using exercise-based treatments in dysphagia intervention · 2020-02-20 · however, significant...
Post on 22-May-2020
5 Views
Preview:
TRANSCRIPT
USING EXERCISE-BASED TREATMENTS IN
DYSPHAGIA INTERVENTIONLORI BURKHEAD MORGAN, PHD, CCC-SLP
DEPARTMENT OF NEUROLOGY, MEDICAL COLLEGE OF GA AT AUGUSTA UNIVERSITY
DISCLOSURES
Financial
Paid educational consultant for Passy-Muir (but receives no royalties nor any financial benefit from discussing the
company’s products)
Financial compensation from Vanderbilt for this presentation
Nonfinancial
None
LEARNING OUTCOMES
Describe the structure and muscle fiber type associated with oropharyngeal musculature
Name two changes occurring in muscle with both conditioning and deconditioning
Define at least two theoretical principles that an “activity” must incorporate to be considered “exercise”
Identify at least two evidence-based treatments for swallowing rehabilitation that incorporate exercise science
principles
FOOD IS MEANT FOR MORE THAN EATING
START AT THE BEGINNING
NEUROMUSCULAR DEVELOPMENT
HOW MUSCLES WORK
SKELETAL MUSCLE COMPOSITION
Type I
Type II
IIa
IIb
Whole muscle contains blend with a predominance of one type
Slow-twitch, fatigue-resistant
Fast-twitch, fatigable
Adaptable, more efficient Type II fiber
Best force generation, but inefficient
OROPHARYNGEAL MUSCLE COMPOSITION
Type II is predominant
Type I, IIa, IIb, and hybrid fibers
Unique architecture
Regional differences in proportion and diameter of fiber types
Complex arrangement
(Kent, 2004)
OROPHARYNGEAL MUSCLE COMPOSITION
Muscular hydrostat
Tongue
Kier & Smith (1985)
Pharynx?
Kairaitis (2010)
MUSCULAR HYDROSTAT
Composed entirely of muscle with complex, three-dimensional fiber
arrangement
Maintains constant volume, as a fluid-based muscle structure
Shape alteration is dependent on redistribution of hydrostatic tissue pressure
Mechanical effect depends upon integrated activity of other muscles within the
organ
(Kairaitis, 2010)
WHY DO WE CARE?
Do contemporary exercise principles apply to these unique structures?
In what ways can we maximize function of these muscles?
FOR MORE DETAIL
Burkhead, Sapienza, & Rosenbek (2007)
FOR MORE DETAIL
March 2017, Perspectives of the ASHA Special Interest Groups
MUSCLE RESPONSE TO DECONDITIONING AND
CONDITIONING Conditioned:
John Burkhead – world record bench
press, 515 lbs.
Deconditioned:
Muscle-wasting, cachexia
DECONDITIONING
Peripheral
Atrophy
Loss in cross-sectional area
Decreased size
Force-generating capacity (“strength”)
Fiber-type shift
More easily fatigued
Sarcopenia
Age-related reduction in muscle fibers
Preferentially affects Type II
Central
Decreased neural activation
(“drive”)
Decrease in number of motor units
Remodeling of motor units
DECONDITIONING
Muscle atrophy & deconditioning
4-6 weeks bed rest (young, healthy) – up to 40% decrease in strength (Bloomfield,
1997)
Ill & elderly even more susceptible (Urso et al., 2006)
Canu, M. et al, 2019
“Vicious Loops”
in Sarcopenia
“VICIOUS LOOPS” IN DYSPHAGIA?
Decreased swallow
frequency
Deconditioning
Exacerbation of
dysfunction
Swallow
frequency/min
Normals 3
Dysphagia, - asp 1.16
Dysphagia, + asp .71
(Murray et al., 1996)
Dysphagia – NPO
“VICIOUS LOOPS” IN DYSPHAGIA?
Decreased
swallow frequency
Deconditioning
Exacerbation of
dysfunction
Swallow
frequency/min
Normals 3
Dysphagia, - asp 1.16
Dysphagia, + asp .71
(Murray et al., 1996)
Dysphagia – NPO
FUNCTIONAL RESERVE
The proportion of potential force-generating capacity in relation to the
effort required to perform a certain task
SARCOPENIA Age-related reduction in skeletal muscle mass
~0.5-1% loss in healthy individuals > 50 years old
Can be prevented or reversed by EXERCISE!
