
– Incentive spirometry
– Breather
– EMST 150
– Horn/whistle/bubble
program
– Stretch shoulders back
– Wiggle bubble
– Blow bubble off wand
– Blow bubble out of wand
– Increase distance
• PT prior to speech?
Denise Dougherty MA, CCC-SLP
BIOFEEDBACK is MOST effective evidence based tool
Improved Breath Support
IMPROPER POSTURE
• EFFECTS
– Low voice level
– Breathy voice
– Increased aspiration risk
– Coughing
– Food spillage
– Fatigue
– Poor hand-eye
coordination
•
99
Improved Breath Support: Breather
Denise Dougherty MA, CCC-SLP
Used with permission
100
EMST-150
[email protected]
239-938-6692
Pressure threshold trainer
Resistance set at 75% max expiratory pressure
5-6 sets of 5 breaths
3-5 days/wk.
4-8 wks.
www.pnmedical.com or Alimed
Inspiratory/expiratory resistive breathing training may improve
swallowing and phonation
May improve swallow safety leading to diet upgrade
Teach diaphragmatic breathing
Reduces dyspnea
Minimizes congestion and clears airway
Strengthens skeletal muscles of neck, pharyngeal and laryngeal muscles
Improves respiratory support for phonation
Denise Dougherty MA, CCC-SLP
101
Expiratory muscle training improves cough, swallow & speech
Improves P-A scale scores
Increases expiratory pressures/improves cough
Increased submental muscle activity
Dougherty MA, CCC-SLP
influences hyolaryngealDenise
elevations
102
17
2/14/2014
IOPI
TYPES OF MUSCLE INTERVENTION
used with permission
• Isometric exercises
– Contracting muscles against fixed resistance –
Oralite/crossbar/button pull/fruit rollup
– Tongue pressure –
• Iowa Oral Performance Instrument (IOPI) measures 5.1% volume increase in tongue bulk per MRI
• 8 week progressive resistance – 100% pts improved –
airway protection improved – generated pressure in
mouth has downstream effect into larynx
• strength/fatigability of tongue
Denise Dougherty MA, CCC-SLP
103
Madison Oral Strengthening Therapeutic (MOST) Device used with permission
Denise Dougherty MA, CCC-SLP
104
Therasip – Tongue Press
used with permission
Facilitates increased pressures generated by tongue and other
oropharyngeal musculature through progressive resistance
isometric exercise
• Measures pressure generation
• Multi-sensor custom fit mouthpiece
• Auto calculates exercise targets
• Provides knowledge of results to user
• Transfers from non-swallowing practice to swallowing behavior
U.S. patent # 6702765 FDA Registered
Denise Dougherty MA, CCC-SLP
105
TYPES OF MUSCLE INTERVENTION
– Tongue strengthening – observed increased blood
flow with lingual gestures /t/, /k/
– Therabite
• If unable to insert 3 fingers between teeth =
trismus
– Shaker
• May elevate blood pressure
Denise Dougherty MA, CCC-SLP
106
Laryngeal Musculature
• Intrinsic laryngeal
muscles
– Control VC closure &
tension
• Strengthening exercises
– Bear Down
– LSVT
• Improves swallow
function(13)
• Extrinsic laryngeal
muscles
• Hyolaryngeal elevation,
epiglottic inversion & UES
dilation
• Shaker
• Mendelsohn
• Pitch glides
– Targets longitudinal
pharyngeal muscle groups
Denise Dougherty MA, CCC-SLP
107
Denise Dougherty MA, CCC-SLP
108
18
2/14/2014
Shaker Exercise
EXERCISES
Shaker exercises
• Reduces pyriform sinus residue &
backflow aspiration
• Contraindications
– cervical spine deficits
– reduced neck movement
ability
– carotid stents
– heart problems
•
•
•
•
Isometric
Improves laryngeal elevation &
UES dilation(13)
Pts. committed to 6 wk. program
more likely to attain goals than
those who discontinued within
first 2 weeks
Extended Shaker
– Lie flat w shoulders against firm
surface
– Elevate head only & look at feet
– Hold for 60 seconds
– Repeat 3 times
• Perform exercises 3 x day for 6 wks.
