Dysphagia Treatment
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Transcript of Dysphagia Treatment
DYSPHAGIA TREATMENT
How do I treat dysphagia?
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
LINGUAL MUSCLES
Your tongue is comprised of both intrinsic and
extrinsic muscles.
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.
INTRINSIC MUSCLES OF THE TONGUE
Transverse
Vertical
Superior longitudinal
Inferior longitudinal
TRANSVERSE
Origin: tongue septum, median portion
Insertion: mucosa at sides of tongue
Action: elongates, narrows, thickens tongue, lifts
the sides.
Innervation CN XII
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
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
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.
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
EXTRINSIC MUSCLES OF THE TONGUE
Styloglossus
Genioglossus
Hyoglossus
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.
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.
HYOGLOSSUS
Origin: greater cornu of hyoid bone.
Insertion: posterior half of the side of the tongue.
Action: depress and retracts tongue.
Innervation: CN XII.
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.
INTRINSIC MUSCLES OF MASTICATION
Temporal
Masseter
Internal pterygoid
External pterygoid
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).
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).
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.
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)
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
MUSCLES OF THE SOFT PALATE
Levator veli palatine
Tensor veli palatine
Uvula
Glossopalatine
Pharyngopalatine
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)
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)
UVULA
Origin: posterior nasal spine; palatal aponeurosis
(anterior)
Insertion: mucous membrane of uvula
Action: raises and shortens the uvula.
Innervation: CN X (pharyngeal plexus)
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)
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)
MUSCLES OF THE PHARYNX
Reflex:
Peristalsis reflex: propels the bolus to the esophagus
Sensory and motor innervation CN IX, X, XI
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
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)
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)
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)
CRICOPHARYNGEAL
Origin: sides of cricoid cartilage.
Insertion: posterior median raphe of pharynx.
Actions: contracts pharynx.
CN X (pharyngeal plexus)
PHARYNGEAL LEVATOR MUSCLES
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)
SALPINGOPHARYNGEAL
Origin: lower edge of eustachian cartilage.
Insertion: muscous membrane of pharynx.
Action: elevates pharynx.
CN X (pharyngeal plexus)
INTRINSIC MUSCLES OF THE LARYNX
Lingual-laryngeal connection=CN XII
Reflexes:
Glottal Effort Closure Reflex which generates the
airway.
Reflexive throat clearing/cough reflex.
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)
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)
POSTERIOR
Origin: posterior surface of cricoid cartilage.
Insertion: muscular process of arytenoid cartilage.
Action: rotates arytenoid, abducting vocal
processess.
CN X (recurrent laryngeal nerve).
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).
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).
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).
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).
EXTRINSIC MUSCLES OF THE LARYNX
Reflexes:
Laryngeal elevation reflex: epiglottal ROM
Laryngeal depression reflex: epiglottal recoil speed.
SUPRAHYOID
STYLOHYOID
Origin: styloid process of the temporal bone.
Insertion: body of the hyoid bone.
Action: elevates and draws hyoid bone backward.
CN VII
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).
MYLOHYOID
Origin: mylohyoid ridge of mandible.
Insertion: hyoid bone and median raphe.
Action: raises and projects hyoid bone and tongue.
CN V.
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.
INFRAHYOID
Unsupervised cup drinking and straw usage.
Goes with larynx muscles.
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.
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
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
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.
MUSCLES OF FACIAL EXPRESSION
Control levels:
Cortical (conscious): middle brain
Brainstem (oral stage swallow)
QUADRATUS LABIL SUPERIOR
Origin: frontal process maxilla; lower margin of
orbit; zygomatic bone.
Insertion: upper lip at midline.
Action: elevates upper lip
CN VII
ZYGOMATIC MINOR
Origin: canine fossa of the maxilla.
Insertion: angle of mouth, upper lip.
Action: elevates portion of upper lip.
CN VII.
ZYGOMATIC MAJOR
Origin: zygomatic bone.
Insertion: angle of mouth; upper lip.
Action: draws corner of mouth up and back.
CN VII.
RISORIUS
Origin: fascia over masseter.
Insertion: skin at angle of mouth.
Action: retracts corner of mouth.
CN VII.
DEPRESSOR ANGULI
Origin: oblique line of mandible.
Insertion: angle of mouth, lower lip.
Action: depresses angle of mouth.
CN VII.
QUADRATUS LABII INFERIOR
Origin: oblique line of mandible (anterior).
Insertion: lower lip at angle of mouth.
Action: depresses and retracts lower lip.
CN VII.
MENTAL
Origin: incisive fossa of mandible.
Insertion: integument of chin.
Action: raises and protrudes lower lip.
CN VII.
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.
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.
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.
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.
CRANIAL NERVE V: TRIGEMINAL
Motor
Mastication
HLE
Tenses velum
o Sensory
o cheek
o anterior 2/3 tongue (not taste)
**(trouble chewing)
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).
CRANIAL NERVE VII: FACIAL
Motor
Lip closure
Buccal tone
HLE
Sensory
Taste anterior 2/3 of tongue
Salivation
**dry mouth, decreased lip closure
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.
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
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.
CRANIAL NERVE XII: HYPOGLOSSAL
Motor
Tongue motility
HLE
**decreased laryngeal elevation
**no sensory component
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.
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
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*
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*
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*
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*
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*
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*
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)
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.
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.
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.
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.
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.
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)
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.
INTERVENTIONS
Exercises
Mendelsohn Manuever
Masako
Shaker
Oral manipulation exercises
Effortful swallow
Cheek/lingual with resistance
Chewing
Weighted bolus
Swallow trials
Suck-swallow
IOPI
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)
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.
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).
ORAL MANIPULATION EXERCISES
Resistance/Coordination.
Cheese cloth
Toothette
Gauze
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)
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)
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.
CHEWING
Texture
Viscosity
Cold
Sour
WEIGHTED BOLUS
Add viscosity
Thickened liquids/pudding through straw
SWALLOW TRIALS
Challenging boluses-find a safe, challenging
consistency to increase strength.
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
STRETCHES
Myofascial release
Beckman program
MODALITIES
Biofeedback (sEMG)
NMES (VitalStim, Eswallow)
Thermal-Tactile Stimulation
Pressure Biofeedback (IOPI)
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).
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.
TREATMENT
DPNS (Deep Pharyngeal Neuromuscular
Stimulation)
Thermal Tactile Stimulation
EMST (Expiratory Muscle Strength Training)
LSVT (Lee Silverman Voice Treatment)
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)
MANEUVERS/POSTURES
Mendelsohn
Chin Tuck
Head Turn
Supraglottic
Super Supraglottic
Head back
Side lying
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)
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.
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)
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)
HEAD BACK (CHIN UP)
Gravity assistance.
Helps lingual deficits.
Not for use with delayed pharyngeal swallow or
poor airway closure.
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)
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)
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.
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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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.
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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.
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