DECONDITIONING AND
NONFUNCTIONAL FUNCTION
Synkinesis
Involuntary movements that accompany voluntary movements
Results from rewiring of misfiring nerves
Functional decompensation (Crary, 1995)
Compensatory gestures that interfere with (rather than help) swallowing function
Excessive throat-clearing, tongue-pumping, etc.
CONDITIONING
Peripheral
Hypertrophy
Increased cross-sectional area
Increased force-generating capacity
Fiber-type shift
Increased endurance
Central
Increased neural activation (“drive”)
Increased number of motor units
4-8 weeks
6-12 weeks
***PLASTICITY***
Cortical reorganization
Blood flow changes
Peripheral muscle changes
IDENTIFY PHYSIOLOGY TO
TREAT PHYSIOLOGY
HISTORY OF DYSPHAGIA EVALUATION
Look, Listen, Feel
Much like phenology?
Imaging
Ultrasound
Scintigraphy
Videofluoroscopy
FEES
Manometry
HRM
MOST COMMONLY AVAILABLE OROPHARYNGEAL
EVALUATION TOOLS
Videofluoroscopy Endoscopy
EVALUATION:
PAST AND PRESENT PERSPECTIVES
PAST PRESENT
One test is superior to others Different techniques provide unique
information, can be complementary
Purpose of exam to document
aspiration
Purpose of exam to assess physiology
to determine compensations & Tx
options
SLP “domain” = lips to UES Swallowing is synergistic & influenced
by other systems (i.e., respiration,
esophageal function)
Are we using our instrumental swallowing
assessments as tools or weapons?
ARE PATIENTS “PUNISHED” FOR “FAILURE”?
“The patient failed the swallow test”
Pass vs. fail mentality
“Banished” to altered textures
“Punished” for physiologic disorder/disease
PURPOSE OF INSTRUMENTAL EXAMS?
PURPOSE OF EVALUATION
Underlying cause of dysfunction
Effect of compensations (temporary)
Method/manner of intake
Texture modifications
Effect of treatment techniques (long-term)
Ability to perform
Effectiveness of techniques
PROBLEM-BASED TREATMENT
Start with physiologically based assessment
What is causing the underlying problem?
Speed
Strength
Coordination
Movement pattern
Detective vs. Reporter
INSTRUMENTAL EXAMINATION
FEES
More specific visualization of structures
Portability (advantage in ICU, etc.)
No time limit for assessing therapeutic interventions
Videofluoroscopy
Broader view of overall swallow
Visualization of oral phase & hyolaryngeal excursion
Visualization of esophagus
DO OUR TOOLS BIAS US?
MBSS
FEES
Bedside/clinical exam
WNL OROPHARYNGEAL SWALLOW…
OR IS IT??
MBSS FINDINGS
PRESENTED WITH NECK MASS,
C/O COUGH WITH SWALLOW
FEES WNL
MBSS DETERMINES EXTENT OF
CERVICAL OSTEOPHYTES
MBSS AND FEES?
When one exam yields unusual findings that cannot be fully appreciated
When both esophageal and oropharyngeal symptoms are reported
When one exam does not answer all clinical questions
TAKE-HOME MESSAGE
EACH exam has different strengths
Choice of exam should be based on clinical question
Both may be warranted
Don’t just diagnose disorder –
think physiology!
• Coordination
• Speed
• Endurance
• Strength
• Various conditions
EVALUATION: LESSONS FROM
PHYSICAL REHABILITATION
Ambulation Swallowing
Leg strength/ROM O-P-L strength/ROM
Standing, balance Dry swallow, cough, breath-
hold
Few steps Few bites/sips
Greater distance, speed Greater volume, rate
Variety of terrain Variety of consistency &
situation
THE BIGGEST LESSON
FROM PHYSICAL REHABILITATION
One successful step ≠ ambulation
One successful swallow ≠ eating
WHAT ABOUT THE
CLINICAL/BEDSIDE EXAM?
CLINICAL/BEDSIDE EXAM
Value
Assess readiness, attentiveness, overall status
Examine structure/ROM
Observe with oral trials
It is NOT
Physiologic assessment (!!!!)
