use of evidence and instrumentation in the treatment of dysphagia

use of evidence and instrumentation in the treatment of dysphagia
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USE OF EVIDENCE AND
INSTRUMENTATION IN THE
TREATMENT OF DYSPHAGIA
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Disclosures
• All of the speakers on the panel received an
honorarium from ISHA for this talk
Dee Dee Hammond MA, CCC-SLP, University Hospital
Jessica Huber PhD, CCC-SLP, Purdue University
Michele Parrish, MA, CCC-SLP, ENT Associates
Dawn Wetzel MAT, CCC-SLP, Purdue University
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GOALS
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CONTENT
• Name appropriate evidence-based exercise(s) given
disordered physiology.
Exercises
Instrumentation
• Provide examples of instrumentation to facilitate learning
• Lingual Strengthening
• IOPI/Swallow Strong
of specific exercises.
• Identify the instrumentation that is best suited to target
specific physiologic deficits
• Mendelsohn
• sEMG
• Super-Supraglottic
• EMST/IMST
• Effortful Swallow
• Endoscopy
• Shaker
• Chin Tuck Against
Resistance
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Rehabilitating the Swallow
• Specificity
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Rehabilitating the Swallow
• Intensity:
• The exercise task should correspond with the
• Percent maximum performance
desired outcome
• Strength training may work best when paired
with task specific practice
• Number of repetitions
(power/pressure)
• Frequency of practice
• Duration of training over time
• Overload
• Mechanical
• Feedback
• Resistive
• Accountability
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Rehabilitating the Swallow
Interpretation of Video
• Transference
• Identify primary physiologic deficits
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• Cross training and non-specific strength
• Plan of Care
training
• What treatment has evidence to support its use
• What instrumentation/feedback could facilitate
learning of the treatment technique
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EVIDENCE AND INSTRUMENTATION
LINGUAL STRENGTHENING, SHAKER
AND CHIN TUCK AGAINST
RESISTANCE
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SwallowSTRONG
(Swallow Solutions, LLC)
Dee Dee Hammond, M.A. CCC-SLP
IU Health, University Hospital
Indianapolis, IN
[email protected]
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• 8 weeks of Isometric Progressive
Swallow STRONG Program
• Swallow STRengthening OropharyNgeal Gustatory
(Swallow STRONG) program
• Project Developers: Jo Anne Robbins, Ph.D, Nicole Pulia,
Ph.D, Nasia Safdar M.D, Ph.D, and Jacqueline Hind, M.S.
Resistance Oropharyngeal (I-PRO)
therapy using the Madison Oral
Strengthening Therapeutic (MOST) device
(newer version: SwallowSTRONG by Swallow Solutions)
• Followed by a simple long-term
oropharyngeal strength maintenance
program
• Grant received by William S.Middleton Memorial Veterans
Hospital in Madison, WI
• Intensive oropharyngeal strengthening program designed
to decrease health-related complications in veterans with
dysphagia
• Main goal: Improve swallowing and eating
in veterans with dysphagia by providing
strength training and biofeedback.
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Strengthening Protocol
• I-PRO therapy with SwallowSTRONG
• Involves active application of pressure by the tongue
•
•
•
Pressure is measured, by sensors, at four different
locations of the tongue
Sensor locations remain the same given the custommolded mouthpiece
Electronic interface shows patient performance and
calculates therapy targets. (Swallow Solutions)
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• SwallowSTRONG software provides
knowledge of performance and results for both
the patient and clinician.
• Provides information regarding accuracy of
movement and overall performance. Positive
feedback encourages increased motivation
• Progressive resistance training can increase
strength and structural volume thus decreasing
penetration, decreasing oropharyngeal residue
and improving quality of life
• Cost: Device and one mouthpiece: $3,995.00
(PNA ~$17,000)
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against stable resistance in the mouth (targets anterior,
posterior, left, right, middle and whole tongue)
• PROTOCOL:
10 lingual presses per sensor
3 times a day
3 days a week
8 weeks
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Iowa Oral Performance Instrument
System consists of carrying case, 1 connecting tube, 10
tongue bulbs and user manual. (IOPI Medical, LLC, ~$1100.00)
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Swallow STRONG
Clinical Demonstration Project
• Results from first 40 patients enrolled were presented
•
•
•
•
•
at DRS conference in Nashville, TN, by Nicole Pulia,
Ph.D.
