Disclosures. Common feature in current rehab approaches: Dysphagia Management: In the Beginning 11/28/18

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1 Disclosures Ê ML Huckabee is employed by the University of Canterbury, who is the owner and manufacturer of the BiSSkiT software that will be discussed. Skill based swallowing training Can the pharyngeal response be trained Maggie-Lee Huckabee PhD Director, The UC Rose Centre for Stroke Recovery and Research Professor, Department of Communication Disorders, University of Canterbury Dysphagia Management: In the Beginning Ê All about compensation/adaptation Ê Chin tuck Ê Head rotation Ê Supraglottic swallow Ê Effortful swallow Ê Thermal stimulation Ê Mendelsohn manoevre and others. Ê The reflexive pharyngeal swallowing could not be rehabilitated Common feature in current rehab approaches: Ê Increasing strength Ê These exercises are focused on generating a safer and a more efficient swallow by strengthening muscles that contribute to swallowing through exercise (Burkhead et al., 2007). Ê We usually need to strengthen something if it is weak. But... is weakness always the case? ML Huckabee: 2018, Auckland 1

2 Deb...my tipping point Deb Ê Early 40 s began experiencing subtle neuro changes: dysphagia, dysphonia, visual disturbance, gait disturbance. Ê 7 years later: MRI revealed foramen magnum meningioma Ê Resected surgically intra-operative hemorrhage Ê Post-op very difficult course Ê After long and protracted acute stay of 3 months, to outpatient rehab: Had all the right therapy Ê On discharge, ambulatory but ataxic; VERY dysphagic Ê Outpatient speech pathology for swallowing twice weekly for 2 months no improvement Ê Discharged on PEG, no oral intake Ê Four bouts of pnemonia post discharge Deb Clinical outcome Ê Treatment approach Ê How do you do effortful swallow when you don t swallow? Ê semg guided rehabilitation Ê make the line move like mine Ê try to remember what it was like to swallow Ê Ingestion and expectoration of food for sensory stim Ê Move to effortful-type swallowing Ê Return to full oral diet within 6 months Ê Continuing to do very well, now 26 yrs post treatment Ê No pneumonia Ê Significant weight gain ML Huckabee: 2018, Auckland 2

3 What happened Is all, or any, dysphagia due to weakness? Ê Strength training? Ê Did we make her stronger? Ê Did she acquire a new cortically generated skill? Ê Encephalisation of swallowing? Ê Using cortical motor programming regions for pharyngeal motor control Ê Or increase cortical modulation of brainstem response? Ê Many pathophysiologic imbalances may cause motor impairment Ê Spasticity Ê Ataxia Ê Apraxia Ê Flaccidity Ê Strengthening may not be WRONG, but it may also not be right! A shift up Rethink rehab Ê Emergence of a large corpus of research supporting the role of the cortex in modulating the pharyngeal response Ê fmri studies Ê TMS studies Ê Non-invasive brain stimulation techniques have gone a long way to encourage a re-thinking of behavioural rehabilitation approaches. Ê Change brain first -> change swallowing as an outcome Ê Lacks some degree of specificity ML Huckabee: 2018, Auckland 3

4 semg biofeedback applications Ê Used for years as means of feedback for muscle strengthening Ê Huckabee & Cannito 1999: Ê 10 patients with brain stem injury Ê Mean time post onset 22 months Ê 8/10 returned to full oral intake following treatment Can we behaviourally alter the pharyngeal reflex, with subsequent encoding in neural change? Spatiotemporal adaptation? Ê Patients with Parkinsons disease Ê But can we do more? Athukorala et al: Pilot Study 1. To evaluate the cumulative influence of skillbased training on swallowing biomechanics, muscular change and patient perception. 2. To identify retention of skills after termination of treatment. Ê Felt instinctively wrong to work on muscle strengthening Ê Used semg to monitor and control non-functional, pre-swallow motor activity ML Huckabee: 2018, Auckland 4