Assessment of airway compromise
Reliable
DEALING WITH CONSTRAINTS
Mobile FEES services/equipment
Mobile MBSS vans
Structured bedside screening/assessment tools
MASA
TORR-BSST
Yale Swallow Protocol
3-OUNCE WATER TEST
Been in the literature previously
Studied by Leder et al. (2008) in a different way as the “3-
Ounce Water Challenge”
Drink ALL at once without stopping
Fail = risk for aspiration, instrumental test recommended
Cannot or refuses to perform test
Stops/starts to complete ingestion of full amount
Coughs or chokes on water at any time
3-OUNCE WATER TEST
Clinical utility of the 3-ounce water swallow test (Suiter & Leder, 2008)
Concurrent FEES with 3-oz. water test, 3,000 pts, referral-based sample
96.5% sensitivity
48.7% specificity
51.3% false positive rate
Failure doesn’t necessarily mean patients cannot tolerate liquids
May result in over-referral
VALID ITEMS FOR SCREENING DYSPHAGIA RISK IN
PATIENTS WITH STROKE
Systematic review of four databases: 1985-March 2011
Search terms:
Eligibility
Homogenous stroke population
Comparison to instrumental exam
Clinical exam without equipment
Outcome measures of dysphagia or aspiration
Validity of screening items
Studies that met criteria evaluated for:
Methodology
Sensitivity, specificity, predictive capability(Daniels, Anderson, & Willson, 2012)
CVA Stroke deglutition disorders Dysphagia
VALID ITEMS FOR SCREENING DYSPHAGIA RISK IN
PATIENTS WITH STROKE
Total documents sourced = 832
Documents meeting criteria = 16
Inconsistent protocol methods across studies
Water swallows of various methods employed in most studies, but non-swallow
items also included
(Daniels, Anderson, & Willson, 2012)
VALID ITEMS FOR SCREENING DYSPHAGIA RISK IN
PATIENTS WITH STROKE
Cough & wet voice in response to a water swallow test appear to be ESSENTIAL
predictors of aspiration and should be part of a clinical screening
However, significant dysphagia can exist without aspiration, and lead to decreased
nutrition, hydration, quality of life
Conclusion: A cluster of swallowing and non-swallowing features may be the best to
achieve optimal sensitivity & specificity in the clinical screen
(Daniels, Anderson, & Willson, 2012)
ASSOCIATED INFLUENCES
Esophagus
Respiratory system
ESOPHAGEAL INFLUENCE
Esophageal disorders can
be perceived as pharyngeal
Esophageal dysmotility can
influence pharyngeal
function
DOING A COMPLETE FLUORO EXAM
Is Visualization Complete?
A-P view
Esophagus scan
Is Investigation Complete?
Compensatory maneuvers
Volume & texture trials
Introduction of a fatigue condition
Pill swallowing
• IV-D of the American College of Radiology (ACR) Practice Parameter Document
(2017) indicates:
✓ “An esophagram may be required.”
• Intro of the same document:
✓ “…a complete study may also include spot films…and an esophagram, as
symptoms of dysphagia are often poorly localized.”
ESOPHAGEAL EVALUATION IN MBSS
Section D-2 of ACR Practice Parameters:
✓ “…may need to be prematurely terminated if the patient demonstrates severe
aspiration (…below the sternal notch)…and does not respond to protective or
therapeutic maneuvers.”
Section D-3 of ACR Practice Parameters:
✓ “When aspiration does occur, the effect of maneuvers to limit or prevent
aspiration may be assessed.”
PREMATURE CESSATION OF MBSS
Section D-1 of ACR Practice Guidelines:
“If aspiration occurs, the patient’s response to aspiration and ability to
clear the aspirated materials and his or her response to the protective
and therapeutic maneuvers should be assessed wherever possible.”
PREMATURE CESSATION OF MBSS
RESPIRATION & SWALLOWING
Interrelated & Tightly Coordinated
Shared neural substrates
Central pattern generator (three “arms”) (Doty, Richmond, & Storey, 1967)
Peripheral inputs (input)
Interneurons (organization)
Motoneurons (output)
Structural & functional interdependence
Voice
Airway protection
Swallowing
RESPIRATION & SWALLOWING
Role of Subglottic Air Pressure & Lung Volume
Gross, Steinhauer, Zajac, & Weissler (2006)
Direct subglottic air pressure measured during normal swallowing (healthy single subject)
Gross et al. (2012)
Confirmed presence of deglutitive subglottic pressure generated by lung recoil
RESPIRATION & SWALLOWING
Swallowing-Breathing Coordination Training
30 HANC pts, chronic dysphagia
Respiratory-swallow training via biofeedback improved:
Coordination/phase patterning
Laryngeal-vestibular closure
BOT retraction
Pharyngeal clearance
Airway protection
(Martin-Harris et al., 2015)
THERAPEUTIC EXERCISE:
EXERCISE VS. ACTIVITY
NOT THIS
MASLOW’S LAW OF THE HAMMER
“I suppose it is tempting, if the only
tool you have is a hammer, to treat
everything as if it were a nail.”
