Dysphagia Treatment

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DYSPHAGIA TREATMENT How do I treat dysphagia?

description

I hope someday to present on dysphagia.

Transcript of Dysphagia Treatment

Page 1: Dysphagia Treatment

DYSPHAGIA TREATMENT

How do I treat dysphagia?

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MUSCLES OF THE SWALLOW

To treat the dysphagia, you must understand how

the SYSTEM works.

We treat the swallowing system, not the specific

signs and symptoms.

We treat the muscle dysfunction, not the aspiration or

penetration.

Information for Slides 3-71 taken from DPNS Manual by Karlene Stefanakos and VitalStim manual by Yorick Wijting

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LINGUAL MUSCLES

Your tongue is comprised of both intrinsic and

extrinsic muscles.

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INTRINSIC MUSCLES

Shapes the tongue

Reflexes

Tongue Base Retraction-propels bolus into pharynx

Reflexive lingual groove-maintains cohesive bolus for

pharyngeal transfer.

Innervated by CN XII

No sensory pathways, all motor.

Sensory is CN V, VII, IX

XII meets with above nerves at nucleus solitarius in the

brainstem.

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INTRINSIC MUSCLES OF THE TONGUE

Transverse

Vertical

Superior longitudinal

Inferior longitudinal

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TRANSVERSE

Origin: tongue septum, median portion

Insertion: mucosa at sides of tongue

Action: elongates, narrows, thickens tongue, lifts

the sides.

Innervation CN XII

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VERTICAL

Origin: superior surface of tongue near tip edges.

Insertion: inferior surface of the tongue.

Action: assists in TBR posterior depression

(cohesive bolus, propels bolus.)

Innervation CN XII

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SUPERIOR LONGITUDINAL

Origin: septum of tongue, submucosoa near

epiglottis.

Insertion: sides of tongue

Action: widens, thickens and shortens tongue,

raises tongue tip and edges; forms concave

dorsum.

Establishes lingual-dental connection.

A-P pattern.

Innervation CN XII

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INFERIOR LONGITUDINAL

Origin: hyoid bone; inferior surface of base of

tongue.

Insertion: apex of tongue.

Action: wides, shortens tongue; creates convex

dorsum, depresses teeth.

A-P pattern-assists in propulsion of the bolus.

Innervation CN XII.

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EXTRINSIC MUSCLES OF THE TONGUE

Give movement to the tongue.

Tongue retraction-primitive, protective reflex.

Styloglossus with glossopalatine generate posterior lingual elevation.

Reflexes:

Tongue base retraction-propels bolus into pharynx.

Reflexive lingual groove-maintain cohesive bolus for pharyngeal transfer.

Reflexive protective retraction-prevents pharyngeal infiltrate, or premature lingual spillover during mastication.

Innervation: CN XII

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EXTRINSIC MUSCLES OF THE TONGUE

Styloglossus

Genioglossus

Hyoglossus

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STYLOGLOSSUS

Origin: inferior portion of the styloid process of the

temporal bone.

Insertion: lateral border of the tongue.

Action: elevates rear of tongue; retracts protruded

tongue during mastication.

Innervation: CN XII.

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GENIOGLOSSUS

Origin: upper mental spine on lingual surface of the

mandible.

Insertion: Lingual fascia, dorsum of tongue and

body of hyoid bone.

Action: alternate fibers work to depress, retract and

protrude tongue.

Innervation: CN XII.

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HYOGLOSSUS

Origin: greater cornu of hyoid bone.

Insertion: posterior half of the side of the tongue.

Action: depress and retracts tongue.

Innervation: CN XII.

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INTRINSIC MUSCLES OF MASTICATION

Reflex: jaw jerk reflex-generates rotary mastication pattern. (Returns jaw from lateral to midline).

Mastication Patterns:

Rotary-normal.

Vertical-no lateral jaw movement, jaw jerk reflex absent (trigeminal affected.)

Suck-swallow-primitive, motoric innervation, oral XII, pharyngeal X Absent O-M pattern-bilateral destruction of CN motor lines V,

X, XII.

Tonic bite: Contraction of temporal, masseter and internal pterygoid bilateral deficit muscles exterior pterygoid, platysmus, digastric, mylohyoid, geniohyoid.

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INTRINSIC MUSCLES OF MASTICATION

Temporal

Masseter

Internal pterygoid

External pterygoid

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TEMPORAL

Origin: temporal fossa and the whole of the

covering fascia.

Insertion: anterior borders of mandibular ramus and

coronoid process.

Action: raises and retracts the mandible.

Innervation CN V (mandibular division).

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MASSETER

Origin: lower edge of the zygomatic arch

(superficial) medial edge of the zygomatic arch

(deep).

Insertion: lateral surface of the angle of the jaw;

lateral surface of the ramus.

Action: raises the mandible against the maxilla.

Innervation: CN V (mandibular division).

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INTERNAL PTERYGOID

Origin: lateral pterygoid plate; slips from the

palatine bone; maxillary tuberosity.

Insertion: ramus and able of mandible.

Action: raises the mandible and protrudes the jaw.

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EXTERNAL PTERYGOID

Origin: upper head arises from the infratemporal

fossa and greater wing of the sphenoid bone; lower

head arises from the lateral aspect of the lateral

pterygoid plate of the sphenoid bone.

Insertion: mandibular condyle and the disc of the

joint of the jaw.

Action: depresses mandible and draws mandible

forward and sideways. (additional mandible

depressors: platysma, digastric posterior,

mylohyoid, geniohyoid.)

Innervation: CN V (mandibular division)

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MUSCLES OF THE SOFT PALATE

Reflex: Palatal Reflex-generates velopharyngeal

closure.

