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156 Cards in this Set
- Front
- Back
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What three questions need to be answered after the evaluation of the patient with an oropharyngeal swallowing problem?
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1. What type of nutritional management is necessary?
2. Should therapy be initiated and what type? 3. What specific strategies should be used? |
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The continuous goal of any treatment program is
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the reestablishment of oral feeding while constantly maintaining adequate hydration, nutrition, and safe swallowing
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A therapy regimen involves
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progressive exercise programs or sensory stimulation activites designed to improve oropharyngeal swallow physiology
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During and after each therapy session, the patient's performance should be evaluated in terms of _________.
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Quantitative measures
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The decision to provide therapy for a patient with dysphagia should be based on:
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the patient's potential for improvement or recovery of swallowing ability or longer maintenance of oral intake because of exercise.
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Patient characteristics to consider when deciding to initiate/planning therapy
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1. diagnosis
2. prognosis 3. reaction to compensatory strategies 4. severity of the patient's dysphagia 5. ability to follow directions 6. respiratory function 7. availability of caregiver support 8. patient motivation and interest |
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Patients will not include a particular food consistency in their diet unless the combined oral and pharyngeal transit time for swallow of that material is ______
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10 seconds or less
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The _____________ to swallow a single bolus of a particular consistency appears to be an important parameter in nutritional management, as well as ________
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Time taken, aspiration
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Nasogastric tubes are not often left in place for more than
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3-4 weeks
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Does the SLP decide on what type of non oral nutrition is appropriate?
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No -- except to discourage use of wide semiflexible feeding tubes
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Patients who aspirate more than ____ of a food consistency and are aware of it, will ___________
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10%, eliminate that food consistency from their diet.
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Compensatory treatment procedures are usually introduced first in ______
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the diagnostic procedure
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A patient who is aspirating more than _____ of every bolus, regardless of _______, should not be feeding orally
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10%, consistency
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Compensatory procedures _______ and ________ but do not _________
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1. control the flow of food
2. eliminate symptoms such as aspiration 3. necessarily change the phsyiology of the patients swallow |
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Compensatory treatment procedures are under the control of ______ and are used with patients who are _____ and _____. Compensatory procedures involve less/more muscle effort and do/do not fatigue the patient as quickly as some swallow exercises.
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1. the caregiver/clinician
2. all ages 3. cognitive levels 4. less 5. do not |
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Five types of compensatory strategies.
Go! |
1. postural changes
2. increasing sensory output 3. modifying volume & speed of food presentation 4. changing food consistency and viscosity 5. introducing intraoral prosthetics |
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No _________ improves swallowing in all patients
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single posture
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Before chosing a posture, the clinician must
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correctly diagnose the physiologic and anatomic disorder in teh patient's deglutition
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Changing the patient's head or body posture can be effictive in eliminating aspiration on liquids in ______ of dysphagic patients
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75%-80%
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Why are some patients unable to use postural strategies?
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Head stabilization devices or cognitive or physical constraints
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Postural techinques work by
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redirecting food flow and systematically changing pharyngeal dimensions
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True/False
Postural techniques are usually used temporarily until the patient's swallow recovers or direct therapy procedures to improve orophayrngeal motor function take effect |
true!
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Which two postures may be combined to achieve the best airway protection in some patients?
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Chin down and head rotation
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Before advising the patient to eat lying down, the patient's _____ should be observed radiographically. Why?
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straw drinking; to be sure the patient is creating suction in the mouth and not inhaling
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True or False
Patients who exhibit a buildup of residue in the pharynx with successive swallows are good candidates for the lying down posture. |
False!
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When using the lying down posture, what should the patient do at the end of the meal (before sitting up)?
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Cough
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Why is swallowing the best exercise for swallowing?
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Swallowing involves greater muscle contraction and generates greater pressure than speech, use of the mechanism may infact result in best muscle function
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True or False
The patient can discontinue using a postural strategy once he or she feels his or her swallowing has improved. |
False!
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Why are techniques to improve oral sensory awareness both compensatory and therapeutic?