(3)
•
Increased anterior laryngeal
excursion of larynx, maximum
anteroposterior diameter &
cross-sectional area of UES
opening(6)
Denise Dougherty MA, CCC-SLP
109
Repetitive Shaker
– 30 repetitions
– hold for 1 second then rest
rather than 60 second
hold/rest
OR
– 45 degree lift w 30 reps– but
no data on this position
Modifications:
• Neckline Slimmer
• Resistance exercise bands around head
• Hand on forehead or back of head
Denise Dougherty MA, CCC-SLP
MUSCLE INTERVENTION
Strength Training
Results in:
– Hypertrophy (more fibers)
– Change of fiber action
– Recruitment of additional
motor units
– Highly specific for trained
behavior
– Exercises produced at low
resistance increase
endurance
– High resistance equals
increased strength
– Improved oral transit time
– Decreased % of oral residue
• Check oral cavity residue at
end of meal
– Improved tongue base
function
– Oropharyngeal swallow
efficiency
Icing
• Increase swallow speed
• New data suggests warm may
be better in oral cavity
(Selinger, 94)
• Cold stroking of anterior
faucial pillar
• Intended to reduce delay in
swallow initiation
• Does not seem to impact
aspiration
• Temporarily reduces nerve
conduction
• Effect suspected to be
analgesic rather than true
ROM increase
Lemon
• Lemon swab – may cause
xerostomia
– Can freeze
• Lemon straw
• Lemon ice
• Laryngeal mirror – temp increases
from time mirror removed from ice
to time placed in oral cavity
• Ice sticks – freeze; single pt.
use only
– Do not use if
• Pt. at risk for biting
• Cannot maintain
oxygen saturation rate
above 90
• Exhibit extreme
bradycardia or
tachycardia due to
significant cardiac
problem
Denise Dougherty MA, CCC-SLP
111
MUSCLE INTERVENTION
Heat
– Elevates threshold for pain –
able to stretch further without
pain
– Passive warming BEFORE
stretch can increase ROM
– Most studies use activities to
warm muscle
– Warming muscle causes calcium
release, increased motor unit
recruitment
– Reduces muscle spasm
– Improves blood flow – may
facilitate muscle strength
Thermal Tactile Stim
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered trademark of
Innovative Therapists Int'l Inc.
• Benefits of tongue
strengthening exercises
Denise Dougherty MA, CCC-SLP
110
•
•
•
•
•
•
112
Nautilus Exercises
20+ muscles involved w successful swallow
4 way neck press & triceps press
Written up in Sept 3, 01 Advance
Works upper shoulder, neck & sternum muscular
regions & helps emphasize chin tuck
Isolating/strengthening laryngeal muscles provides
improved airway closure
Triceps press used for voice therapy
– strengthening cords aids swallowing by increasing airway
protection/reduces aspiration
• AEGIS therapists using program in some facilities
Denise Dougherty MA, CCC-SLP
113
Denise Dougherty MA, CCC-SLP
114
19
2/14/2014
DPNS
LSVT (Lee Silverman)
•
•
•
•
•
•
Tongue/palatal residue reduced 50%
for liquid, 12.5% for paste, 25% for
cookie
Improved tongue coordination &
lateralization
Rocking tongue motion disappeared =
reduced oral transit time
Delayed trigger of pharyngeal swallow
disappeared during swallows of
liquids, 25% reduction for paste, 66%
reduction for cookie
Activate neuromuscular control of
entire aerodigestive tract improving
pharyngeal stages of swallow
Also targets respiratory musculature
Intensive treatment protocol
• Intensive stimulation of one
sensorimotor system results in
positive neural plastic changes in
brain related to other systems
• Transference (3)
•
www.lsvtglobal.com for info &
registration
Denise Dougherty MA, CCC-SLP
115
VitalStim™
Adjustable parameters for dysphagia
Multiple treatment settings
Visible muscle contraction
30-minute treatment protocol
Adjustable parameters to manage
pt. comfort
119
• DPNS study (1991-1993)
indicated high efficacy rate
(83%) of swallow function
improvement w CVA pts. (all
types inclusive of brainstem),
Parkinson’s (mild - moderate
stages), TBI, Dementia (into
stage 6), & aspiration
pneumonia.
