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THE ART OF SWALLOWING THERAPY

Carolyn Abraham M.S., CCC-SLP, CLT4/6/19

DISCLOSURES:

FINANCIAL:HONORARIUM

COMPLIMENTARY CONVENTION REGISTRATIONSALARY

NON-FINANCIAL: SIG 13

AZ STATE LICENSEASHA MEMBERSHIP

LEARNING OBJECTIVESAt the culmination of this session, participants will be able to:

• List the basics of exercise physiology in its application to dysphagia management.

• Understand how cross-systems function (e.g. respiration andswallowing) and its impact on swallowing.

• Provide a framework for current best practices in making functional gains for patients with dysphagia.

• Discuss factors to consider when reviewing complex dysphagia cases

What do we know?• Aspiration by itself is not sufficient to cause pneumonia, that there must be other factors

(Langmore et al., 1998; Cook et al., 1999)• Aspirators aspirate more than just food and liquid; they also aspirate saliva and reflux. (Feinberg

et al.,1990; Feinberg et al.,1996) • The lungs have defense mechanisms of their own and are not simply receptacles for pneumonia

(Raz, 2007)• It is possible to rehabilitate the swallowing mechanism but that it’s not possible to plan this

without instrumentation (Crary et al., 2012)• We don’t rehabilitate simply a trachea and a pharynx, but a patient, who has choices (Leslie &

Krival, 2016). • Without adequate nutrition and hydration, the human organism is far more susceptible to

disease due to the impact on the immune system (Chandra, 1997)• Altered diets don’t necessarily lead to improvements in nutrition and hydration (Vivanti et al.,

2009; Sura et al., 2012) • The best way to be sure that patient with “comply” with a treatment plan is to develop the

treatment plan with the patient (Leslie & Krival, 2010) Pamela Smith, P. (2019). The Supposedly unsolvable sliding tile puzzle of dysphagia management - Dysphagia Cafe. Retrieved from https://dysphagiacafe.com/2019/03/03/supposedly-unsolvable-sliding-tile-puzzle-dysphagia-management/

SWALLOW PHYSIOLOGY & COORDINATION OF

RESPIRATION

Swallowing Review:

Pearson, W. and Molfenter, S. (2018). Anatomic and Physiologic Targets For Intervention.

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Exercise Physiology■ When proteins are activated in a repetitive cycle a muscle contraction

occurs– Muscle contraction must meet intent in order to result in

functional movement■ A coordinated series of contraction (agonist) and relaxation

(antagonist) produces purposeful movement■ The types of fibers that make up a muscle determine the force

produced (strength) or how well a muscle responds over time (endurance)

■ Muscle fibers are type I or type II based on how it uses fuel and its force generating capacity

Muscle Fibers

Type I■ Smaller in diameter

■ Utilize low force

■ High endurance activities

■ Can perform many repetitions without a load

Type II■ Structurally superior for force

■ Predisposed to fatigue

■ Quick forceful movements

■ Heavier load needed fewer repetitions

■ A concentration of Type I and IIa fibers are found in the anterior tongue

■ Type II fibers are best suited for quick ballistic movements such as driving a bolus through a hypopharynx and toward the esophagus

■ The majority of upper aerodigestive tract muscles are type IIA high concentration of Type II fibers are found in the tongue base and pharyngeal constrictors

Dysphagia and Exercise PhysiologyPrinciples of neuroplasticity:– Use it or Lose it– Use it and improve it– Neuroplasticity is

experience-based– Repetition Matters■ Performance does not

mean learning– Intensity matters■ Unless a system is pushed

beyond its normal capacity, change will not occur

– Salience Matters■ Change is best when

movement is purposeful and tied to the behavior being change How Neuroplasticity Changes the Brain. (2019). Retrieved from https://www.linkedin.com/pulse/how-

neuroplasticity-changes-brain-jurie-rossouw

Richard, T., & Bice, E. (2019). What does Neuroplasticity have to do with swallowing therapy? Spoiler

alert: Everything! [Podcast]. Retrieved from https://www.mobiledysphagiadiagnostics.com/057-ed-

bice-m-ed-ccc-slp-what-does-neuroplasticity-have-to-do-with-swallowing-therapy-spoiler-alert-

everything%E2%80%A8/

Adaptation

■ In order to learn a new skill and achieve adaptation and neuroplasticity high repetitions are required