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They are compensatory becasue they are under the control fothe caregiver and do not change the motor control of the swallow.
They are theraputic because using them changes the timing of the swallow by reducing OTT and pharyngeal delay |
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Sensory enhancement techniques include:
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1. increasing downward pressure of spoon on tongue when placing food
2. sour bolus 3. cold bolus 4. chewy bolus 5. ≥3ml bolus (larger volum) 6. thermal-tactile stimulation |
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______ and ______ are the most commonly used oral sensory awareness techniques to improve triggering of the pharyngeal swallow
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Thermal tactile stimulation, suck swallow
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An exagerrated suck-swallow involves
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increased vertical tongue-jaw sucking movements with lips closed
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Why is suck-swallow a good technique for patients with poor saliva control?
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It draws saliva to the back of the mouth
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Three ways to measure the effectiveness of sensory enhansement procedures in increasing oral sensory input
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1. duration of time from command to iniation of oral stage of swallow
2. ott 3. pharyngeal delay time |
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Thin liquids are most appropriate for which disorders?
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1. Oral tongue dysfunction
Reduced 2. tongue base retraction 3. pharyngeal wall contraction 4. laryngeal elevation 5. cricopharyngeal opening |
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Thickened liquids (yum!) are most appropriate for which disorders?
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1. Oral tongue dysfunction
2. Delayed pharyngeal swallow |
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Purees and thick foods as well as thickened liquids are most appropriate for which disorders/
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1. Delayed pharyngeal swallow
Reduced 2. laryngeal closure at the entrance 3. airway closure |
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Intraoral prosthetics can be an important therapeutic/compensatory procedure to improve swallowing in oral cancer patients who have lost _____ of oral tongue tissue
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compensatory; 25% or more
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What three disorders might benefit from intraoral prosthetics?
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1. loss of oral tongue tissue
2. bilateral hypoglossal paralysis 3. velopharyngeal deficits |
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A _______ lifts the soft palate into an elevated (closed) position in patients with velar paralyssi
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palatal lift prosthesis
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A ________ can be used in oral cancer patients with significant resection of the soft palate
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palatal obturator
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A _______ can be effective in patients with significant tongue resections or bilateral tongue paralysis
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palatal augmentation or reshaping prosthesis
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A ________ recontours the hard palate to interact with the remaining tongue, filling in areas of the hard palate that cannot be contacted.
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palatal reshaping prosthesis
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Without a prosthesis a patient has ______ and ____ and is incapable fo controlling food in the mouth or chewing and swallowing
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large oral cavity, very small tongue
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Construction on a palatal prosthesis should begin when? Why?
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4-6 weeks postoperatively
to prevent poor swallowing habits |
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The difference between therapy procedures and compensatory strategies is:
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Therapy procedures are designed to change swallow physiology
Compensatory procedures are designed to eliminate symptoms |
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Therapy procedures generally, but not always, require the patient to _______ and _____ to get the best effect.
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follow directions, practice independently of the clinician
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True or False
Indirect therapy involves exercise programs and swallows of saliva and liquids but not food. |
False
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True or False
If the patient is consistently aspirating more than 10% of the bolus, the clinician should consider indirect therapy procedures to improve muscle control and eliminate the risk of aspiration |
True
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True or False
Direct therapy involves presenting food or liquid to the patient to swallow while following specified instructions. |
True
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3 therapy techniques
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Oral motor control and ROM exercises
procedures to heighten sensory input swallow maneuvers |
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True or False
Bolus control and chewing exercises with gauze or food can be used to improve fine motor control of the tongue |
True
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Three types of oral motor control exercises
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ROM Tongue exercises
Resistance Exercises Bolus Control exercises |
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What aspects of tongue control do patients have difficulty with during swallowing? (4)
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1. lateralization during chewing
2. elevation to the hard palate 3. cupping around the bolus 4. a-p movement midline |
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Can ROM exercises be done to teach a patient to voluntarily close the airway?
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Yup
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In most cases, vocal fold exercises effect improvement within _____ weeks
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2-3
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True or False
Since the tongue base is an involuntary muscle, there are no exercises that can improve tongue base range of motion. |
False.