Penetration-Aspiration Scale decreased for thin liquids
Isometric pressures increased at front and back
sensors
Quality of life subscale scores improved as well as
Functional Oral Intake Scale
Several patients progressed from feeding tube
dependency to full oral intake
Number of pneumonia diagnoses decreased by 88%
and hospital admissions decreased by 79%
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• Single air-filled plastic bulb attaches to a
hand-held pressure transducer that
measures pressure generated when the
tongue is pressed against the hard palate
• Objectively measures tongue and lip
strength and endurance
• PEAK function allows measurement of
maximum pressure
• LIGHTS function provides biofeedback
for exercise and endurance
• TIMER function allows measurement of
time (helpful for endurance)
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Tongue Depressors as an Alternative
• Typical Training Protocol
• Elevation at 50% Pmax (max
• In a study by Cathy Lazarus, et.al in 2003, three groups (all
healthy adults between 20-29 years) were targeted.
pressure)
• 3 sets
• 10 reps 3 times a day
• Total 8 weeks
• Squeeze bulb until top green light
is on
• Group 1: No exercise
• Group 2: Use of tongue depressors for lingual
strength
• Group 3 Use of the IOPI for lingual strength
Group 2 and 3: Exercised 5 days/week for one
month
(10 reps 5x day) targeting tongue lateralization,
propulsion and elevation
(Lazarus et. al, Folia Phoniatrica Logopaedica 55(4), 199-2005)
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After 4 weeks, results revealed significantly
greater change in maximum tongue strength
with both exercise groups
No statistical difference was found between the
exercise group using tongue depressors or the
group using the IOPI
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So, what if my clinic has no money???
• Use your thumb! (Anterior tongue press)
• Place the thumb just behind the top teeth and
press the anterior tongue against the thumb
• Pretend to say “k” (Posterior tongue press)
• Place the thumb against the hard palate
where tongue meets the hard palate for the
“k” sound
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• Sustained Head-Lifts (Do this first)
The Shaker Exercise
• Created by Dr. Reza Shaker, gastroenterologist at
the Medical College of Wisconsin.
• Designed to treat pharyngeal dysphagia involving
incomplete relaxation of the upper esophageal
sphincter
• Targets strengthening the suprahyoid muscles,
thyrohyoid, mylohyoid, geniohyoid, and anterior
belly of the digastric, as these muscles contribute
to the upward and forward movement of the larynx
and hyoid bone which results in relaxation of the
UES
(Shaker, et al. Am J Physiol 1997: 272)
• Lie flat on your back with no pillow
under your head.
• Keep your shoulders flat against the
bed or floor.
• Lift your head only and look at your feet
(chin tuck).
• Work up to 60 seconds
• Release and rest for one minute, repeat
x2
• Complete 3 reps, 3 times a day
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• Exercise was found to increase the duration and width
• Repetitive Head-Lifting:
of the UES in the normal elderly population
• Lie flat on your back.
• Repetitively lift your head and look at
• Shaker et al. in 2002, noted significant change in
your feet.
• Let your head go back down (slower
• Shaker et al 1997, Easterling et al, in 2005, and
speed=greater strength)
functional swallow measures
Logemann et al. in 2009, noted improved laryngeal
elevation and UES dilation
• Repeat this 30 times.
• Rest for one minute.