■ Principles of adaptation: – When you take a break there is a period of de-adaptation – When you re-start the exercise you re-learn the movement– The rest breaks help to get faster, more neuroplastic changes

SWALLOWING & RESPIRATION

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* Swallow and respiratory event occur within 2 seconds of the swallow

* Cessation in respiration during a swallow

* Most single swallows are both preceded and followed by expiration (71-100% of healthy individuals)

* An inspiratory/inspiratory pattern becoming a dominant pattern is associated with high incidences of aspiration during a MBSS

Swallowing and Breathing Relationship Coughing Physiology

■ Cough and swallowing are sensorimotor behaviors that involve highly coordinated sequences of structural movements that require reconfiguration of the ventilatory breathing pattern (Bolser, Poliacek, Jakus, Fuller, & Davenport, 2006; Davenport, Bolser, & Morris, 2011; Troche, Brandimore, Godoy, et al., 2014)

■ Can be triggered on command (voluntarily) or in response to a sensory stimulus (reflexively)

■ The effective production of voluntary and reflex cough requires timely coordination of the respiratory and laryngeal systems during three phases:

– First phase of cough is the inspiratory phase– Second compression phase during which the vocal folds adduct– Third expiratory muscles are contracting which then results in high

expiratory flows once the glottis opens

SWALLOWING EXERCISES:

Richards, T., & Levy, R. (2017). Exercises, Exercises, and more Exercises! Evidence-Based Treatment for Every Swallowing Impairment [Podcast]. Retrieved from https://www.mobiledysphagiadiagnostics.com/013-rebecca-levy-m-s-ccc-slp-exercises-exercises-more-exercises-evidence-based-treatment-for-every-swallowing-impairment/

Effortful Swallow

■ Directions: – As you swallow push hard with the tongue against the hard palate and squeeze your neck

and throat muscles hard as you swallow (Logemann, 1999)

■ What it does:– Increases posterior tongue base movement to facilitate bolus clearance. (Huckabee &

Steele, 2006)– Achieves overload by high effort, may facilitate long-term adaptations and improved

swallowing function (Clark & Shelton 2014) – Lengthens laryngeal vestibule closure, improved pharyngeal response duration, UES

opening– Airway is protected longer, offering a smaller window of opportunity for material to be

aspirated (Hind & Nicosia, 2001)

Mendelsohn Manuever

■ Directions: – Put your hand on your throat and feel when you swallow. You can feel your Adam’s apple

move up. Now, when you swallow I want you to hold your Adam’s Apple up for a few seconds, squeezing your throat and neck muscles and not letting go (Logemann, 1999)

■ What it does:– Significantly increases maximal vertical hyoid displacement during swallowing Bulow et al.,

1999; Ding et al., 2002; Hind et al., 2001; Lazarus et al., 1993; Logemann, 1999).– Positively affects displacement and duration of the hyoid movement. hyolaryngeal elevation

and hyolaryngeal excursion increased after 2 weeks of using only the Mendelsohn■ 20 treatments incorporating 30 to 40 Mendelsohn maneuvers seem to have a rehabilitative effect.

(McCullough, 2012)

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CASE STUDIES

Case Number 1: Anterior Cervical Neck Discectomy and Fusion (ACDF):■ Case History: 62 year old man, Patient went to doctor with axial

cervical pain, consistent with cervical myelopathy. Imaging showed stenosis of C4-C7 and spinal cord compression. Patient underwent a C4-C7 ACDF

■ Past Medical History: Meige syndrome, torticollis, mild reactive airway disease, hypertension

■ Meige Syndrome: Rare neurological movement disorder, involuntary contractions of muscles of jaw and tongue and involuntary muscle spasms of muscles around the eyes