Denise Dougherty MA, CCC-SLP
116
FDA cleared for treatment of
dysphagia
Used w active exercise
Carnaby-Mann & Crary
Study (2007):
20% improvement in
swallow function
E Series Electrodes & Muscle Stimulator used with permission
–
–
–
–
–
• systematized therapeutic
method for oral & pharyngeal
dysphagia utilizing 11 specific
stimulation techniques.
used with permission
Denise Dougherty MA, CCC-SLP
Shape ensures proper placement
Reusable, single-patient use
Patented electrode and the most
economical
Only 2 placements – facial & submental
Disperses current evenly for added comfort
• Increase muscle strength,
endurance, ROM, & function.
Ampcare’s ESP™
Effective Swallowing Protocol
used with permission
• www.ciaoseminars.com
for info & registration
• External stimulation of
laryngeal/facial muscles
• Re-education of
muscles
• Unit approved by FDA
for use over larynx
• Improved muscle
function, strength &
speed of swallow
• Electrical stimulation
during oral intake
• Pharyngeal stimulation
utilizing frozen lemon
glycerin swabs
• Technique requires
certification
• 888-900-2163 or
www.speechteam.com
• utilize reflex stimulation thru
thermal (cold) modality
• direct, targeted reflex
triggering generates muscle
group contraction.
E Series Electrodes
ES™ Powered Muscle Stimulator
Posture Device – resistive
exercise protocol
(682) 561-2444
www.ampcarellc.com
117
The Guardian Stimulator used with permission
[email protected]
• Facilitates observable & palpable
hyolaryngeal excursion
• Stimulation combined w
swallowing = neuromuscular reeducation
• Therapeutic response achieved
in 30 minutes.
• Progress pt. w different
foods/liquids as tolerated
• online or hands on seminar
• Adjustable parameters
Denise Dougherty MA, CCC-SLP
120
20
2/14/2014
Electrode Placement
Suprahyoids/Submental Region
E Swallow
Used with permission
used with permission
• Online training program +
minimum 4 hrs. training under
supervision of qualified SLP
• Reusable electrodes – up to 3
sessions
• FDA cleared
• eswallowusa.com for training
information & registration
Denise Dougherty MA, CCC-SLP
121
Denise Dougherty MA, CCC-SLP
122
ADAPTIVE EQUIPMENT
DASI – Elixer Research, Vashon, WA*****
Location: Swedish Medical Center, Seattle WA
Participants: limited to 10 participants Contact: Ken Gillies
Email: [email protected]
P: 206 463 7200
Day 1 – Dysphagia Evaluation
Day 2 – Dysphagia Rehabilitation
Denise Dougherty MA, CCC-SLP
123
OralFlo Pill Cup Spray n Swallow
used with permission
Denise Dougherty MA, CCC-SLP
124
Redware - Alimed
www.spraynswallow used w permission
Pill Glide
Denise Dougherty MA, CCC-SLP
125
Denise Dougherty MA, CCC-SLP
126
21
2/14/2014
Used with permission from Innovative Therapists Int'l, Inc.
TalkTools® is a registered trademark of Innovative Therapists Int'l Inc.Talk Tools
Provale Cup
mealtimepartners.com – used with permission
•
•
•
•
•
Traditional nosey
cups
Pink (1 oz.), blue
(2 oz.) & green (7
oz.)
Stimulate corners
of mouth to
facilitate lip
closure
Eliminates
head/neck
extension.
•
•
•
•
•
•
•
•
Recessed Lid Cup
2 handles keep hands at
midline
Recessed lid encourages
tongue retraction &
improved lip closure.