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Are pretend yawning, pretend gargling, and pulling your tongue back and the effortful swallow ROM exercises for the anterior tongue?
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Nope. Tongue base.
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What sort of improvement do you expect to see with the falsetto exercise? What is it?
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Improvement in laryngeal elevation.
Slide up & down the scale |
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In sensory-motor integration procedures, sensory stimulation can take a number of forms, namely 5 according to page 211 of your text. What are they?
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1. Downward pressure on tongue w/ spoon
2. increasing sensory characteristics of the bolus 3. providing a chewy bolus 4. thermal-tactile stimulation 5. providing a larger volume bolus |
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For some patients, the sensorimotor act of swallowing begins with _____
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the arm-and-hand action of the feeding act itself.
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Thermal-tactile stimulation should be done onlny when a delay in triggering the pharyngeal swallow has been defined radiographically on at least ____________. Why?
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two consecutive swallows. Some neurologically impaired pts exhibit a warm-up period
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____ of patients with a delay in triggering the pharyngeal swallow improve after thermal-tactile stimulation
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95%
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The purpose of thermal tactile stimulation is to heighten sensitivity for the swallow where?
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CNS
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The physician has ordered no oral feeding for the patient and you want to try thermal-tactile stim. What will you do?
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Saliva swallows. Stimulation will still stimulate swallow.
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If oral transit plus delay is greater than _____, it is abnormal.
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2 seconds
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Once the pharyngeal swallow starts to trigger, therapy may be expanded by:
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1. increasing amounts of material presented
2. changing the consistency/increasing thickness of food |
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In thermal-tactile stim, food is presented where?
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At the base of the faucial arches
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True or False
The supraglottic swallow closes the airway at the level of the true vocal folds during and after the swallow. |
False! Before and during the swallow.
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Which swallow closes the airway entrance before and during the swallow?
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Super-supraglottic swallow
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True or false
The effortful swallow increases posterior motion of the tongue base during the pharyngeal swallow, improving bolus clearing from the pyriform sinuses. |
False. Improves clearing from the valleculae.
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What does increasing the extent and duration of laryngeal elevation during the Mendelsohn maneuver do?
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Increases duration and width of UES opening.
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If the patient has reduced or late vocal fold closure, which swallow maneuver would you choose and why?
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The supraglottic swallow because a voluntary breath hold usually closes the VF before and during swallow
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If the patient has a delayed pharyngeal swallow, which swallow maneuver would you choose and why?
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The supraglottic swallow because it closes the VF before and during the delay
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If the patient has reduced closure of the airway entrance, which swallow maneuver would you choose and why?
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The super-supraglottic swallow because an effortful breath hold tilts the arytenoid forward, closing airway entrance before and during swallow, while the voluntary breath hold usually closes the vocal folds before and during swallow
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If the patient has reduced posterior movement of the tongue base, which swallow maneuver would you choose and why?
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The effortful swallow because the effort increases posterior tongue base movement.
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If the patient has reduced laryngeal movement, which swallow maneuver would you choose and why?
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The Mendelsohn maneuver because the laryngeal movement opens the UES and prolonging laryngeal elevation prolongs that opening.
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If the patient has a discoordinated swallow, which swallow maneuver would you choose and why?
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The Mendelsohn maneuver because it normalizes the timing of pharyngeal swallow events. How cool is that?
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True or False
Often voluntary maneuvers (swallow maneuvers) are used permanently to ensure safe and efficient swallowing. |
False.
Usually they are used temporarilty as the patient's swallow recovers, and are discarded as the physiology returns to normal |
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The effects of swallow maneuver on _____ or ______ and ________ or _______ are best observed using videofluoroscopy, because videoendoscopy does not allow visualization of these maneuvers _______ the swallow.
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safety or aspiration
efficiency or residue during |
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What is this patient doing?