– https://rarediseases.org/rare-diseases/meige-syndrome/

■ Swallow Status: After 2 MBSS’s he was placed on a puree and nectar thick liquid diet

ACDF:

■ Involves removing a damaged disc to relieve spinal cord or nerve root pressure

■ Risks include vagal neuropathy including superior laryngeal nerve, recurrent laryngeal nerve and pharyngeal plexus issues

■ Early swallowing issues are likely to include aspiration, incomplete epiglottic inversion, increased pharyngeal wall thickness, decreased stripping wave and PES opening

Recommendations:

■ Diet Recommendations:– Continue Puree and nectar thick liquid diet

■ Swallow Strategies:– ½ tsp bite size boluses– Self feed– Avoid distractions– Dry re-swallow 3-4 times after each bite of food/sip– Eat slowly

■ Should this patient receive therapy?– Yes!

Swallow Therapy:

■ Upgraded diet to mechanical soft and nectar thick liquids

■ Used sEMG to identify coordination of swallow

■ Worked on different bolus sizes and textures, focusing on function and coordination of swallowing rather than strength

■ Patient participated in over 15 swallowing therapy sessions

Recommendations:

■ Diet Recommendations:– Upgraded diet to soft solids and thin liquids

■ Swallow Strategies:– Avoid distractions– Oral care– Alternate solids/liquids– Take 2 swallows for each bite of food

■ Should swallow therapy continue?– Maybe….but yes..

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ACDF Case Continues:

■ Decreased frequency to 1x/week instead of 2x/week

■ Focusing on larger boluses, including puree consistency

■ Discharged on a regular and thinliquid diet; patient will always be at risk for aspiration secondary to we did a feeS?

Case Number 2: Brainstem stroke

■ 59 year old male, had a brainstem stroke at outside facility in 2016. Received inpatient rehabilitation in 2016. Discharged home end of 2016.

■ PMH: CABG x2, diabetes, multiple TIA’s

■ MBSS at outside facility current swallow status: NPO

Brainstem Stroke

■ Typically multisymptomatic due to location of cranial nerves in nuclei

■ The brain stem mechanisms contributing to the sequential and rhythmic motor events involved in swallowing

■ Bilateral and/or asymmetric pharyngeal paresis

Swallow therapy:

■ Patient participated in 13 therapy sessions in 2017 with inconsistent attendance.

■ Completed swallowing exercises including masako, hard swallows and tongue based exercises

■ Continued to expectorate saliva into cups throughout the day

■ Continued NPO with ice chips only

■ Was discharged because of non-compliance with appointments

Recommendations:

■ Diet Recommendations: – Begin oral diet of nectar thick liquids and soft foods– Continue to supplement using feeding tube (family wanted it

out!)

■ Swallow Strategies:– Stay upright, eat slowly– Dry re-swallow every 5 bites, wait until throat feels clear

before swallowing again– Cough after every 2-3 bites

■ Is swallow therapy recommended? – Yes!

Therapy continued:

■ Patient participated in 12 therapy sessions

■ Focused on improving strength and coordination of swallow, using sEMG

■ Caregiver had feeding tube removed despite recommendation

■ Patient continued to eat soft diet and nectar thick liquids, with a lot of protein shakes

■ Patient was admitted to hospital andtherapy ceased

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Recommendations:

■ Diet Recommendations: – Continue oral diet of nectar thick liquids

and soft foods– May do ice chips in between meals, after

oral care

■ Swallow Strategies:– Stay upright, eat slowly– Dry re-swallow every 5 bites, wait until

throat feels clear before swallowing again– Cough after every 2-3 bites

■ Is swallow therapy recommended? – Yes!

Case Number 3: Head and Neck Cancer

■ Case History: – 62 year old male, diagnosed with Head and neck cancer of the left

aryepiglottic fold with invasion into the thyroid cartilage and vocal cords in January of 2018.

– Underwent chemotherapy and radiation starting 2/1/18, ended 3/23/18. Had 35 fractions of radiation and 7 chemotherapy treatments.