2 twist-off lids included
Cup or straw drinking. (BPA
Free, Phthalate Free, Lead
free)
Denise Dougherty MA, CCC-SLP
Wedge Cup
•
•
•
5cc & 10cc bolus size
Thin liquids
Increases independence
Decreases cues
127
Denise Dougherty MA, CCC-SLP
128
Adaptive Equipment
used with permission
Works w honey thick liquids
985-722-8269
The Wedge Group, LLC
Novo Cup from Kapitex
Medical
• Control fluid flow rate w cap
plug in place
• suck on spout.
• Ideal if head/neck
movements restricted
Denise Dougherty MA, CCC-SLP
129
Denise Dougherty MA, CCC-SLP
130
Honey Bear
Talk Tools® and Ark Therapeutics used with permission
• Control flow of liquid
into child´s mouth
• Encourages straw
drinking
• Transition from bottlefeeding to cup drinking
• Spill-proof lid.
Doidy Cup
SmartBabyMall.com
Dysphagia Cup
Also in opaque
Heavier than provale
Used with permission
Denise Dougherty MA, CCC-SLP
131
Denise Dougherty MA, CCC-SLP
132
22
2/14/2014
Sip-Tip® – Ark Therapeutics
ARK's Cip-Kup™
used with permission
•
•
•
•
•
•
•
•
Denise Dougherty MA, CCC-SLP
•
•
•
•
•
•
•
•
•
•
Learn or re-learn straw drinking w
less effort.
Helps generate & maintain suction
Squeeze liquid & release.
Valve keeps fluid in straw
Reduces air ingested & effort to
drink
Slows flow, control quantity &
fluid deposited in front of mouth.
Less coughing & choking
Transition from bottle to cup
Denise Dougherty MA, CCC-SLP
134
Sammons®
Adaptive Transparent Mug w 2 Handles
•
•
133
Sammons®
•
used with permission
Helps generate & maintain
suction
Transition from bottle to cup
1 way straw/built-in valve keeps
straw full, reduces air ingested
& effort to drink
Valve slows flow
Controls quantity & deposits
fluid in front of mouth
Less coughing & choking
Snap on lid minimize spillage
Markings to monitor fluid intake
Clear, high-strength plastic; secure
grip
Wide base prevents tipping. 10-oz.
capacity.
Dishwasher safe to 125°F. Latex
free.
Spouted lid; Replacements
available
$6.95
•
•
•
•
•
•
Adaptive Clear Cup w Snorkel Lid
2 Handled Nosey Cup
Replacement lids
Polypropylene 8-oz.
Lid regulates flow of liquids.
Suck liquids if hole covered,
Liquid flows if hole uncovered
Dishwasher safe up to 180°F. Latex
free
$7.69
• Approximately $8.75
• Drink w/out head tilt
• Fits transparent mug &
snorkel lid cup
• Package of 6 lids
• $12.68
Denise Dougherty MA, CCC-SLP
135
Sammons®
Adaptive No Tip Weighted Base Cup
Denise Dougherty MA, CCC-SLP
136
Controlled Flow Baby Feeder
Adaptive Insulated Weighted Cup
www.Bionix Med.com used with permission
• Available in preemie &
standard bottle
• Flow Level Descriptions
• Weighted rounded base.
• Self-righting
• Keeps warm or cold.
• 2 lids, one w two holes to let
• Weight added to base to
beverage flow, one w plastic
reduce hand tremors
mouth piece.
• Holds 8 oz.
• Holds 6½ ounces.
• Top Shelf Dishwasher Safe
• Latex free.
• BPA & Latex free.
