CMDS674 dysphagia part 2 PDF

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Professor Maggie-Lee Huckabee's Lectures on Compensatory Techniques for Dysphagia ...

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CMDS 674 Dysphagia and related disorders: Management Part 2 Compensatory strategies Postural strategies  Designed to change dimensions of pharynx and bolus flow  USE: change the way the bolus travels through pharynx  Need to evaluate on VFSS  Chin tuck -most researched o Drop chin to chest o Widen vallecular space, reservoir to contain bolus in proximal pharynx WRONG o Main effect -drop chin position anterior structure more posterior, encourages improved airway protection o Pre-swallow pooling or pyriform residual -BAD  Drop chin, collapses pyriform sinuses  Head rotation o MLH likes this o Difficulty squeezing pharynx o Turns pharynx to decrease lumen of pharynx --> squeeze less o Geniohyoid pulls hyoid ---> cricopharyngeus o Provides improved bolus flow through distal pharynx when non-compliant UES o Try weak side first  Head tilt o No research, described in textbooks as appropriate for head and neck cancer patients who lose part of tongue o Get the bolus to go to one side  Side lying o Described anecdotally -appropriate for few pts. o Use for pts with dense weakness on one side -use gravity o MLH exp -not helpful, spinal pts only  Neck extension -looking up o Pt with oral phase impairment -transfer bolus out of oral cavity o Disadvantages UES opening as FOM muscles stretched o May help, not often used Airway protection  Supraglottic swallow o Voluntary airway protection instead of voluntary brain stem response o Pen/asp pt o Forcing adduction before swallowing -hold breath before swallowing o Works well for some pts -head and neck cancer -clearing supraglottic penetration  Super-supraglottic swallow o Supraglottic swallow paired with effortful swallow -bolus flow and airway protection Bolus control techniques  3-second prep: delayed pharyngeal swallowing o Taking onset of pharyngeal response made voluntary o 3-2-1 swallow, 'swallow when i tell you to swallow' -group swallow  Lingual sweep -tongue clears oral cavity o Food pocketing o Reminder to use tongue or finger to get food out

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Cyclic ingestion o Reminding patients that they don't clear -extra swallow  Volume and rate of bolus delivery o Slow down eating o Example: spoon with a hole in it o Some pts eat fork -things fall through o Tachyphagia -eating too fast -right cortical stroke, TBI o OT has weights that can strap on -reminder to slow down o Straws for slowing liquids, hole in straw slows even more o Coffee cup -cover half the hole (inside cup) DONT do toddler's cup  Dry swallows o Bowl of food and empty bowl  Take a bite from this bowl, take a bite from empty bowl  Reminder to dry swallow Sensory enhancement  Thermal-tactile stimulation -comp more than rehab  Temperature o Very cold  Strong flavours  Carbonation  Slurp and swallow -not in public, some head and neck pts o Suck bolus into pharynx and then swallow -airway protection needed All techniques  As a clinician, multiple compensatory methods isn't going get carried out o Patient: why am i do it?  Short term fix, need to move away from them quickly  Potential to hinder recovery, may help, keep oral intake in  Tx planning -careful balance of keeping lungs safe and neurosensory stimulation, maladaptive behaviours  Compensatory and rehab unless old frail  Safe until we fix the problem

Diet Modification Postural strategies  Designed to change dimensions of pharynx and bolus flow  USE: change the way the bolus travels through pharynx  Need to evaluate on VFSS  Chin tuck -most researched o Drop chin to chest o Widen vallecular space, reservoir to contain bolus in proximal pharynx WRONG o Main effect -drop chin position anterior structure more posterior, encourages improved airway protection o Pre-swallow pooling or pyriform residual -BAD  Drop chin, collapses pyriform sinuses  Head rotation o MLH likes this o Difficulty squeezing pharynx o Turns pharynx to decrease lumen of pharynx --> squeeze less o Geniohyoid pulls hyoid ---> cricopharyngeus

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Provides improved bolus flow through distal pharynx when non-compliant UES Try weak side first  Head tilt o No research, described in textbooks as appropriate for head and neck cancer patients who lose part of tongue o Get the bolus to go to one side  Side lying o Described anecdotally -appropriate for few pts. o Use for pts with dense weakness on one side -use gravity o MLH exp -not helpful, spinal pts only  Neck extension -looking up o Pt with oral phase impairment -transfer bolus out of oral cavity o Disadvantages UES opening as FOM muscles stretched o May help, not often used Airway protection  Supraglottic swallow o Voluntary airway protection instead of voluntary brain stem response o Pen/asp pt o Forcing adduction before swallowing -hold breath before swallowing o Works well for some pts -head and neck cancer -clearing supraglottic penetration  Super-supraglottic swallow o Supraglottic swallow paired with effortful swallow -bolus flow and airway protection Bolus control techniques  3-second prep: delayed pharyngeal swallowing o Taking onset of pharyngeal response made voluntary o 3-2-1 swallow, 'swallow when i tell you to swallow' -group swallow  Lingual sweep -tongue clears oral cavity o Food pocketing o Reminder to use tongue or finger to get food out  Cyclic ingestion o Reminding patients that they don't clear -extra swallow  Volume and rate of bolus delivery o Slow down eating o Example: spoon with a hole in it o Some pts eat fork -things fall through o Tachyphagia -eating too fast -right cortical stroke, TBI o OT has weights that can strap on -reminder to slow down o Straws for slowing liquids, hole in straw slows even more o Coffee cup -cover half the hole (inside cup) DONT do toddler's cup  Dry swallows o Bowl of food and empty bowl  Take a bite from this bowl, take a bite from empty bowl  Reminder to dry swallow Sensory enhancement  Thermal-tactile stimulation -comp more than rehab  Temperature o Very cold  Strong flavours  Carbonation  Slurp and swallow -not in public, some head and neck pts o Suck bolus into pharynx and then swallow -airway protection needed

All techniques  As a clinician, multiple compensatory methods isn't going get carried out o Patient: why am i do it?  Short term fix, need to move away from them quickly  Potential to hinder recovery, may help, keep oral intake in  Tx planning -careful balance of keeping lungs safe and neurosensory stimulation, maladaptive behaviours  Compensatory and rehab unless old frail  Safe until we fix the problem...