Functions of velopharyngeal closure:

Maximize nutritional intake

Provide passage of bolus

Cease nasal inhalation

Triggered by anterior faucial arches

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MUSCLES OF THE SOFT PALATE

Levator veli palatine

Tensor veli palatine

Uvula

Glossopalatine

Pharyngopalatine

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LEVATOR VELI PALATINE

Origin: apex of the petrous portion of the temporal

bone; eustachian tube

Insertion: aponeurosis of soft palate

Action:

Raises soft palate to meet posterior pharyngeal wall

Dilates eustachian tube orfice

Innervation: CN X (Pharyngeal plexus)

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TENSOR VELI PALATINE

Origin: scaphoid fossa; medial pterygoid plate

spine; posterior border of hard palate.

Insertion: palatine aponeurosis; eustachian tube.

Action:

Tenses the soft palate

Opens the eustachian tube during swallowing

Innervation: CN V (mandibular division)

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UVULA

Origin: posterior nasal spine; palatal aponeurosis

(anterior)

Insertion: mucous membrane of uvula

Action: raises and shortens the uvula.

Innervation: CN X (pharyngeal plexus)

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GLOSSOPALATINE

Origin: merges with transversus and superficial mm

of side and undersurface of tongue

Insertion: palatin aponeurosis

Action:

Raises posterior portion of tongue

Constricts isthmus of fauces

Depresses side of palate

Innervation: CN X (pharyngeal plexus)

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PHARYNGOPALATINE

Origin: posterior thyroid cartilage; aponeurosis of

pharynx

Insertion: aponeurosis of the soft palate

Action:

Depresses the soft palate

aids in elevating larynx and pharynx

Constricts faucial isthmus

Innervation: CN X (pharyngeal plexus)

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MUSCLES OF THE PHARYNX

Reflex:

Peristalsis reflex: propels the bolus to the esophagus

Sensory and motor innervation CN IX, X, XI

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SUPERIOR CONSTRICTOR

Origin: Lower posterior border of medial pterygoid

plate; pterygomandibular ligament and raphe;

mylohyoid ridge of the mandible; mucous

membrane of oral cavity; sides of tongue.

Insertion: Posterior median raphe of pharynx.

Action: Contracts pharynx; aids movement of food

bolus toward the esophagus.

CN X-Pharyngeal Plexus

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MIDDLE CONSTRICTOR

Triggers Peristalsis

Origin: both cornua of hyoid bone; stylohyoid

ligament.

Insertion: posterior median raphe of pharynx.

Action: contracts pharynx; aids movement of food

bolus toward esophagus.

CN X (pharyngeal plexus)

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INFERIOR CONSTRICTOR

Triggers peristalsis

Origin: inferior side of cricoid cartilage; obliques

line of thyroid cartilage.

Insertion: posterior median raphe of pharynx.

Action: Contracts pharynx; aids movement of food

bolus.

CN X (pharyngeal plexus)

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VELOPHARYNGEAL SPHINCTER

Origin: midline of soft palate.

Insertion: posterior median raphe of pharynx.

Action: protrusion and elevation of portion of

pharyngeal wall; aids in forcing soft palate

posteriorly.

CN X (pharyngeal plexus)

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CRICOPHARYNGEAL

Origin: sides of cricoid cartilage.

Insertion: posterior median raphe of pharynx.

Actions: contracts pharynx.

CN X (pharyngeal plexus)

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PHARYNGEAL LEVATOR MUSCLES

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STYLOPHARYNGEAL

Origin: base of styloid process of temporal bone.

Insertion: mucous membrane of pharynx and

thyroid cartilage.

Action: elevates and widens pharynx.

CN IX (only group of muscles to be innervated by

IX)

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SALPINGOPHARYNGEAL

Origin: lower edge of eustachian cartilage.

Insertion: muscous membrane of pharynx.

Action: elevates pharynx.

CN X (pharyngeal plexus)

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INTRINSIC MUSCLES OF THE LARYNX

Lingual-laryngeal connection=CN XII

Reflexes:

Glottal Effort Closure Reflex which generates the

airway.

Reflexive throat clearing/cough reflex.

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CRICOTHYROID

Origin: anterior and lateral surfaces of arch of

cricoid cartilage.

Insertion: caudal border of the thyroid cartilage;

anterior surface of lower cornu of thyroid cartilage.

Action: draws thyroid down and forward; elevates

cricoid arch; lengthens, tenses vocal folds.

CN X (superior laryngeal nerve)

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CRICOARYTENOIDS LATERAL

Origin: superior borders of cricoid cartilage.

Insertion: anterior surface of muscular process.

Action: draws arytenoids forward; aids in rotating

arytenoids; tenses and adducts vocal folds.

CN X (recurrent laryngeal nerve)

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POSTERIOR

Origin: posterior surface of cricoid cartilage.

Insertion: muscular process of arytenoid cartilage.

Action: rotates arytenoid, abducting vocal

processess.

CN X (recurrent laryngeal nerve).

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INTERARYTENOIDS TRANSVERSE

Origin: posterior surface of arytenoid cartilage.

Insertion: posterior surface of opposite arytenoid.

Action: draws together arytenoid cartilages;

adducts vocal folds.

CN X (recurrent laryngeal nerve).

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OBLIQUE

Origin: base of one arytenoid cartilage at muscular

juncture.

Insertion: apex of the opposite arytenoid.

Action: draws arytenoid cartilages together.

CN X (recurrent laryngeal nerve).

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THYROARYTENOID

Origin: internal and inferior surface of the angel of

the thyroid cartilage.

Insertion: vocal process and anterior lateral surface

of the base of the arytenoid cartilages.

Action: draws arytenoids forward; shortens and

relaxes vocal folds.

CN X (recurrent laryngeal nerve).