1. Take a deep breath and hold your breath. 2. Keep holding your breath (cover your trach) 3. Keep holding your breath while you swallow. 4. Cough immediately after you swallow |
Supraglottic swallow
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True or False:
If the patient is able to follow directions correctly several times in therapy with food, then the procedure may be tried under fluoroscopy with some expectation of success. |
False. No food!
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True or False
The clinician should continue to provide verbal directions for each step of a swallow maneuver at all times. |
True
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Can you hold your breath and still have an open airway? Why or why not?
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Yes, by stopping chest wall movement. (revealed under fluorographic exam). Instruct patient to exhale slightly then hold.
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Another name for dump and swallow is ____. Why use it?
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extended supraglottic swallow. Pt. has sever reductions in tongue mobility and/or bulk; pharyngeal trigger is ok and airway closure is sufficient
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What is this patient doing?
1. hold the breath tightly. 2. put the entire 5-10 ml of liquid in your mouth 3. hold your breath and toss your head back, dumping the liquid into the pharynx as a whole 4. keep holding your breath and swallow 2-3 times as needed. 5. cough |
extended supraglottic swallow aka dump and swallow
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What is this patient doing?
1. hold your breath very tightly, bearing down. 2. Keep doing this as you swallow. 3. Cough! |
Super-supraglottic swallow.
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The patient has had a full course of radiotherapy to the neck. Which swallow maneuver would you probably use?
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Super-supraglottic swallow
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What is this patient doing?
1. as you swallow squeeze hard with all your muscles! |
Effortful swallow
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What is this patient doing?
1. swallow your saliva several times. pay attention to your neck. Can you feel something lifting and lowering? 2. now as you swallow, don't let your adam's apple drop. Hold it up with your muscles for several seconds. |
Mendelsohn maneuver
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What is this patient doing!
Hold the squeeze! |
Mendelsohn maneuver
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What's an apparatus to help the patient keep the mouth closed until the patient can do it automatically?
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A buccinator apparatus
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What's a prostheses that can help guide the mandible into proper alignment?
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A guide plane prosthesis
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True or False
Radiotherapy may increase fibrosis in the muscles of mastication, narrow the mouth opening, and restrict mandibular movement. |
True
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The ultimate design of an oral prosthesis depends on ______ as well as ______
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speech, swallowing
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Name 9 disorders that affect the oral preparatory phase of the swallow
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Reduced
1. labial closure 2. lateral ROM of tongue during mastication 3. buccal tension/scarring 4. lateral ROM of mandible 5. vertical ROM of tongue 6. tongue movement to form bolus 7. ROM/coordination of tongue to hold bolus 8. ability to hold bolus normally 9. oral sensitivity |
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Patient positions food on most mobile side of tongue and tilts head slightly during oral prep phase. Why?
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Reduced lateral ROM of tongue during mastication
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True or False
Slight pain is acceptible when moving mandible during ROM exercises. |
False! Strong pull, no pain.
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What's a helpful interim measure for a patient that has reduced tongue movement to form a bolus?
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Tilting head slightly forward, keeping bolus anteriorly positioned until ready to initiate swallow.
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Your patient has trouble holding a bolus in a normal position. What do you do?
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Put 1/3 thick paste consistency on tonge and ask them to consciously hold it, tongue tip and sides contacting alveolar ridge.
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Your patient has reduced oral sensitivity. What can you do?
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Postiont food on more sensitive side, use cold material to aid localization, use spices or tastes they are sensitive to.
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What 8 disorders affect the oral phase of the swallow?
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1. Tongue thrust
2. Reduced tongue elevation 3. Reduced a-p movement of tongue 4. disorganized patterns of tongue a-p movement 5. reduced tongue strength 6. swallowing apraxia 7. scarred tongue contour 8. delayed/absent triggering of the pharyngeal swallow |
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You're asking your neurologically impaired patient to consciously position their tongue on the alveolar ridge and begin swallowing with an upward-backward push during the oral phase of the swallow. Why?
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Patient exhibits tongue thrust.
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True or False
Applying a downward pressure to the middle of the tongue can reduce tongue thrust during the oral phase of swallow. |
True.