• $22.45
• $11.25
Denise Dougherty MA, CCC-SLP
– 0.Zero Flow - Non-nutritive
sucking
– 1.Taste
– 2. Slow Drip
– 3.Trickle
– 4. Steady Flow
– 5. Stage 1 Nipple
137
Denise Dougherty MA, CCC-SLP
138
23
2/14/2014
Safe Straw - bionix medical
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered trademark of
Innovative Therapists Int'l Inc.Talk Tools
used with permission
• Limits bolus size
• Fluid chamber, 1 way
valve, & float
• Fluid flows through valve
into chamber
• Float rises w sucking
• After 6.2ml’s, float closes
chamber preventing pt.
receiving more fluid.
• Float sinks when sucking
stops
• Gives pt. time to control
liquid & safely swallow.
Haberman Mini-Feeder
• Same design as
Haberman Feeder
• Teat is ⅓ smaller for
smaller/premature
infants
• Instruction book
Denise Dougherty MA, CCC-SLP
139
Straws w Valves
Ark Therapeutics – used with permission
Denise Dougherty MA, CCC-SLP
Maroon Spoons
140
Weighted Spoon w Vibration
Used with permission from Innovative Therapists
Int'l, Inc. TalkTools® is a registered trademark
of Innovative Therapists Int'l Inc.Talk Tools
Ark Therapeutics
Used w permission
• Decreases fatigue &
swallowing air
• Liquid stays at top of
straw after suck
• Disposable OR reusable
• Clean reusable valves in
dishwasher
Denise Dougherty MA, CCC-SLP
Denise Dougherty MA, CCC-SLP
141
Duospoon
Right Bite
Small Textured Spoon
Ark Therapeutics used with permission
used with permission from Ark Therapeutics
•
•
•
•
Denise Dougherty MA, CCC-SLP
142
143
2 tools in 1
Increases upper lip activity w
food removal.
FDA approved food-grade
Both ends provide sensory
variation during mouth
exploration & as food taken
from bowl.
•
•
•
•
Textured bottom provides
increased awareness &
stability during feeding.
Promotes transitioning from
puréed to textured foods.
Hand-over-hand assistance
Contains no latex.
Denise Dougherty MA, CCC-SLP
144
24
2/14/2014
PureGreen 24
Disinfecting Tools
Used with permission from Innovative Therapists Int'l, Inc. TalkTools® is a registered trademark of
Innovative Therapists Int'l Inc.Talk Tools
•
• Benefect
– www.benefect.com
• Dental supply catalogs - cleaning solution
• AMA standard is bleach
– Bleach – 96 parts water to 4 parts bleach
(gallon of water to capful of bleach)
– New solution every 24 hours
Denise Dougherty MA, CCC-SLP
Hard surface antimicrobial disinfectant &
deodorizer
24-hour effectiveness
Non-flammable, non-corrosive, odorless
No fumes or skin irritation
Kills germs & the most deadly of superbugs
Product NOT considered hazardous (OSHA)
EPA registered - use on children's toys (no
rinsing required)
Wet surface, wait few minutes, wipe clean.
•
•
•
•
•
•
•
Denise Dougherty MA, CCC-SLP
145
Portable Vibe Sanitizer
Ark Therapeutics – used with permission
Mesh Dishwasher Bags
146
Spill Proof Valve Cleaner
Ark Therapeutics – used with permission
• Battery operated unit
• sanitize tips, select-flow
valves while traveling/in
office
• Vibration cleans debris from
inside valves
• Water & ultrasonics to
sanitize
• Auto shut-off mode
• Sanitize vibe products w
germicidal ultraviolet
technology.
• Destroys 99.9% of germs
• Holds 4 Vibe products
• Automatic shut off in 10
minutes
Denise Dougherty MA, CCC-SLP
• small items - valves, tips,
probes.
147
The “Plan”
Dishwasher basket made
specifically for valves!
• Jets shake basket to clean all
brands of valves.
• Washes 11 valves at a time.
Denise Dougherty MA, CCC-SLP
148
Therapy Plan: Combination of….
MBS/FEES
• RESEARCH EVIDENCE
ALONE IS NOT ENOUGH
Compensatory
Diet & Liquid
Strategies
Modification
Evidence
Based
Practice
• Patient preference AND
SLP’s EXPERIENCE must
be considered!