Abraham Maslow,
American psychologist (1908-1970)
EXERCISE: WHAT IS IT?Strength, Timing, Coordination, ROM (Burkhead, Sapienza, & Rosenbek, 2007)
Intensity
• Overload principle
(> 60% MVC)
• Progressive resistance
• Volume & frequency of exercise
Specificity
• Do practiced tasks mimic
or relate to target
movements?
MOTOR LEARNING: WHAT IS IT?
Process for learning voluntary control of more automatic physiological processes
If swallowing is a sensory motor task, is motor learning part of retraining swallow
behaviors?
SURE!
MOTOR LEARNING
Performance is temporary
Learning is permanent change due to practice
Consistent, intense practice
MOTOR LEARNING
Cognitive Stage
Associative Stage
Autonomous Stage
Understanding task
Refining movement pattern
Developing independent,
transferable skill
Three-Stage Model
(Fitts & Poser, 1967)
WHAT QUALIFIES AS EXERCISE?
Exercise is activity that challenges the body beyond
its typical level of activity
Exercise that does not force the neuromuscular system beyond usual activity will not elicit an adaptation
Resistance training recruiting 60-75% effort is required to achieve the greatest improvement
AS YOUR MUSCLES GET STRONGER, THE
CHALLENGE MUST ALSO INCREASE TO
ELICIT CONTINUED IMPROVEMENT!
STRENGTH DEFINED
The force-generating capacity of a muscle
Lifting a heavy weight
Swallowing a large bolus of peanut butter
ENDURANCE DEFINED
The ability to continually produce force over a period of time
Marathon runner
Eating a meal
POWER DEFINED
Combination of strength & speed
Ability to exert force quickly in a “burst”
Jumping, sprint start
Strong, forceful BOT retraction
SPEED DEFINED
Maximal velocity achieved (how fast one can go!)
Sprinter
Swallowing liquids
COORDINATION DEFINED
All of the previous components mentioned working in
concert to efficiently and effectively perform functional
tasks
• Basketball player in a game
• Ballet dancer performing
• My husband ingesting a rack of ribs & a beer
SO HOW DO WE PROCEED?
Best judgment – based on literature, knowledge, experience, & common sense
Know limitations of the clinical and instrumental exam
SO HOW DO WE PROCEED?
Weigh risks vs. benefits
Risk of malnutrition/dehydration vs. aspiration
Pt wishes/QOL vs. risks of eating/drinking with dysphagia
Risks of NPO vs. risks of feeding
You may not be able to to eliminate risk, but how can you best minimize
patient risk/maximize safety?
ONCE THE PROBLEMS ARE IDENTIFIED…
PROBLEM-BASED TREATMENT
Start with physiologically based assessment
What is causing the underlying problem?
Speed
Strength
Coordination
Movement pattern
Detective vs. Reporter
REMEMBER….
THE CHALLENGE
• Critically evaluate & implement findings from research to solve
clinical problems
• Provide the best patient care possible
• Treatment must be both time-efficient & cost-efficient
EVIDENCE-BASED PRACTICE
Treatment should be based on:
• Best available evidence
• Patients wishes
• Clinician knowledge & experience
EXERCISE?
What?
Who?
Why? How?
When?
Which?
“BORROWING”
FROM PHYSICAL THERAPY &
ATHLETICS
THINK OUTSIDE THE BOX
…or the cage
SPECIFICITY
Work toward the end goal by working on movements and movement patterns you
wish to improve
“Best treatment for swallowing is swallowing”
Or is it?
IS INTENSE STRENGTHENING OUR ONLY HAMMER?
Studentbranding.com
NON-SWALLOWING EXERCISES
Expiratory Muscle Strength Training (EMST)
Chin Tuck Against Resistance (CTAR)
Lee Silverman Voice Treatment (LSVT)
Shaker Head Lift, Recline Exercise
Isometric Lingual Strengthening• IOPI
• SwallowSTRONG
EXERCISE: WHAT?
“Direct” vs. “indirect” exercises
Direct exercise
• Mendelsohn
• Effortful swallow
• Tongue hold swallow
(Masako)
• Etc.
Indirect exercise
• Shaker head lift
• Recline
• EMST
• Lingual
strengthening
SKILL VS. STRENGTH?