• Logemann et al in 2009, noted significantly less
• Repeat two more times (90 total “sit-
postswallow aspiration after 6 weeks of using Shaker
exercise in tube fed population with severe
oropharyngeal dysphagia due to abnormal UES
opening
ups” for your neck)
• Do this exercise 3 x day for 6 weeks
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Chin Tuck Against Resistance
Problems with Compliance
• Elderly may need structured and gradually progressive
program to achieve goals
• Isometric exercises (sustained head lifts) were found to
be harder than isokinetic exercises and therefore goals
achieved less often
• Muscle discomfort and time constraints were also
reported
• Head lifts were found to be too demanding for patients
with chronic conditions
• Resistance for Shaker: lifting head against gravity
• Enhances Suprahyoid Muscle Activity (opening
UES) using a Shaker-like exercise
• Used for patients with dysphagia due to upper
esophageal sphincter dysfunction
• Aim of study: determine if the CTAR exercise was
as effective as the Shaker exercise in raising the
sEMG activation levels of the suprahyoid muscles
during both isometric and isokinetic tasks.
(Yoon et. al, Dysphagia (2014) 29:243-248
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• Participants found the sitting position of CTAR to be
Instructions
• Sit up comfortably in chair. Keep shoulders still.
• Place an inflatable rubber ball (~12cm) under the chin
A hand may be used to hold it in place
• Tuck the chin as hard as possible against the ball.
• Hold for 10seconds
less strenuous
• Greater maximum sEMG values were noted during the
CTAR isokinetic and isometric exercises than during
the equivalent Shaker exercises
• CTAR isometric exercise showed significantly greater
sEMG values than the Shaker isometric exercise.
• Next, squeeze the ball as hard as possible by tucking the
chin against it 10 successive times
• With clinical trials, the hopes are that this exercise is
effective as exercising the suprahyoid muscles,
achieving therapeutic benefits comparable to the
Shaker exercise with the potential for greater
compliance.
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JOAR: Jaw Opening Against Resistance
Rhythm Slim Chin Muscle Exercise
• Watts (2013) used sEMG to compare the
Shaker exercise and the JOAR exercise
• Participants were asked to open jaw for
10seconds against resistance
• Suprahyoid muscle activation was found
to be greater with the jaw opening
exercise than the Shaker exercise
• Further clinical research is needed
• Developed in Japan as
an anti-aging device that
also decreases face,
neck, and jaw pain
• Position under chin and
push down for 10
seconds, do for 3 minutes
a day
• ~$77.00
www.japantrendshop.com/rhythm-slimchin-muscle-exercise-p-1292.html
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ISO Swallowing Exercise Device
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EVIDENCE AND INSTRUMENTATION
MENDELSOHN MANEUVER,
EFFORTFUL SWALLOW AND SEMG
• Co-invented by Page
and Jolie Parker (an
SLP)
• Flexible plastic device
with padding to allow
CTAR and JOAR
• Instructions are for
isokinetic first and then
isometric
• Cost: ~100.00
Dawn Wetzel MAT, CCC
Clinical Associate Professor, Purdue University
[email protected]
(Swallowingexercises.com)
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Strengthening and Compensating
Mendelsohn
• Suprahyoid group
constriction and UES
opening
Effortful Swallow
• Tongue base
retraction and
pressure generation
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Mendelsohn Maneuver
• Can be used as strengthening/skill training/ROM
or as a maneuver
• Load= holding larynx in elevated position against
resistance
• Using with bolus may increase salience, load
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Effects of MM on Measures of Swallowing
Duration Post Stroke
Mendelsohn Maneuver
• VFSS completed after each week regardless of whether
• Increased activation of submental muscles
patient had had treatment
(Wheeler–Hegland et al, 2008)
• Increased vertical-anterior duration & extent of
hyoid & laryngeal movement (Wheeler–Hegland et al, 2008)
• Increased A-P diameter and duration of UES
opening (Wheeler–Hegland et al, 2008)
• Improved coordination
• Improved timing
• Increased pressure/BOT-PPW
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• Improved measures after treatment weeks and not after
no treatment weeks
• Increased improvement after 2 vs 1 treatment weeks.
• Worsening of symptoms after 2 vs 1 week of no
treatment.
• Significant improvements in MDOHE and MDOHAE
• MUESO trending toward significance
• Improvements noted after 10 sessions. Much better after
20 sessions.