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VOCALIS

Origin: inferior surface of the angle of the thyroid

cartilage.

Insertion: vocal process of the arytenoid cartilage

and vocal ligament.

Action: differentially tenses vocal folds.

CN X (recurrent laryngeal nerve).

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EXTRINSIC MUSCLES OF THE LARYNX

Reflexes:

Laryngeal elevation reflex: epiglottal ROM

Laryngeal depression reflex: epiglottal recoil speed.

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SUPRAHYOID

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STYLOHYOID

Origin: styloid process of the temporal bone.

Insertion: body of the hyoid bone.

Action: elevates and draws hyoid bone backward.

CN VII

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DIGASTRIC

Origin: anterior belly arises from internal aspect of

mandible close to midline, posterior belly arises on

medial side of mastoid process of temporal bone.

Insertion: intermediate tendon and the hyoid bone.

Action: elevates hyoid; depresses mandible.

CN V (anterior belly) CN VII (posterior belly).

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MYLOHYOID

Origin: mylohyoid ridge of mandible.

Insertion: hyoid bone and median raphe.

Action: raises and projects hyoid bone and tongue.

CN V.

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GENIOHYOID

Origin: internal surface of the mandible at the

inferior mental spine.

Insertion: anterior surface of the hyoid bone.

Action: draws tongue and hyoid bone forward.

CN XII.

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INFRAHYOID

Unsupervised cup drinking and straw usage.

Goes with larynx muscles.

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STERNOHYOID C1-C3

Origin: medial extremity of clavicle; superior and

posterior portion of the sternum; sternoclavicular

ligament.

Insertion: body of the hyoid bone, inferior surface.

Action: depresses hyoid bone.

CN XII.

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STERNOTHYROID C1-C3

Origin: superior and posterior portion of the

sternum and first costal cartilage.

Insertion: oblique line of thyroid cartilage.

Action: depresses the thyroid cartilage.

CN XII

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THYROHYOID

Origin: oblique line of the thyroid cartilage.

Insertion: body and greater cornu of hyoid bone.

Action: depresses hyoid bone or elevates larynx.

CN XII

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OMOHYOID C1

Origin: superior margin of scapula.

Insertion: inferior border of the body of the hyoid

bone.

Action: depress and retracts the hyoid bone.

CN XII.

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MUSCLES OF FACIAL EXPRESSION

Control levels:

Cortical (conscious): middle brain

Brainstem (oral stage swallow)

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QUADRATUS LABIL SUPERIOR

Origin: frontal process maxilla; lower margin of

orbit; zygomatic bone.

Insertion: upper lip at midline.

Action: elevates upper lip

CN VII

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ZYGOMATIC MINOR

Origin: canine fossa of the maxilla.

Insertion: angle of mouth, upper lip.

Action: elevates portion of upper lip.

CN VII.

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ZYGOMATIC MAJOR

Origin: zygomatic bone.

Insertion: angle of mouth; upper lip.

Action: draws corner of mouth up and back.

CN VII.

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RISORIUS

Origin: fascia over masseter.

Insertion: skin at angle of mouth.

Action: retracts corner of mouth.

CN VII.

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DEPRESSOR ANGULI

Origin: oblique line of mandible.

Insertion: angle of mouth, lower lip.

Action: depresses angle of mouth.

CN VII.

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QUADRATUS LABII INFERIOR

Origin: oblique line of mandible (anterior).

Insertion: lower lip at angle of mouth.

Action: depresses and retracts lower lip.

CN VII.

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MENTAL

Origin: incisive fossa of mandible.

Insertion: integument of chin.

Action: raises and protrudes lower lip.

CN VII.

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ORBICULARIS ORIS

Origin: a sphincteric muscle, driving from others of

the area, with no definite origins or insertions.

Action: closes mouth and puckers lip.

CN VII.

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BUCCINATOR

Origin: alvoelar ridges of maxilla and mandible;

pterygomandibular raphe.

Insertion: angle of the mouth mingling with fibers of

mm forming upper and lower lips.

Actions: flattens cheek.

CN VII.

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PLATYSMA

Origin: thoracic fascia over pectoralis major, deltoid

and trapezious mm.

Insertion: mental protuberance of the mandible,

skin of cheek and corner of mouth.

Action: depresses mandible; aids in pouting

reaction; depresses corner of mouth, wrinkles skin

of neck and chin.

CN VII.

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CRANIAL NERVE V: TRIGEMINAL

Cutaneous pressure sensation to anteror 2/3 of tongue.

Thermal sensation hot/cold (safety).

Oral pain.

Cutaneous pressure sensation to all teeth, lips, chin, tongue, oral gums, hard and soft palate.

Salivary flow to major and minor glands.

Mouth opening (ext. pterygoids).

Mandible movement (temporalis, masseter, lat/med pterygoids)-moves mandible from side to side, elevate and protrude the jaw.

Innervates muscles of mastication.

Innervates floor muscles with aid in elevation of larynx (mylohyoid, ant. Belly of digastric)-depresses mandible, raises hyoid bone, stabilizes hyoid bone.

Aids in velopharyngeal closure (tensor veli palatine)-tenses soft palate prior to elevation.

Everything powered to contraction by V is mandibular (mastication).

Reflex: jaw jerk reflex.

Also innervates tensor tympani.

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CRANIAL NERVE V: TRIGEMINAL

Motor

Mastication

HLE

Tenses velum

o Sensory

o cheek

o anterior 2/3 tongue (not taste)

**(trouble chewing)

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CRANIAL NERVE VII: FACIAL

Taste receptors: anterior 2/3 of tongue (sweet, sour, salty).

Autonomic salivary glands (submandibulars and sublinguals).

Muscles of facial expression.