Maybe both?
Stronger muscles move more quickly (power)
Must have some base of strength for movement first
BRIDGING STRENGTH TRAINING AND FUNCTIONAL
PRACTICE
Historically common in PT/OT
Isolated training ➔ integrated movement
E.g., leg extensions ➔ gait training
Most effective in the weakest patients
SKILL-BASED TRAINING
Premise:
Swallowing utilizes submaximal strength
Integrated movements
Precision/speed/coordination
Specificity would underscore skill training concept
SKILL TRAINING
Targeted lingual precision, not just strength
Varying degrees of lingual pressures
(Steele et al., 2013)
SKILL TRAINING
Two main conclusions:
Tongue responds to task specificity (precision vs. strength)
To elicit carryover, perhaps training should include
integrated swallowing tasks
(Steele et al., 2013)
SKILL TRAINING
Swallowing-Breathing Coordination Training
30 HANC pts, chronic dysphagia
Respiratory-swallow training via biofeedback improved:
Coordination/phase patterning
Laryngeal-vestibular closure
BOT retraction
Pharyngeal clearance
Airway protection
(Martin-Harris et al., 2015)
SKILL TRAINING
Biofeedback in Swallowing Skill Training (BiSSkiT)
Uses sEMG biofeedback to train varying motor patterns that mimic eating
Goal altered based on pt performance
(Athukorala et al., 2014)
SEMG BIOFEEDBACK
One of the oldest evidence-based practices in dysphagia rehabilitation
(Haynes, 1976)
Outcomes superior with biofeedback when compared with “traditional” treatment alone
(Sukthankar et al., 1994; Crary, 2004; Huckabee & Cannito, 1999)
INTENSITY
There is no magic number
Work to challenge status quo
Strengthening: > 60% 1RM
Other parameter: Habit or motor pattern?
Eat 3x/day, exercise 3x/day??
EXERCISE: WHEN?
The sooner the better
“Use it or lose it” principle
(Kleim & Jones, 2008)
Early intervention can improve diet tolerance, airway protection, & overall nutrition**
(Emstahl et al., 1999; Carnaby et al., 2006)
Pre-treatment exercise beneficial in H&N cancer
(Kulbersh et al., 2006; Carroll et al., 2008)
EXERCISE: WHEN??
“OUR PATIENTS ARE TOO SICK”
If you do nothing, you will improve nothing
Function may only get worse as you “wait” for the patient to “get better”
Remember the concept of “vicious loops”
MAJOR CULPRITS IN THE ICU PATIENT
Systemic inflammatory response syndrome
Critical illness myopathy
Critical illness polyneuropathy
HR > 90 bpm
Body temperature, 36 or > 38°C
WBC count, 4000 cells/mm3
SIRS + infection = sepsis
Systemic Inflammatory Response
Syndrome (SIRS)
SIRS
Occurs in adults and children
Up to 50% of ICU pts on vent have SIRS
50-70% of those pts develop diffuse myopathy and polyneuropathy
SIRS
Results in:
Muscle weakness
Difficulty weaning from the ventilator
CRITICAL ILLNESS MYOPATHY (CIM)
& POLYNEUROPATHY (CIP)
Usually co-occurring
Presents as ventilator-weaning difficulty
Seen in 25-63% of pts on vent > 1 week
Sensorimotor with motor predominance
Limbs & respiratory muscle affected most
Cranial nerves usually spared
CRITICAL ILLNESS MYOPATHY (CIM)
Diffuse weakness
Diagnosed with EMG studies & biopsy
Type II muscle atrophy or undergo necrosis
“OFFENDERS” SPECIFICALLY IMPACTING
COMMUNICATION & SWALLOWING
Deconditioning
Endotracheal intubation
Tracheostomy
Ventilator dependency
DECONDITIONING NEGATIVELY IMPACTS STRUCTURE &
FUNCTION
Muscle atrophy
Reduced force-generating capacity
AKA “strength”
Lower endurance
WHAT ABOUT COMMUNICATION & SWALLOWING
IN THE ICU?
Intubation
Tracheostomy
Ventilator dependency
NPO
ENDOTRACHEAL INTUBATION
Bypasses use of upper airway
Disuse atrophy
Desensitization
Trauma to mucosa, particularly larynx
Cuff over inflation is common
AIRFLOW CHANGES WITH TRACHEOSTOMY
Airflow bypasses upper airway
Deflated cuff and/or fenestration can facilitate some upper airway airflow
AIRFLOW
NORMAL LARYNX (FOR REFERENCE)
Granuloma
Subglottic Stenosis
Glottic & Subglottic Trauma
POST-INTUBATION ULCERATION
WHAT CONTRIBUTES TO STRUCTURAL DEFICITS?