McCullough et al, (2012)
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Effortful Swallow
Effortful Swallow
• Began as compensatory strategy
• Increased generation of oral pressure
• Then considered strengthening
• Increased linguapalatal pressure after 4 weeks of
training (Clark & Shelton, 2013)
• Evolved to skill training
• Task-oriented form of skill training with a strength
component from greater muscular activation
• Potential for increased load/resistance by
increasing bolus viscosity
• Increased BOT/PPW motion with longer duration
contact
• Increased pharyngeal pressure
• Increased hyoid vertical displacement (Wheeler –Hegland
et al, 2008)
• Increased duration of anterior excursion of hyoid
(Wheeler –Hegland et al, 2008)
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Effortful Swallow
• Increased amplitude of submental activation (Wheeler–
Hegland et al, 2008)
• Reduced pharyngeal area pre-swallow (Fritz et al 2014)
• Increased pharyngeal closure during swallowing (Fritz et al
2014)
• May consequently affect airway protection and UES
activation
earlier onset/longer duration /extent motion
• Increased duration of UES opening (Wheeler–Hegland et al,
2008)
• Significantly higher mean esophageal peak pressure
across all sensor locations- striated >smooth>mixed
al 2012)
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High Resolution Manometry of
Pharyngeal Swallow Pressure
in ES and MM
• MM decreased UES pressure
• MM increased duration VP pressure
• ES may promote increased VP pressure which
can overcome decreased BOT pressure
• ES is a FOM rather than BOT event
• Both maneuvers increased minimum pressure at
(Neki et
UES
(Hoffman et al, 2012)
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Effortful Swallow (ES)
Mendelsohn Maneuver (MM)
• Logemann: As you swallow, squeeze hard with all
• When you swallow, hold your Adam’s apple up for
your throat and neck muscles.
2-3s by squeezing your throat and neck muscles.
• Huckabee and Steele: As you swallow, push your
tongue really hard against the roof of the mouth.
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• Swallow normally and in the middle of the
swallow when you feel your Adam’s Apple lift,
hold it up for 2-3s with your throat muscles before
you finish your swallow.
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sEMG
sEMG
http://theprogrp.com/speech-therapist/
• Biofeedback: Use of equipment to measure body
functions that are not monitored consciously
Steele (2004)
• sEMG: Surface electromyography
• A visual or auditory display representing muscle
activity
• A linear relationship between the force of muscle
contraction and the amplitude of an EMG signal
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sEMG
sEMG
• Potential Benefits
• One of the oldest evidence-based practices in
• Objective feedback
dysphagia rehabilitation
• Immediate feedback
Haynes (1976)
• Relative information re: amplitude and duration of
muscle activity
• Teaches control and challenges effort
• Safe, easy, noninvasive
• Limitations
• Outcomes superior with biofeedback when
compared with “traditional” therapy alone.
Sukthankar et al (1994), Crary (2004), Huckabee & Cannito (1999), Steele, (2004)
• No norms for submental sEMG activity
• Does not provide information re: specific muscle activity
• Does not measure specific amount of muscle activity
• Cost : $1395.00- $1795.00
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sEMG
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sEMG Protocol for MM and ES
• Hand-held portability
• Protocols developed at Swallowing Rehabilitation
• 9V Battery
Research Laboratory, Toronto Rehabilitation Institute
• Easy to operate
• USB communication to PC
• Software developed Biofeedback Foundation of Europe
• Automatic data storage
• Continuous operation or work/rest prompts
• Practice approximately~60 saliva swallows/session
• Session number
• Locked/unlocked mode
• Participate in 20-24 treatment sessions/2x/week
• Functional electrical stimulator interface
• Goal types include: Above Tone, Below Tone, Above Stim,
Below Stim, Maximum Display with Marker. A/B Ratio for
Dual Channel Systems
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• Focus is target amplitude practice for effortful swallow and
prolonged muscle contraction for Mendelsohn
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sEMG Protocol for MM and ES
sEMG Protocol for MM and ES
(Steele et al, http://www.intechopen.com)
(Steele et al, http://www.intechopen.com)
• Attach electrodes under the chin
• Participants completed repeat videoswallow studies
• Ensure signal quality and appropriate graded amplitude
• Two primary measures used to assess improvement
•
•
•
•
•
response
Record baseline series of 5 regular effort saliva swallows(RESS)1/30 seconds
Determine RESS reference range
Practice RESS with target set at 100% of RESS reference
range: series of 3-5 x5 swallows
Practice effortful saliva swallows (ESS) with target set at 100%
of RESS reference range and increase by increments of 1020%: series of 3-5 x5 swallows
Practice MM at lower threshold 30% of reference range. Goal
is to prolong contraction for 2-3 seconds above this level.