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True or False
Patients rarely experience both reduced tongue range of motion in both elevation and a-p movement. |
False! It's frequent.
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What's an IOPI and what do you use it for?
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Iowa Oral Pressure Instrument, can be used with tongue strengthening exercises to guage the amount of pressure applied vertically to it (between tongue and palate)
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What therapy techniques work best with swallowing apraxia?
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techniques to improve sensory input
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True or False
A scarred tongue contour cannot be improved with exercises. |
True. Place food posterior to scarring (compensatory), tilt head back to aid transit using gravity.
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True or False
The effects of scarring are usually not seen except in the dynamics of movement. |
True.
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True or False
The Masako maneuver can improve pharyngeal contraction on all levels. |
False! No (indirect or) direct therapy technique improves the swallow at all levels. The Masako exercises only the glossopharyngeal portion of the superior constrictor.
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What compensatory techniques can be used to remediate bilateral reduction in pharyngeal contraction.
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1. alternating liquid and semisolid or solid swallows (wash it down)
2. limiting diets to liquids or thin pastes (less pressure) 3. dry swallows after food to clear residue |
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What 9 disorders affect the pharyngeal stage of the swallow?
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1. bilateral reduction in pharyngeal contraction
2. unilateral phayngeal paralysis 3. scarred pharyngeal wall 4. cervical osteophyte 5. psuedoepiglottis 6. UES dysfunction 7. reduced laryngeal elevation 8. reduced laryngeal closure at airway entrance. 9. reduced laryngeal closure at vocal folds |
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3 ways to deal with a pseudoepiglottis
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1. surgically
2. turn head 3. liquids and thin pastes |
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3 ways to deal with a cervical osteophyte
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1. surgically
2. postures 3. thinner consistencies |
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Cricopharyngeal (UES) dysfunction may result from what three things?
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1. failure of muscular portion to relax adequately (larynx cannot lift)
2. reduced laryngeal lift 3. poor pressure |
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True or False
UES dysfunction occures most frequently because of failure to relax muscle. |
False.
Most frequently caused by reduced laryngeal movement with unilateral weakness. |
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True or False
The effectiveness of a posture and swallow maneuver should be examined separately bedside before being assessed in combination. |
False.
Assessed separately then combined during MBS. |
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Postural technique + swallow maneuver
Patient has a severe problem with airway entrance closure. |
head rotation to damaged side and chin down + super-supraglottic swallow
AIRWAY ENTRANCE PROTECTION OPTIMIZED@!!!! |
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Postural technique + swallow maneuver
Patient has poor tongue base motion |
chin down + effortful swallow
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Postural technique + swallow maneuver
Patient has poor UES opening due to reduced laryngeal elevation and unilateral pharyngeal wall weakness |
head rotation to damage side + Mendelsohn maneuver
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I want to provide biofeedback regarding the amount of effort utilized during lip closure. What instrumental procedure could I use?
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Surface electromyography
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I want to provide biofeedback regarding the degree of muscle effort used during the effortful swallow or Mendelsohn. What instrumental procedure could I use and how?
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Surface electromyography, by placing electrodes under chin on the submandibular muscles
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I want to provide biofeedback on the electrical activity of laryngeal elevators during the Mendelsohn. What instrumental procedure could I use and how?
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Surface electromyography, by placing electrode above larynx and showing amplitude (effort) and duration of muscle contractions.
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I want to provide biofeedback regarding tongue movement patterns during swallowing. What instrumental procedure could I use and how?
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Ultrasound, by observing tonge motion over time while practicing upward and backward motion of the tongue to propel bolus through oral cavity
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I want to provide biofeedback regarding closure of the true vocal folds/closure of the airway entrance before a swallow attempt. What instrumental procedure could I use and how?
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Videoendoscopy, by observing the movement of these structures during breath hold maneuvers.
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I want to provide biofeedback regarding pharyngeal swallow movements, point out defective elements of the swallow. What instrumental procedure could I use?