Lip shape and movement (orbicularis oris).

Closure of lips, cheeks and tongue (buccinator- aids in mastication by pressing the bolus laterally into the molar teeth, platysma-depresses the mandible, stylohyoid-elevates the hyoid, retracts hyoid distally, stapedius)-

Lip closure and prep of bolus for transfer (orbicularisoris).

Assists in hyoid bone elevation by raising and stabilizing the hyoid bone (mylohyoid, post belly of digastric).

Raises larynx for airway protection (epiglottic ROM).

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CRANIAL NERVE VII: FACIAL

Motor

Lip closure

Buccal tone

HLE

Sensory

Taste anterior 2/3 of tongue

Salivation

**dry mouth, decreased lip closure

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CRANIAL NERVE IX:

GLOSSOPHARYNGEAL

Taste receptors: posterior 1/3 of tongue (bitter).

Cutaneous pressure receptors, pain, thermal receptors, posterior 1/3 of tongue.

General cutaneous pressure receptors on palatal arch, soft palate, tonsils, mucous membrane of oropharynx, facial pillars and eustachian tube.

Autonomic secretory function of parotid salivary glands.

Assists in velopharyngeal closure to prevent reflux to nose at start of pharyngeal and end of oral phase through elevation of larynx and pharynx (stylopharyngeal-only muscle).

Upper pharyngeal constrictor fibers.

General cutaneous pressure/thermal/pain sensation of upper pharynx.

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CRANIAL NERVE IX:

GLOSSOPHARYNGEAL

Motor

Pharyngeal constriction

Pharyngeal shortening

Sensory

Taste/sensation posterior 1/3 of tongue, velum, faucial

arches, superior portion of pharynx

**no thermal stimulation, pharyngeal phase dysphagia

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CRANIAL NERVE XII: HYPOGLOSSAL

Only motor/no sensory pathways.

Tongue movement to posterior oral cavity (A-P propulsion pattern and lingual-alvoelar seal).

Creating bolus of proper size (int/ext muscles).

Collection of food partilces from lateral/anterior sulci, palate and molars (int/ext muscles).

Mixing bolus with saliva.

Alvoelar-palatal contact before swallow (inf./sup. Longitudinals, transverse, vertical).

Transporting bolus from mid-palate to posterior 1/3 of tongue (same as above).

Bolus transport to pharynx.

Raises and lowers the hyoid bone to protect the airway (supra/infra muscles).

Tongue base retraction and lingual groove reflex and reflexive protective retraction.

**if sensory decreased cannot get movement**

Genioglossus-depresses tongue and allows protrusion, hypoglossus-depresses and retracts tongue.

styloglossus-retracts tongue and draws up lateral borders to generate a chute

Geniohyoid-pulls hyoid anteriorly and superiorly widening the pharynx and pulling the larynx out of the bolus path.

Sternohyoid, omohyoid, sternothyroid and thyrohyoid (infrahyoids)-depress the hyoid after swallow or stabilizes the hyoid and elevates the larynx.

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CRANIAL NERVE XII: HYPOGLOSSAL

Motor

Tongue motility

HLE

**decreased laryngeal elevation

**no sensory component

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CRANIAL NERVE X: VAGUS

Taste receptors in pharynx and epiglottis/mucosa of valleculae.

Visceral sensation from pharynx and larynx.

Trachea.

Pharyngeal reflexes and pharyngeal constrictor muscles except sylopharyngeus. Superior, meidal and inferior constrictors to constrict the walls of the pharynx.

Salpinopharyngeus-elevates pharynx and larynx.

Laryngeal reflexes-all laryngeal muscles (intrinsic laryngeal muscles-oppose vocal cords to protect the airway during the swallow, cricothyroid tips thyroid cartilage anteriorly to help protect the airway during the swallow).

General sensation of abdominal viscera.

Upper esophageal sphincter (UES) function-cricopharyngeus inhibits reflux.

Peristalsis/motility of esophagus.

Velopharyngeal closure-all muscles of soft palate except tensor veli palatine (levator veli palatini elevates the soft palate).

Palatoglossus-elevates posterior part of the tongue and draws the soft palate onto the tongue. Palatopharyngeus tenses the soft palate, draws pharynx superiorly, anteriorly and medially.

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CRANIAL NERVE X: VAGUS

Motor

VP closure

TBR

UES closure/opening

Esophageal motility

Sensory

Posterior/inferior portions of pharynx

Larynx

Esophagus

**affects entire swallow

**recurrent laryngeal nerve can be affected by lung tumor or sx cervical vertabrae

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SWALLOW IN DETAIL

Hunger

Smell of food, empty stomach or electrolyte imbalance

informs hypothalamus of the need to eat.

Brainstem activates nucleii of CN VII and IX to promote

secretion of salivary gland juices to prep for bolus.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

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SWALLOW IN DETAIL

Chewing Bolus in mouth. CN VII ensures good lip seal (orbicularis oris) while CN

V relays sensory info to brainstem to constantly modify the fine motor control of bolus prep.

Motor activity to CN V, VII, IX, X, XII to create an enclosed environment within the mouth to prepare the bolus.

Cheeks provide tone (buccinator CN VII)

Soft palate tense and drawn down towards tongue (tensor veli palatini CN V and palatopharyngeus CN IX)

Tongue is drawn up towards the soft palate (palatopharyngeus CN X, styloglossus CN XII)

Hyoid bone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow movement of the mandible).

Bolus prepared by closing (temporalis, masseter, meial pterygoid, lateral pterygoid, CN V) and opening (mylohyoid and anterior belly of digastricCN V, geniohyoid CN XII &C1-C3.)

Bolus pushed around the mouth by actions of the tongue to create a consistent, homogenous texture (hypoglossus, genioglossus, styloglossus and 4 groups of intrinsic muscles of the tongue CN XII).