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• Imagery
• Palpation
• Auscultation
• Amount of residue (4 point scale)
• (Also looked at hyoid excursion and UES opening)
• ESS appeared to increase swallowing safety
• ESS did not decrease post swallow residue
• MM resulted in varying changes- amplitude and/or
durational changes in maneuver
• MM appeared to affect hyoid excursion and swallow
efficiency with decreased post swallow residue
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So You Don’t Have sEMG………..
• Mirrors
• PASS
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EVIDENCE AND
INSTRUMENTATION
EXPIRATORY AND INSPIRATORY
MUSCLE STRENGTH TRAINING
Jessica E. Huber, Ph.D.
Professor, Purdue University
[email protected]
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Inspiratory and Expiratory Muscle Trainers
• Individual breathes into
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Inspiratory and Expiratory Muscle Trainers
• Can increase the amount of resistance as the individual
a tube with nose clips on
or into a mask
• On the end of the tube
or mask is a resistance
• Resistance makes it
difficult to breathe in or
out
• Expiratory: EMST 150
from Aspire Products
• Inspiratory:
PowerBreathe (can buy
on Amazon)
becomes stronger
• Can help with breath support for anyone with weak
respiratory muscles
• Also may help for professional voice users who need additional
respiratory support
• Do not use with patients who get fatigued easily (ALS, Myasthenia
Gravis) or with those who problems do not involve muscle
weakness
• Generally need an MD script for use
• Must follow basic muscle training guidelines
www.aspireproducts.org
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Basic Muscle Training Guidelines
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Basic Muscle Training Guidelines
• Specificity of training:
• Train with the task you are trying to improve
• Muscle trainers do this to a point (especially in expiratory muscle
training)
• You are training with a downstream resistance and speech is breathing
with a downstream resistance (larynx and articulators)
• But do not use the trainers instead of speech therapy, only in
conjunction – continue to work on speech
• Must overload the muscle
• Low resistance, high repetition
• High resistance, low repetition
• Must repeat the movements
• But do not go to the point of exhaustion
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• Frequency:
• Must train regularly – 5-6 days per week
• Generally only use with individuals who can
continue to train on their own, outside of
therapy
• During therapy, you check progress
• Takes less to maintain strength than build
• Once strength is increased, do not need to
continue with strengthening exercises as often
• Can just do exercises a few times per week
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When To Use Strength Training?
• Is weakness present?
• Does the weakness interfere with speech
functioning?
• Speech only requires 10-20% of the max
force of the lips
• Are there contraindications for strengthening
exercises?
• Will the course of the disease make
strengthening exercises futile?
• Will the person fatigue to the point of not
being able to complete everyday activities
(communication, swallowing)?
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Cautions About Strength Training
• Do not delay other interventions until you are
done strengthening the muscles
• Only use with individuals who will do drills at
home daily
• Do not use EMST with patients who are not safe
to perform a Valsalva maneuver
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EMST Improves Cough Dynamics in PD
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EMST Improves P-A Score (but not in all
patients): 33% of treatment group
6
0.4
Duration (seconds)
0.35
5
0.3
0.25
4
0.2
Pre EMST
Post EMST
0.15
0.1
Pre-EMST
Post-EMST
3
2
0.05
1
0
Compression Phase
Duration
Expiratory Rise Time
0
Sham
Treatment
Pitts, Bolster, Rosenbek, Troche, Okun, and Sapienza (2009), n = 10
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EMST Program (Sapienza and
colleagues)
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EMST Patient Instructions
• Place nose clips on your nose
• 5 sets of 5 breaths completed 5 days per week
• Do the training in the seated position at the same time of
day
• Set muscle trainer to 75% of the patients maximum
expiratory pressure (MEP)
• Completely inhale until you cannot breathe any more air
in your lungs.