Pt.
Preference
Adaptive
Therapeutic
Equipment
Exercise
Denise Dougherty MA, CCC-SLP
149
Denise Dougherty MA, CCC-SLP
SLP
Experience
150
25
2/14/2014
Ora-Lite Distributors
Bibliography
• Bryan Medical Inc.
3914 Miami Road, Suite 309, Cincinnati, Ohio, 45227 Tel: 513 2721600 • Lauder Enterprises, Inc.
PO Box 780249, San Antonio, Texas, 78278-0249, Tel: (210) 492-0864, Toll
Free: (800) 388 8642 Fax: (210) 492 1584
• Luminaud, Inc.
8688 Tyler Boulevard, Mentor, Ohio, 44060 Tel: 800-255-3408 Fax: 440-2552250 • Speech Pathology Associates
PO Box 2289, South Portland, Maine, 04116 Tel: 207 741 2443 Fax: 207 799
2289
Denise Dougherty MA, CCC-SLP
151
(1) Mackie, E. Oral-Motor Activities for Young Children. LinguiSystems, Inc., 1996.
(2) Model Medical Review Guidelines for Dysphagia Services, ASHA, 11-30-2001
(3) Kays, S. and Robins, J. Principles – Neural Plasticity, Repetition, Intensity & Specificity Framing Oral Motor Exercise in Principles of Neural Plasticity. ASHA 2007
(4) 201011 130(11):1204-8 Language: eng Country: England Speech & Swallowing Centre,
Department of Otorhinolaryngology, Hudiksvall Hospital, Sweden. [email protected]
(5) Masako F, Logemann J., Effect of Tongue holding Maneuver on Posterior Pharyngeal Wall
Movement During Deglutition, AJSLP Vo. 5, No. 1, 23-30, Feb. 1996
(6) Shaker R, Kern M, Barden E, Taylor A, Stewart ET, Hoffman RG, Arndorfer RC, Hofman C.,
Bonnevier J, Augmentation of Deglutitive Upper Esophageal Sphincter Opening in the
Elderly by Exercise, American Journal of Physiology, 272:G 1518-22, 1997
Denise Dougherty MA, CCC-SLP
152
Bibliography
(7) Lazarus C, Logemann J, Huang C, & Rademaker A, (2003). Effects of two types of tongue strengthening
exercises in young normals. Folia Phoniatrica et Logopaedica, 55(4), 199-205.
(8) Sharkawi,A.E., Ramig,L, Logemann, J.A, Pauloski,B.R., Rademaker,A.W., Smith,C.H., Pawlas, A., Baum, S., &
Werner, C. (2002).Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): A pilot study. Journal
of Neurology, Neurosurgery, and Psychiatry,72(1), 31-36.
(9) Swigert, N. The Source for Dysphagia, 3rd edition. Linguisystems, 2007.
(10) Barclay, L., MD, CME Lie, D., MD. MSEd. Poor strength function and low muscle density linked to
hospitalization in Elderly. CME Released08/11/2009.
(11)Oommen, E, Kim, U., McCullough, G. Stage Transition and Laryngeal Closure in Poststroke Patients with
Dysphagia. Dysphagia (2011) 26:318-323
(12) Leow, LP, Beckert, L, Anderson, T., Huckabee, ML.Changes in Chemosensitivity and Mechanosensitivity in
Aging and Parkinson’s Disease. Dysphagia (2012) 27:106-114.
(13) Clark, H., Effects of Exercise-Based Dysphagia Interventions. ASHA Dysphagia in Older Adults, May 2013.
(14) Dorner, Becky & Associates, Diet Manual, 002
(15) Dorner, Becky 7 Associates; Dysphagia Diet Solutions.
(16) Leder, SB, Suiter, DM, Murray, J, Rademaker, AW. Can an Oral Mechanism Examination Contribute to the
Assessment of Odds of Aspiration? Dysphagia online Jan.,2013
Denise Dougherty MA, CCC-SLP
153
26

Download Report