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Videofluoroscopy
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True or False
As soon as an inpatient is identified as dysphatic, a videofluorographic assessment of swallow function should be accomplished. |
False. Medically stable and ID'd as dysphagic
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After an assessment, when an appropriate therapy plan is initiated, the patient should be seen _______ in the hospital and _______ thereafter.
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Daily, weekly
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Assessment and treatment of surgically treated head and neck cancer patients should begin as soon as ______ has progressed enough, usually ______ post-operatively
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healing, 7-10 days
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When should a patient undergoing radiation therapy to the head/neck been assessed/treated?
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As soon as they complain of swallowing problems.
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Stroke patients should be assessed when they are _________, usually _____ postictus
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awake and alert, 2-3 days
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True or False
Patients who do not receive therapy soon after the onset of their problem are rarely capable of achieving oral intake. |
False.
Patients who receive therapy months or years after the onset of their problem are still capable of achieving oral intake |
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True or False
A maintenance program is the application of therapy strategies in a continuous way in order to assist patients in improving their function over a period of time. |
False.
Maintaining their function over a period of time. |
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True or false
Typically, maintenance programs are needed in patients who are unable to monitor their own performance |
True
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Do maintenance programs involve compensatory strategies or therapeutic ones (most often, and ignoring that there's incredible overlap)? Such as?
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Compensatory strategies, such as postural and diet changes, repeated swallow therapy techniques to maintain (key word) coordination, such as thermal-tactile stimulation
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True or false
Swallowing therapy may done separately or as a part of mealtime. |
False.
In general, swallowing therapy should be done separately from mealtime. |
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True or false
swallow therapy is not feeding |
True
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Can swallowing therapy be done in groups?
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Yup.
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True or false
Cultural differences should be taken into account when managing dysphagia. |
True
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Swallowing procedures, including ______, _____ and ______, can be successful in returning ______ of oropharyngeal dysphagic patients to oral intake
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compensatory strategies
direct therapy indirect therapy over 80% |
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What advice can a swallowing therapist give families and significant others regarding mealtime management of the dysphagic patient?
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1. don't encourage talking immediately after taking a bite of food or swallowing (aspiration risk)
2. include the patient by including food they can swallow easily |
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What medication can reduce drooling?
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Atropine
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True or false
Medications for patients with progressive neurological diseases can have no impact on swallowing. |
False. They sometimes do.
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Surgical interventions to improve oropharyngeal swallowing should generally not be attempted until _______
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6 months of swallowing therapy
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Name four settings where dysphagia management can present particular challenges.
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1. Acute care hospitals
2. Schools 3. Nursing homes 4. Home |
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In an acute care hospital, what should the swallowing therapist do before the patient is discharged? Quick!
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Identify dysphagic patients, define swallow physiology and outline a treatment plan ASAP
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What's the most important factor regarding continuity of care between an acute care facility and say, a rehab facility or nursing home.
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COMMUNICATION
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What limitations do SLPs face when defining a swallowing disorder at a school, nursing facility or in home care?
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No regular on-site access to diagnostic procedures to define the exact nature of the swallowing disorder
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What sorts of treatment can a therapist initiate in a school, nursing facility or home care setting while waiting for a physiologic or diagnostic study?
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Indirect therapy (sans food)
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Screening information (symptoms) does/does not enable the clinician to develop a workable and effective treatment plan for a patient's swallowing dysfunction.
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does NOT
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The patient should only be treated if she or he will improve his or her functional abilities while keeping _________. Where is this a concern?
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medically healthy. Nursing homes, e.g.
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Why observe a patient's oral intake at one or two meals at a nursing home?
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To define any behavioral characteristics that may interfere with eating a meal.
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What sorts of changes should be noted by the feeding staff throughout a meal (in a nursing home setting)
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Respiratory rate, voice quality, general alertness.
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In the nursing home setting, a clinician should determine whether the patient has ________ swallowing ability before referring the patient for radiographic study.
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potential to improve
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True or false.
Some patients are simply too advanced in their demential or other medical diagnosis to benefit from therapy |
True
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True or false
Family reinforcement can be as effective as reinforcement by any other caregiver or professional. |
True
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