Prolonged intubation (>2 weeks)
Can happen quickly, not just in long-term intubation
(Whited, 1984; Colice, 1992; De Larminat et al., 1995)
Trauma due to movement/friction
INCIDENCE & PREVALENCE
Laryngotracheal injury in 95% (39/41) of previously intubated patients
(Stauffer, Olson, & Petty, 1981)
Dysphagia as high as 56% (27/48), with nearly half those pts aspirating silently
(Ajemian et al., 2001)
BUT WE CAN DO SOMETHING…
ARE OUR PATIENTS “TOO SICK”?
If you do nothing, you will improve nothing – function commonly gets
worse as you “wait” for the patient to “get better”
LESSONS FROM PHYSICAL THERAPY
Early intervention
ROM and facilitation are precursors to rehabilitating functional movement
EXERCISE: WHEN?
The sooner the better
Muscle atrophy & deconditioning
4-6 weeks bedrest = ~40% decrease in strength
(Bloomfield, 1997)
Ill & elderly even more susceptible
(Urso et al., 2006)
FIRST THINGS FIRST…
Restore the system to the most “normal” condition as possible
Passy-Muir Valve use (in-line ventilator use or trach alone)
APPROACHING ASSESSMENT
WITH EXERCISE PRINCIPLES IN MIND
“Hey, what do you say we
get this fella up for nice
walk? Yeah… I bet that
would feel good to
stretch in those legs! If
he falls, we can call PT
for a consult!”
Orthopedics?
“Give it a shot” mentality
Instrumental assessment not just a tool for
diagnosis of dysphagia – think physiology!
• Coordination
• Speed
• Endurance
• Strength
• Various conditions
EXERCISE: WHO?
What conditions would exercise NOT be appropriate for?
Traditionally taught to compensate for deficits rather than treat in
degenerative neuromuscular disease
Working to fatigue in such systems could prove detrimental
EXERCISE?
Disease states we used to treat only with compensation we are learning now
may respond to some forms of exercise
Strengthening in PD
Moderate exercise in ALS
Whole body moderate aerobic exercise benefits
Potential moderate bulbar muscle exercise benefits
(Plowman, 2015)
FUTURE DIRECTIONS IN
EXERCISE APPLICATIONS
Moderate exercise where we once thought it was “taboo”?
Skill vs. strength training?
Further investigation in applicability of modalities in conjunction with
physiologically sound exercise?
USEFUL THERAPEUTIC TOOLS
SEMG BIOFEEDBACK
The most effective, evidence-based tool available!
Detects muscular activity, provides graphic representation
Teaches control and challenges effort
(Huckabee & Cannito, 1999; Crary, 1995)
Effortful swallow Mendelsohn
SEMG – THE EVIDENCE
One of the oldest evidence-based practices in dysphagia rehabilitation
(Haynes, 1976)
Outcomes superior with biofeedback when compared with “traditional” intervention
alone
(Sukthankar et al., 1994; Crary, 2004; Huckabee & Cannito, 1999)
SEMG – THE EVIDENCE
Effective in a variety of populations
More cost-effective than “traditional” tx (faster recovery in fewer visits)
(Crary et al ., 2004)
HOW TO DO IT: SEMG BIOFEEDBACK
Use a smoothed, rectified signal
Obtain/observe baseline resting rate
Head neutral, relaxed
Address tension as necessary (e.g., massage, stretching, cuing)
Obtain amplitude of 3-5 baseline swallows
Determine training target based on goals
SEMG RESOURCES
Synchrony Dysphagia Solutions by ACP
Equipment “rental” along with clinician training & ongoing support
SEMG RESOURCES
Prometheus Group
sEMG alone can be used as
handheld device or coupled to a
monitor using gaming software.