■ Social Situation:– History of frontal lobe injury (TBI) after a motor cycle accident, he is very

anxious

■ Dysphagia status:– At baseline, no complaints of difficulty swallowing– Patient was seen throughout chemotherapy and radiation and by mid-

treatment was using his feeding tube for nutrition– Post-treatment odynophagia, and coughing with thin liquids and nectar

thick liquids

Head and Neck Cancer Treatment:Chemotherapy:

■ Designed to slow or stop the growth of rapidly dividing cancer cells in the body, amplifies effect of radiation• Side effects:

• Taste changes, fatigue, nausea, vomiting, hair loss, and mouth sore

Radiation:

■ Directed from a machine outside the body to shrink tumors, destroy cancer cells and alleviate cancer-related symptoms• Side effects:

• Xerostomia, mucositis, dysphagia, odynophagia, complex nutritional needs, body image challenges, psychosocial challenges

Head and Neck Cancer:

■ Swallowing and speech functioning could regress during radiation due to:– Edema

– Reduced salivary flow

– Increased fibrosis of the musculature

Recommendations:

■ Diet Recommendations: – Begin pleasure feeds of puree and nectar thick liquids

■ Swallow Strategies:– Sit upright, eat slowly, no TV while eating– Alternate solids/liquids– Dry re-swallow 2-3 times per bite– Oral Care

■ Should this patient participate in swallow therapy?– Yes!

Head and Neck Cancer Case...Continued

■ Patient came to therapy, working with sEMG to improve strength, coordination of swallowing

■ Goal to complete 75-100 swallows per day

■ Barriers to therapy: odynophagia, ongoing GI distress, motivation, ongoing pain and fear of swallowing

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Recommendations:

■ Diet Recommendations: – Continue small quantities of puree and

thin liquids and/or ice chips

■ Follow up with MD– Patient was placed on a short course of

steroids to decrease inflammation

■ Continued with swallow strategies

■ Does this patient need therapy?– Yes!

Head and Neck Cancer Case Continued: ■ Patient was seen for 23 Outpatient therapy visits prior to

discharge

■ Tolerating soft solid diet and thin liquids

■ Focused on increasing oral intake, tolerance and safety

■ Reviewed risks of penetration/aspiration with patient given current functional status

■ Patient stops by SLP’s office saying he’s eating everything without any problems

Questions and discussion: Works Cited: ■ Atkins BZ, Petersen RP, Daneshmand MA, Turek JW, Lin SS, Davis RD. Impact of oropharyngeal dysphagia on long-term outcomes of lung transplantation.

Ann Thorac Surg. 2010;90(5):1622-8.

■ Buchholz DW. Clinically probable brainstem stroke presenting primarily as dysphagia and nonvisualized by MRI. Dysphagia. 1993;8(3):235-8.

■ Burkhead, L. M. (2009). Applications of Exercise Science in Dysphagia Rehabilitation. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 18(2), 43. doi:10.1044/sasd18.2.43

■ Clark HM, Shelton N. Training effects of the effortful swallow under three exercise conditions. Dysphagia. 2014;29(5):553–63.

■ EMST150. (2019). Cough dysfunction in the management of patients with dysphagia- By Michelle Troche, PhD, CCC-SLP - EMST150. [online] Available at: https://emst150.com/2019/02/09/cough-dysfunction-in-the-management-of-patients-with-dysphagia-by-michelle-troche-phd-ccc-slp/ [Accessed 24 Feb. 2019].

■ Gross RD, Atwood CW, Grayhack JP, Shaiman S. Lung volume effects on pharyngeal swallowing physiology. J Appl Physiol. 2003;95(6):2211-7.

■ Hind JA, Nicosia MA, Roecker EB, Carnes ML, Robbins J. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys Med Rehabil. 2001;82:1661–1665.

■ How Neuroplasticity Changes the Brain. (2019). Retrieved from https://www.linkedin.com/pulse/how-neuroplasticity-changes-brain-jurie-rossouw

■ Huckabee ML, Cannito MP. Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia. 1999;14(2):93-109.

■ Jean A. Brain stem control of swallowing: neuronal network and cellular mechanisms. Physiol Rev. 2001;81(2):929-69.