Taste sensations (CN VII and IX) provide info to cortex to stimulate areas of brain required to coordinate the swallow (insula and cingulate cortex).

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

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SWALLOW IN DETAIL

Volutary initiation

Once bolus is adequately prepared.

Soft palate elevates slightly (levator veli palatini and palatopharyngeus CN X).

Slight elevation of hyoid bone (suprahyoid muscles contracting on rigid mandible with slight relaxation of infrahyoid muscles.

Pharyngeal tube is elevated (stylopharyngeus CN IX, palatopharyngeus and salpingopharyngeus CN X).

Tongue delivers bolus to force bolus distally towards posterior wall of the pharynx in a “piston-like” manner using hard palate for resistance.

Sensation by CN XI and by CN X (pharyngeal plexus).

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

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SWALLOW IN DETAIL

Larngeal elevation

1st motion for tongue to propel bolus into oropharynx is elevated anterior direction toward roof of mouth (mylohyoid and anterior belly of digastric, CN V; stylohyoid and posterior belly of digastric CN VII; palatoplossus CN X; genioglossus, hyoglossus and styloglossus CN XII; geniohyoid CN XII and C1-C3) affects hyoid elevation in an anterior direction.

Soft palate seals off nasopharynx.

Superior constrictors begin medialization of the lateral walls.

Larynx elevated and moved anteriorly in relation to hyoid bone by thyrohyoid CN X.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

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SWALLOW IN DETAIL

Laryngeal closure During laryngeal elevation-vestibule closes and rises relative to thyroid

cartilage (cricothyroid and intrinsic laryngeal muscles CN X).

Opposition and elevation of arytenoid cartilages provide “medial curtains” of pyriform recesses (aryeppiglottic folds).

Pressure exerted on base of epiglottis causing it to tip and cover the laryngeal vestibule.

Medial constrictors (CN X) “strip” the pharynx by medialization following on from superior constrictors.

Palate descends (palatopharyngeus CN X), constrictors “strip” and tongue moves posteriorly (styloglossus CN XII) to close oropharynx.

Once the bolus has reached pharyngeal areas innervated by the internal branch of the superior laryngeal nerve swallow reflexive and cannot be stopped.

Anterior and elevated movement of larynx allows cricopharyngeus to be stretched (UES) and opened.

Inferior constrictor finishes medialization and bolus in esophagus.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

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SWALLOW IN DETAIL

Resting state

CN X

Cricopharyngeus resumes tonic state.

Glottic opens and larynx lowers.

If bolus present should cough.

Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and

the pharyngeal phase with all consistencies should take

1 second.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

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MOVEMENTS OF THE SWALLOW

o Larynx elevates 2 cm.

o Arytenoids contact base of epiglottis.

o Movement of tongue base is major pressure generating force of swallow.

o Posterior movement of tongue base 2/3 of distance to posterior pharyngeal wall, anterior bulging of pharynx covers approximately 1/3.

o UES opening involves: relaxation of cricopharyngeus, hyolaryngeal excursion (anterior movement of cricoidcartilage, bolus pressure.

o Typically no bolus hesitation in pyriform sinuses, the bolus head reaches UES as it opens.

o Saliva swallows usually 1-2 cc’s.

o During swallow-bolus divides fairly evenly between valleculaeand pyriform sinuses.

(14)

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COMPONENTS OF THE SWALLOW

Lip closure

Hold position/tongue control

Bolus preparation/mastication

Bolus transport/lingual motion

Initiation of the pharyngeal swallow

Soft palate elevation and retraction

Laryngeal elevation

Anterior hyoid excursion

Laryngeal closure

Pharyngeal stripping wave

Pharyngeal contraction

Pharyngoesophageal segment opening

Tongue base retraction

Esophageal clearanceRobbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N.,

Rosenbek J.C. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. JSLPR; 51: S276-S300.

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NEURAL PLASTICITY

The ability of the brain to change.

May result in behavorial change, not necessarily

vice versa.

Increasing evidence that N.P. Plays a substantial

role in centrally remodeling human function after

cerebral injury.

10 Principles: Use it or lose it; Use it and improve it;

Plasticity is experience specific; Repetition matters;

Intensity matters; Time matters; Salience matters;

Age matters; Transference; Inference.

Robbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N., Rosenbek J.C. (2008).

Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. JSLPR; 51: S276-

S300.

Page 86: Dysphagia Treatment

EXERCISE

Exercising healthy muscles=increased muscle tone.

Must overload or tax the muscle beyond the typical use. (Masako, Mendelsohn, effortful swallow, Shaker)

Swallowing rehab should imitate swallowing movements. Gains in strength generalize only to movement very similar to the exercise itself.

Accurate dosage and frequency unknown at this time for therapeutic levels.

Continue therapeutic exercise beyond levels needed for minimal functinoal swallow to maintain adequate functional reserve.

Develop strength training programs that meet the unique needs of patients with various diagnoses and/or swallowing impairments.

Clark, H.M. (2005). Therapeutic exercise in dysphagia management: Philosophies, practices and challenges. Swallowing and Swallowing Disorders, 24-27.

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EXERCISE

Muscles

Sarcopenia-age-related reduction in muscle fibers affecting Type II muscles more frequently.

Sarcomes=smallest functional unit in muscle contraction.

Contraction achieved when successful binding of proteins (actinand myosin) along the sarcomere causing the filaments to slide toward each other, creating shortening action of contraction.

Bundles of sarcomeres form muscle fibers.

Type I muscles: slow twitch, slow-oxidative fibers, fatigue-resistant, increased endurance (lingual lateralizers, jaw closers and in anterior tongue along with Type IIa).