SEMG GENERAL GUIDELINES
A great place to start:
Basic Concepts of Surface Electromyographic Biofeedback
in the Treatment of Dysphagia:
A Tutorial
(Crary & Groher, 2000)
LINGUAL STRENGTHENING DEVICE RESOURCES
IOPI (Iowa Oral Performance Instrument)
www.iopi.info
Swallow Strong
Formerly known as the MOST (Madison Oral Strengthening Therapeutic device)
Swallowsolutions.com
ISOMETRIC LINGUAL STRENGTHENING
Lingual strengthening*
Train at >60% of maximal effort for strengthening effect
Provides biofeedback on performance
ANOTHER LINGUAL STRENGTHENING OPTION
• Swallow Strong
(Next generation of the MOST-Madison
Oral Strengthening Therapeutic device)
• Mouthpiece with sensors coupled to
visual output device
LINGUAL STRENGTHENING –
THE EVIDENCE
8-week progressive resistance exercise with IOPI in older, healthy volunteers
100% increased their isometric pressures and also oral pressure during swallowing
tasks
5.1% volume increase in tongue bulk on MRI
(Robbins et al., 2005)
LINGUAL STRENGTHENING –
THE EVIDENCE
10 stroke pts with dysphagia 51-90 y.o. (6 acute, 4 chronic)
8-week progressive resistance with IOPI
10 reps, 3x/day, 3 days/wk at 60% on week 1, then 80% on weeks 2-8
All increased isometric pressures and oral swallowing pressures
Airway protection improved with liquids
Tongue volume increased on two subjects
(Robbins et al., 2007)
ISOMETRIC LINGUAL STRENGTHENING
Progressive Resistance Oropharyngeal Therapy Using the Madison
Oral Strengthening Therapeutic Device
(Juan et al., 2013)
Case study
56 y.o. female, 27 months s/p brainstem CVA
PEG dependent, expectorating saliva
“Traditional” treatment plus NMES in the home
ISOMETRIC LINGUAL STRENGTHENING
8 wks. Isometric Progressive Resistance Oropharyngeal Therapy (I-PRO)
10 reps anterior & posterior 3x/day, 3 days/wk.
5 wks. detraining
9 wks. maintenance (NO device)
Anterior & posterior tongue press to palate, 3 sets of 10, 3x/day, 1 day/wk.
ISOMETRIC LINGUAL STRENGTHENING
Isometric lingual pressures
Decreased some following detraining, with some rebound in anterior after
maintenance phase
Maximum oral pressures during swallowing
Some increases, particularly in anterior tongue
Bolus flow kinematics
Decreased residue, increased safety (PAS scores)
EMST – PRESSURE THRESHOLD DEVICE
EMST 150
www.EMST150.com
OTHER RESPIRATORY TRAINERS
The BreatherThreshold PEP
EMST – THE EVIDENCE
EMST compared to wet & dry swallows showed increased muscle activity
and hyoid excursion in healthy volunteers
EMST can improve muscle contraction as well as neuromuscular control of
suprahyoid muscle, which is important for laryngeal elevation/airway
protection
(Wheeler et al., 2007)
EMST – THE EVIDENCE
EMST can improve cough strength, pulmonary function, and vocal loudness as well as
swallowing function
(Troche et al., 2010; Pitts et al., 2009; Wingate et al., 2007; Chiara et al., 2006; Saleem et al., 2005)
WORKING OUT WITH EMST
3-5 sets of 10, 3-5 x/day at > 60% MEP
If unable to calculate 60% of MEP, can use perception of 6 on a 1-10 scale
(Morishita et al., 2013)
HOW TO DO THE SHAKER EXERCISES
Part 1: Sustained Hold
1. Lie flat on your back with no pillow under your head.
2. Lift your head to look at your toes.
3. Keep your shoulders flat on the floor/bed.
4. Hold this position for ___ seconds.
5. Release. Repeat 3 times and rest 1 minute between repetitions.
Part 2: Lift and Lower (same starting position as sustained hold)
1. Lift your head and look at your toes.
2. Let your head go back down with control.
3. Repeat 30 times.
4. Rest in between as needed.
5. Repeat 3 times a day. WARNING: Patients with neck problems (e.g., arthritis) may not be able to perform this exercise.
CHIN TUCK AGAINST RESISTANCE (CTAR)
Yoon, Khoo, & Rickard Liow (2014)
Seated upright
Press chin to chest against resistance
Alimed.com Alternativespeech.com
RECLINE EXERCISE
Head Lift Exercise performed at 45 degree angle vs. supine
Comparable outcomes
Easier to perform, reported more comfortable.