■ Kris Stutchbury & Alison Fox (2009) Ethics in educational research: introducing a methodological tool for effective ethical analysis, Cambridge Journal of Education, 39:4, 489-504, DOI: 10.1080/03057640903354396

■ Lever, T., Cox, K., Holbert, D., Shahrier, M., Hough, M., & Kelley-Salamon, K. (2007). The Effect of an Effortful Swallow on the Normal Adult Esophagus. Dysphagia, 22(4), 312-325. doi: 10.1007/s00455-007-9107-2

Works Cited Continued■ Martin-harris B, Brodsky MB, Michel Y, Ford CL, Walters B, Heffner J. Breathing and swallowing dynamics across the adult lifespan. Arch Otolaryngol Head Neck Surg.

2005;131(9):762-70.

■ McCoy, Y. and Wallace, T. (2019). The adult dysphagia pocket guide. 1st ed. Pleural Publishing.

■ Mccullough, Gary. (2014). One Step Back and Two Steps Up and Forward: The Superior Movements of Research Defining the Utility of the Mendelsohn Maneuver for Improving UES Function. Perspectives on Swallowing and Swallowing Disorders (Dysphagia). 23. 5. 10.1044/sasd23.1.5.

■ O'Rourke, MD, A. and Davidson, K. (2018). Swallowing Dysfunction After Cervical Discectomy & Fusion.

■ Pamela Smith, P. (2019). The Supposedly unsolvable sliding tile puzzle of dysphagia management - Dysphagia Cafe. Retrieved from https://dysphagiacafe.com/2019/03/03/supposedly-unsolvable-sliding-tile-puzzle-dysphagia-management/

■ Pearson, W. and Molfenter, S. (2018). Anatomic and Physiologic Targets For Intervention.

■ Pitts, T., Bolser, D., Rosenbek, J., Troche, M., & Sapienza, C. (2008). Voluntary cough production and swallow dysfunction in Parkinson's disease. Dysphagia, 23, 3, 297-301. Epubahead of print.

■ Radiation therapy for head and neck cancer. (1, January 1). Retrieved March 10, 2015, from http://www.cancercenter.com/head-and-neck-cancer/radiation-therapy/?source=GOOGLPPC&channel=paid search&c=paid search:Google:Non Brand:Broad:radiotherapy for head and neck cancer:Broad&OVMTC=Broad&site=&creative=41478371481&OVKEY=radiotherapy for head and neck cancer&url_id=190233033&adpos=1t2&device=c&gclid=CjwKEAiAjsunBRCy3LSlz_PJqCgSJACJY7yKkJPQeJaa3GGRPfUncHFPIi-EcoUWfLWtaXzJm__LFRoCunvw_wcB

■ Richard, T., & Bice, E. (2019). What does Neuroplasticity have to do with swallowing therapy? Spoiler alert: Everything! [Podcast]. Retrieved from https://www.mobiledysphagiadiagnostics.com/057-ed-bice-m-ed-ccc-slp-what-does-neuroplasticity-have-to-do-with-swallowing-therapy-spoiler-alert-everything%E2%80%A8/

■ Richards, T., & Levy, R. (2017). Exercises, Exercises, and more Exercises! Evidence-Based Treatment for Every Swallowing Impairment [Podcast]. Retrieved from https://www.mobiledysphagiadiagnostics.com/013-rebecca-levy-m-s-ccc-slp-exercises-exercises-more-exercises-evidence-based-treatment-for-every-swallowing-impairment/

■ Suzuki M, Asada Y, Ito J, Hayashi K, Inoue H, Kitano H. Activation of cerebellum and basal ganglia on volitional swallowing detected by functional magnetic resonance imaging. Dysphagia. 2003;18(2):71-7.

■ What is cancer? (1, January 1). Retrieved March 10, 2015, from http://www.cancercenter.com/what-is-cancer/

■ Wheeler hegland KM, Huber JE, Pitts T, Sapienza CM. Lung volume during swallowing: single bolus swallows in healthy young adults. J Speech Lang Hear Res. 2009;52(1):178-87.