Type II muscles: to propel and move bolus, fast twitch, larger, generate more force, easily fatigued. (tongue base, pharyngeal constrictors). No resistance=no need for type II muscles. Type IIa-fast oxidative/glycolytic.

Type IIb-greatest capacity for force, easily fatigued, uses glycogen.

Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and directions for future research. Dysphagia; 22: 251-265.

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EXERCISE

Exercise efforts that do not force the neuromuscular system beond the level of usual activity will not elicit adaptations.

Swallowing is submaximal, meaning it does not generate maximal force of muscles involved.

Reps: 8-12 most effective, 6-8=greater outcomes for generating strength.

“If improved swallowing is the goal, then swallowing would be the optimal training task.”

Transference might explain swallow imprvement with non-swallow exercise programs (EMST, lingual strengthening, LSVT, Shaker).

Combine strength and swallow treatments.

Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and directions for future research. Dysphagia; 22: 251-265.

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DYSPHAGIA THERAPY

Therapy helps return swallow function.

High intensity, aggressive therapy, not diet monitoring

helps patients regain swallow function.

Fewer complications arise when the swallowing system

is rehabilitated. (7).

Volitional swallowing involves bilateral neural

involvement, however some areas are hemisphere-

specific, 63% showing left dominance. (12)

Stroke patients pharyngeal representation in

undamaged hemispere increased significantly with

recovered swallow function. No changes were seen in

the damaged hemisphere. Recovery of swallowing

depends on compensatory reorganization. (13)

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DYSPHAGIA THERAPY

Weakness=decreased ability to use force.

Fatigue=weakness that becomes evident during

sustained force productions and over repeated

trials.

Tone=tendency of muscle tissue to resist passive

stretch.

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INTERVENTIONS

Exercises

Mendelsohn Manuever

Masako

Shaker

Oral manipulation exercises

Effortful swallow

Cheek/lingual with resistance

Chewing

Weighted bolus

Swallow trials

Suck-swallow

IOPI

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MENDELSOHN MANUEVER

Endurance/resistance. Can use a bolus.

Increases extent and duration of UES opening. (2)

Increases tongue-base/pharyngeal wall pressure and contact duration. (2)

Found to: increase peak pharyngeal pressure, UES contraction pressure, UES opening duration, duration of hyoid-UES separation, duration of laryngeal elevation, bolus transit time, hyoid excursion, distance from the hyoid bone and the thyroid cartilage, duration of contraction for various muscles. (4)

May facilitate clearance of residue.

Research: 20 normal subjects, 1 group given 5ml water swallows compared to 5 ml swallows with Mendelsohnmanuever. Able to sustain laryngeal elevation for 1.5 seconds or greater with increase in submental muscle group (anterior belly of the digastric, mylohyoid and geniohyoid.) (23)

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MASAKO

Resistance. Boluses not recommended.

Increases anterior motion of the posterior

pharyngeal wall at the level of the tongue base. (2)

Increases strength of tongue base and pharygeal

constriction, increases efferent drive of tongue

base.

Increased pharyngeal clearance.

Logemann recommends resistance exercises to

target weak structures, 10 reps, 10x/day.

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SHAKER

Resistance/Endurance.

Increased laryngeal anterior excursion and cross-

sectional opening of UES, improved swallow

function, decreased post swallow aspiration and

ability to return to various levels of oral intake. (2)

Increased strength through HLE and UES opening,

increased efferent drive of HLE and UES opening.

Targets anterior belly of the digastric, mylohyoid,

geniohyoid (hyoid elevation muscles).

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ORAL MANIPULATION EXERCISES

Resistance/Coordination.

Cheese cloth

Toothette

Gauze

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EFFORTFUL SWALLOW

Resistance/Endurance.

Increased: base of tongue retraction, tongue propulsive force, oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, longer duration of pharyngeal pressure and UES relaxation. (2)

Original goal to maximize posterior BOT motion resulting in improved bolus clearance from valleculae.

Increased force-generating ability of swallowing muscles. (4)

Increased strength for TB, HLE, PC and UES opening, increased coordination for HLE, PC, UES opening, Increased afferent (sensory) drive for TB, HLE, PC, UES opening, increased efferent (motor) drive for TB, HLE, PC, UES.

Evidence of early elevation of the hyoid at initiation of effortful swallow. (20)

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LINGUAL EXERCISES WITH RESISTANCE

Research: Progressive resistance training-8 week training, 3 sets, 10 reps 3x/day using IOPI, pressing bulb against palate using tip, blade and dorsum. Lingual strength increased as a result of non-swallowing strengthening exercises. Non-swallow strengthening exercises improved swallow with liquid bolus. Penetration/Aspiration Scores were reduced. (2, 10)

Research: tested strength and endurance-3 groups, 1 with no exercise, 1 with tongue depressors and 1 with IOPI. Exercises completed 5 days/week for 1 month, 10 reps 5x/day. Movement 4 directions (with T.D. and IOPI), left, right, protrusion and elevation. Greater change in both exercise groups. IOPI did not differ therapy. No change in endurance. Increased change in those with initial lower baselines. (9)

Page 98: Dysphagia Treatment

LINGUAL EXERCISES WITH RESISTANCE

BOT=base, between tip of uvula and valleculae.

Pull tongue straight back.

Yawn and hold most retracted.

Gargle and hold at most retracted (most BOT movement).

Increased strength with resistance, IOPI, oral

manipulation, swallow trials. Increased ROM with MFR,

stretch (Beckman), oral manipulation, swallow trials.

Increased coordination with oral manipulation, sensory

stim (Beckman, DPNS), suck-swallow, resistance,

swallow trials. Increased afferent drive with chewing

(cold/sour bolus), swallow trials, CN V, VII, XII.