CTARCHIN TUCK AGAINST RESISTANCE(YOON ET AL., 2014; SZE ET AL., 2016)
ISO-SED (ISO Swallowing Exercise Device)
CTAR Ball
JOARJAW OPENING AGAINST RESISTANCE(WADA ET AL., 2012)
ISO-SED (ISO Swallowing Exercise Device)
LEE SILVERMAN VOICE THERAPY(LSVT)
ASHA, 2016
http://www.lsvtglobal.com/loud-certification
DOCUMENTATION
Clearly important
Should reflect function, not only
performance on exercises/tasks
DOCUMENTATION
We crave “numbers”
Numeric changes on certain measures may not translate to clinically
meaningful outcomes
Think about and document function in addition to “numbers”
EXAMPLE: “SKINNY FAT” CONCEPT
Who weighs more?
Who is more fit?
Who has better functional performance?
https://www.corehealthproducts.com/skinny-fat-to-lean-machine/
DOCUMENTATION
Intensity
Repetitions
Effort/resistance
DOCUMENTATION: INTENSITY
Depends upon the tool you are using
sEMG
Peak amplitude
Duration
Average amplitude
DOCUMENTATION: INTENSITY
Depends upon the tool you are using
EMST
Sets & reps against resistance
DOCUMENTATION: INTENSITY
Depends upon the tool you are using
Lingual strengthening
Peak pressure generated
Duration of pressure generation
Number of sets/reps completed at given goal
DOCUMENTATION: TYING IN FUNCTION
Repetitions
# of swallows in certain time frame if working on speed/initiation of swallow
Volume of food/liquid ingested safely
Factor of time?
Factor of volume?
DOCUMENTATION: TYING IN FUNCTION
If you do decide to document “numbers,” also document
functional gain or relate to eating/swallowing performance
DOCUMENTATION: TYING IN FUNCTION
Pt. able to ingest 4-oz. trial of
puree within 10 minutes
without oral residue and no
clinical s/s airway compromise.
DOCUMENTATION: TYING IN FUNCTION
Pt. triggered laryngeal elevation
within 1 second of attempt to
swallow tsp. of liquid on 6/10
trials. Cough observed only on
delinquent trials.
GOAL WRITING
Don’t focus on the device; however, targets measured by the device can be utilized
80% of effortful swallow attempts above threshold 3 μV above baseline peak
amplitude
Demonstrate increase in 3 kPa during 5 ml bolus pudding trials on 80% of attempts
GOAL WRITING
Although, best to focus on functional changes
Patient able to take 4-oz. trial of thin liquid without overt s/s of airway
compromise.
Patient able to ingest 4-oz. mechanical soft trial within 5 minutes with no oral
residue.
CASE EXAMPLES
Note the following:
Prior treatment had plateaued
Intensity and use of tools for progressively increasing resistance/challenge were key
in progress
Progress was dramatic in a relatively short period of time
CASE REPORT #1
60-y.o. man
Hx/o right CVA
Severe dysfunction,
silent aspiration
Pt carried “spit cup”
PEG dependent
1 yr. of IP & OP Tx
Referred for myotomy
CASE REPORT #1
• 8 weeks of intervention:
BOT and pharyngeal
strengthening & laryngeal
closure
• Used sEMG & NMES
• Pt resumed unrestricted
oral diet
• PEG removed
CASE REPORT #2
• Hx/o 2 left CVAs, DM, renal failure
w/ transplant, heart disease
• 4 months severe dysphagia
following C-spine surgery
• PEG dependent, frank aspiration
w/ ice chips
• In dysphagia tx 3x/wk at local
rehab
• Had ~1 yr Tx prior
CASE REPORT #2
• 16 weeks of intervention:
Oral & pharyngeal strength,
airway protection, timing
• Used EMST, isometric
tongue strengthening,
sEMG
• Unrestricted oral diet; chin
tuck with liquids
• PEG removed
FOOD IS MEANT FOR MORE THAN EATING
CELEBRATION OF CULTURE
Foodnavigator-usa.com
BE THAT MOTIVATOR FOR YOUR PATIENTS!
Encourage your patients!
Even the most motivated patients can do
juuuussst a little bit more if you push them
***REMEMBER***
STIMULUS MUST INCREASE IN PROPORTION TO STRENGTH FOR
CONTINUED IMPROVEMENT!
IN ALL THINGS…
Be a critical consumer of the research
Blend that with knowledge & experience
Look outside our field when necessary
i.e., When doing exercise, learn about “exercise”
Conduct focused, function-driven, purposeful treatment vs. “task-driven” treatment
THANK YOU FOR YOUR ATTENTION LORI_GATOR@YAHOO.COM
top related