• Make sure your lips are completely sealed around the
mouthpiece.
• Obtain by asking patient to breathe to top of VC and then blow hard
and fast into pressure meter
• Or set the device to the highest level the patient can manage
• Hold your cheeks with one hand.
• Breathe out as hard as you can.
• Remove the trainer from your mouth.
• Can follow a similar protocol with inspiratory training
• Inhale again.
• Sapienza recommends training for 4 weeks, but that is
• Rest between each breath on the trainer.
likely not long enough for people with motor disorders
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IMST Patient Instructions
• Place the nose clips on your nose.
• Make sure your lips are completely sealed
around the mouthpiece.
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EVIDENCE AND INSTRUMENTATION
SUPER SUPRAGLOTTIC SWALLOW
AND ENDOSCOPY AS
BIOFEEDBACK
• Completely exhale until there is no more air in
your lungs.
• Breathe in as deeply as you can.
• Exhale again.
• Rest between each breath on the trainer.
Michele Parrish, M.A., CCC-SLP
Ear, Nose, & Throat Associates
Parkview Regional Medical Center
[email protected]
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Physiology of Super Supraglottic
Swallow Maneuver
•
Improve closure ABOVE the glottis
anteriorly
• Closure of the true and false vocal
cords
Reduce aspiration risk before, during, and after the
swallow
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Omhae et al., (1996):
• Glottic and supraglottic closure before the
swallow
• Change in extent of vertical laryngeal
position before swallow
• CP opened earlier
• Prolonged duration of pharyngeal swallow
• Bulow et al., (1999) reported:
• Overall improved pharyngeal clearance
secondary to prolonged laryngeal excursion
resulting in longer period of PES opening
and relaxation
•
• Arytenoids adduct and move more
•
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When to Utilize the Super Supraglottic
Swallow Maneuver
Super Supraglottic Swallow Technique
• Decreased/delayed TVC closure
•
 improve airway protection
Hold your breath
Bear down with your stomach/push your
stomach muscles into your back
• Swallow
• Cough
• Re-swallow
•
• Delayed pharyngeal swallow
 expedite airway protection
• Difficulty coordinating the swallow respiratory
cycle
 improve conscious awareness to “normal” swallow-breathe pattern
• Silent aspiration
 improve airway protection despite reduced sensation
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Super Supraglottic Swallow Technique
Defining Biofeedback
• Contraindications (Chaudhuri et al., 2002):
• Crary et al., 2004
•
Increased stress on heart function during breath
holding maneuvers
 History of stroke
 Cardiac arrhythmia
 CAD
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External means to provide feedback to
patient with the goal to increase rate of
motor learning
Result=improved efficiency of therapeutic
process
In short, enhance new learning
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Biofeedback and EBP
Biofeedback and EBP
• Denk and Kaider (1997)
•
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Results showed biofeedback group exhibited:
• Reduced occurrence of aspiration
33 HNC patients
• Control group=conventional therapy
• Experimental group=conventional therapy with
biofeedback
•
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• Reduced pharyngeal residue
• Improved pharyngeal wall movement
• Faster return to oral feeding compared
to control group (no biofeedback)
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What if you do not have access to
instrumentation?
• Endoscopic Evaluation and Treatment of
Swallowing Disorders, Langmore 2001:
• Hum
• Hold Breath/squeeze neck muscles=suspend
vocalization
• Patient did not fully occlude airway if vocalization
or audible air leakage is noted
• Establish a protocol with local diagnostician
• Accompany patient to diagnostic testing
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