Increased efferent drive with resistance, textured/chewy

bolus, weighted bolus with straw, swallow trials.

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CHEWING

Texture

Viscosity

Cold

Sour

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WEIGHTED BOLUS

Add viscosity

Thickened liquids/pudding through straw

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SWALLOW TRIALS

Challenging boluses-find a safe, challenging

consistency to increase strength.

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IOWA ORAL PERFORMANCE INSTRUMENT

IOPI uses a bulb and a hand-held device to

measure tongue strength.

Can be used as a therapeutic tool for visual

feedback.

Available at www.iopi.info

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STRETCHES

Myofascial release

Beckman program

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MODALITIES

Biofeedback (sEMG)

NMES (VitalStim, Eswallow)

Thermal-Tactile Stimulation

Pressure Biofeedback (IOPI)

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NEUROMUSCULAR ELECTRICAL STIMULATION

NMES-training and equipment through VitalStim

(FDA approved) or Eswallow.

Research: significant descent of the hyoid and

larynx at rest during maximal electrical stimulation.

Aspiration and pooling during swallowing were only

reduced during low sensory thresholds of

stimulation. Also greater hyoid depression during

stimulation at rest. (23).

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THERMAL TACTILE STIMULATION

“00” laryngeal mirror.

Stimulate faucial arches 4-5x then assess speed of

swallow.

Repeat when swallow slows.

Best dosage is 5x/day.

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TREATMENT

DPNS (Deep Pharyngeal Neuromuscular

Stimulation)

Thermal Tactile Stimulation

EMST (Expiratory Muscle Strength Training)

LSVT (Lee Silverman Voice Treatment)

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EMST

Exhale into a device with 1-way, spring-loaded

pressure valve, with valve at 60-80% of max

expiratory pressure.

Afferent stimulation to brain stem swallow centers

through peripheral sensory receptors in tongue and

oropharynx and strengthening oropharyngeal,

laryngeal and supralaryngeal muscles.

Improves ability to cough. (6)

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MANEUVERS/POSTURES

Mendelsohn

Chin Tuck

Head Turn

Supraglottic

Super Supraglottic

Head back

Side lying

Page 110: Dysphagia Treatment

CHIN TUCK

Research comparing chin tuck with thin liquids to NTL and HTL. Estimated $200/month for people on thickened liquids. More aspiration with chin tuck than with NTL or HTL. More adverse affects with thickened liquids (dehydration, UTI, fever). (3)

Narrows the airway, varies pressures in pharynx and UES during swallow, duration of timing of swallowing events and displacement of anatomical structures during the swallow.

Significant change in pharyngeal contraction pressure, duration of pharyngeal contraction pressure, larynx to hyoid bone distance, hyoid to mandible distance before the swallow, *angle between mandible to posterior pharyngeal wall, *angle between epiglottis to PPW of trachea, *width of airway entrance, *distance from epiglottis to PPW. (*all decreased). (4)

Chin tuck effective in 72% of patients studied. May be contraindicated in those with weak pharyngeal contraction pressure as it decreased pharyngeal contraction pressure and duration. (10/11)

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HEAD TURN

Head rotated to weaker side-Increased pharyngeal contraction pressure at the level of the valleculae and pyriformsinus on side of rotation, decreased UES resting pressure on side opposite rotation, increased duration from peak pharyngeal pressure in the pyriform sinus to the end of UES relaxation and increased UES anterior/posterior opening diameter.

Redirected bolus flow through the pyriform sinus on the strong side.

Concurrent decrease in UES resistance to bolus flow and prolongation of UES opening allowing bolus material to flow in a less obstructed manner through the UES and providing more time to clear all bolus material from the pharynx. (4)

o Closes weaker side, applies pressure to larynx with closer approximation of vocal chords to weak side, gravity holds food longer to stronger side for unilateral oral and/or pharyngeal dysphagia. If only pharyngeal dysphagia use head turn to weak side.

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SUPER SUPRAGLOTTIC SWALLOW

Facilitates timing and extent of laryngeal closure at specific levels of the larynx. (2)

For dysphagia secondary to reduced closure of the airway entrance. Increased UES relaxation prssureand duration of hyoid excursion and laryngeal movement, decreased time between UES opening and onset of hyoid movement and BOT movement time between UES opening and the onset of vocal fold adduction and laryngeal closure. (4)

It is indicated that the airway protective sequence happens early in the swallow.

13/15 subjects with CVA showed abnormal cardiac findings. (21)

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SUPRAGLOTTIC SWALLOW

For dysphagia accompanied by reduced or late

vocal cord closure or delayed pharyngeal swallow.

Changes timing of UES opening, duration and

timing of hyoid excursion and laryngeal closure,

timing of BOT movement.

Close vocal cords earlier in swallow, prolongs

hyolaryngeal excursion-before and during swallow

vocal fold closure.

Logemann recommends 10x/day x5 min with 5-6

swallows each time. (4)

13/15 subjects with CVA showed abnormal cardiac

findings. (21)

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HEAD BACK (CHIN UP)

Gravity assistance.

Helps lingual deficits.

Not for use with delayed pharyngeal swallow or

poor airway closure.

Page 115: Dysphagia Treatment

SIDE LYING

Alters gravity for residue.

May help clear residue after the swallow

(pharyngeal).

Before sit upright-cough to clear final residue.

Will hold residual bolus material to the pharyngeal

wall instead of allowing it to drop into the airway.

When pharyngeal contraction is reduced such that

residue is observed throughout the pharynx. (4)

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SENSORY STIMULATION

Sour bolus ½ lemon juice, ½ barium or water.

Helps to decrease time to initiate oral onset of the

swallow and reduce oral transit time. “Quicker”

swallow onset, more synchronous activation of

submental muscles, making the muscle contraction

stronger. (17/18)

Carbonated bolus.

Massage-improves circulation of blood and lymph

system, increases oxygenation of tissues, facilitates

waste removal, relieves pain (does not increase

strength or prevent atrophy or hypotonia.) (8)

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PEG TUBE AND FUNCTIONAL DYSPHAGIA

THERAPY (FDT)

Looked at 2 groups, 1 with PEG and 1 without.

Non-PEG group had significant post tx

improvement in functional oral intake.

Severe dysphagia with PEG showed significant

improvement, still required some PEG feedings.

More complications and increased mortality in PEG

group.

All patients benefited from FDT.

Becker R., Neiczaj R., Egge K., Moll A., Meinhardt M., Schulz RJ. (2010). Functional dysphagia therapy and PEG treatment in A clinical geriatric setting.

Dysphagia, Jan 26.

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PREDICTORS OF ASPIRATION: LANGMORE, ET

AL STUDY (1998)

Aspiration pneumonia is a 3 phase process:

Colonizes pathogenic bacteria in the oropharynx

Aspirates the bacteria into the airway

Unable to clear the material and then develops a bacterial

infection in the respiratory system

Risk factor for aspiration include:

Dependence on others for feeding

Multiple medical conditions

Smoking

Tube feeding

Dependence for oral care

Number of decayed teeth

Number of medicationsLangmore S, Terpenning M., Schork A., Chen Y., Murray J., Lopatin D., Loesche W. Predictors of aspiration pneumonia: How important is dysphagia?

Dysphagia 1998; 13: 69-81

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REFERENCES

1 Clark, H.M. (2005). Therapeutic exercise in dysphagia management: Philosophies, practices and challenges. Perspectives in Swallowing and Swallowing Disorders, 24-27.

2 Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.

3 Robbins, J.A., & Hind, J. (2008). Overview of results from the largest clinical trial for dysphagia treatment efficacy. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 17, 59-66.

4 Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009). Evidence-based systematic review: Oropharyngeal dysphagia behavioral treatments. Parts I-V. JRRD, 46, 175-222.

5 Becker R., Nieczaj R., Egge K., Moll A., Meinhardt M., Schulz R.J. (2010). Functional dysphagia therapy and PEG treatment in a clinical geriatric setting. Dysphagia, DOI: 10.1007/s00455-009-9270-8.

6 Burkhead L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: Principles, procedures and directions for future research. Dysphagia; 22: 251-265.

7 Carnaby G., Hankey G.J., Pizzi J. (2006). Behavioral intervention for dysphagia in acute stroke: A randomized control trial. Lancet Neurology; 5: 31-37.

8 Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. American Journal of Speech-Language Pathology, 12, 400-415.

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9 Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.

10 Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.

11 Shaker, R. et al. (2002). Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology, 122, 1314-1321.

12 Hamdy, S. (2006). Role of cerebral cortex in the control of swallowing. GI Motility online.doi:10.1038/gimo8.

13 Hamdy, S., Aziz, Q., Rothwell, J.C., Power, M., Singh, K., Nicholson, D., et al. (1998). Recovery of swallowing after dysphagic stroke relates to functional reorganization in the intact motor cortex. Gastroenterology, 115, 1104–1112.

14 Logemann, J.A. (1998). The need for clinical trials in dysphagia. Dysphagia, 13, 10-11.

15 Robbins, J.A. (2003, March). Oral strengthening and swallowing outcomes. Perspectives on Swallowing and Swallowing Disorders, 12, 16-19.

16 Steele, C.M. & Van Lieshout, P.H.H.M. (2004). Influence of bolus consistency on lingual behaviors in sequential swallowing. Dysphagia, 19, 192-206.

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17 Logemann, J.A., Pauloski, B.R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P.J. (1995). Effects of a sour bolus on oropharyngeal swallowing measures with neurogenic dysphagia. Journal of Speech and Hearing Research, 38, 556-563.

18 Palmer, P.M., McCulloch, T.M., Jaffe, D., & Neel, A.T. (2005). Effects of a sour bolus on the intramuscular electromyographic (EMG) activity of muscles in the submental region. Dysphagia, 20, 210-217.

19 Oh, B.M., Kim, D.Y., & Paik, N.J. (2007). Recovery of swallowing function is accompanied by the expansion of the cortical map. International Journal of Neuroscience, 117, 1215-1227.

20 Bulow, M., Olsson, R. & Ekberg, O. (1999). Videomanometric analysis of suprglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia, 14, 67-72.

21 Chaudhuri, G., Brady, S., Binnett, A., & Zanotti, E. (2005). Cardiovascular effects of the Shaker exercise in healthy adults. [Online] Available: http://www.marianjoy.org/stellent/groups/public/documents/www/mj_079551.hcsp

22 Ding, R., Larson, C.R., Logemann, J.A., & Rademaker, A.W. (2002). Surface electromyographic and electroglottographic studies in normal subjects under two swallow conditions: Normal and during the Mendelsohn maneuver. Dysphagia, 17, 1-12.

23 Ludlow, C.L. , Humbert, I., Saxon, K., Poletto, C., Sonies, B., & Crujido, L. (2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia, 22, 1-10.

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REFERENCES

Logemann, J.A. (1998). Evaluation and treatment of

swallowing disorders (2nd ed). Austin, TX: Pro-Ed.

Wijting Y., Freed M. (2009). Training Manual for the

use of Neuromuscular Electrical Stimulation in the

treatment of Dysphagia. www.ciaoseminars.com

Stefanakos K.H. (2002). Comprehensive DPNS: A

Dysphagia Workshop on Deep Pharyngeal

Neuromuscular Stimulation. The Speech Team Inc.