5 Baseline 1: intake Methods 10 min block 2 weeks no tx Baseline 2 2 weeks daily tx Outcome 1 Ê Pilot study: 10 patients with PD Ê Self identified; clinical screen Ê 2 baseline evals; 2 post treatment evals 1 hr/day for 10 days 2 min rest 10 0min block 2 min rest 10 min block 2 min rest 10 min block 20 repetitions per block 2 weeks no tx Ê 2 weeks of daily treatment (1 hr) 2 min rest 10 min block Outcome 2 Outcome measures Summary Ê During each baseline sessions and outcome sessions following tests were conducted: Ê Timed water swallow test (Hughes & Wiles, 1996) Ê Test of mastication and swallowing of solids (TOMASS) Ê Surface Electromyography (semg) Ê Ultrasound Ê Swallowing related quality of life questionnaire (SWAL- QOL) Ê Statistically significant improvement in: Ê Water swallow test: vol per swallow, time per swallow, volume over time Ê semg: premotor time (reaction time) pre-swallow time (anticipatory movement) and total duration of swallowing Ê SwalQOL ML Huckabee: 2018, Auckland 5

6 Summary Discussion - Overview Ê TOMASS: nonsignificant trend for time per swallow, masticatory cycle per swallow, swallow per bite Ê No improvement in: Ê Muscle size for anterior belly and geniohyoid Ê Degree of anterior hyoid movement Ê Overall significant effects of treatment in many outcomes congruent with informal reports from patient/family members/friends reports on functional swallowing. Ê Non treatment baseline phase- stable Ê Skill retention phase- no deterioration in any of the outcome measures. So in this study, improvement seen in many aspects of swallowing through a focus on precision in movement. All oral? What about pharyngeal? What is the capacity for pharyngeal adaptation? A reminder ÊThe reflexive, naïve swallow is a reasonably well explored cascade of motor events, triggered by stimulation of SLN and executed by CPG in brainstem ÊPrimitive, hard wired response that is generally considered to be fairly invariant ML Huckabee: 2018, Auckland 6

7 Pharyngeal Mis-sequencing ÊIngestive swallowing requires modulation of this response ÊAdapts strength and duration of pharyngeal events, but not the basic motor plan Ê Swallow harder Ê Swallow longer to accommodate varied textures Ê But maintain the sequence of motor events Ê Recent clinical experience of patients with atypical pharyngeal motor pattern. Ê Not yet reported in the literature Ê Hindered by available diagnostic tools Ê Not easily observable on VFSS in neurologically impaired patient Target Pattern Dave 239 msec Ê 47 year old s/p lateral entry resection of clival meningioma Ê DC d from hospital to home on puree & thickened liquids. Ê Self-referred at 10 mos post surgery for rehab Ê VFSSà good oral, no delay, poor pharyngeal motility with diffuse (pyriform> vallecular residual), reduced anterior hyoid movement, nasal redirection of liquids, trace aspiration of liquids & semi-solids ML Huckabee: 2018, Auckland 7

8 Dave Dave: ultrasound Ê Rehab to focus on increased anterior suprahyoid muscle group à head lifts Ê Baseline ultrasound completed to measure 2D surface area and hyoid movement Ê 6 weeks of head lift à only slight functional improvement Ê 2 nd 6 weeks of head lift à not much better than before Dave Dave: low res manometry Ê Low resolution pharyngeal manometry Ê Pharyngeal pressure WNL Ê Mean= 132 mmhg, [norm of mmhg (95%CI )] Ê Mean = 118 mmhg [norm of109.1 mmhg (95%CI )] Ê BUT UES produced negative pressure outside the range of normal physiology -3 mmhg, compared to normal range of 9.6 mmhg (95%CI 12.4 to 6.8 Ê So is this a non-compliant UES? Ê Average peak to peak separation was calculated at -5 msec, well out of range or normal swallowing behaviour (normal 258 msec, 95% CI ML Huckabee: 2018, Auckland 8

9 Dave: rehab Ê Refocus of rehab: Mano as biofeedback Ê Make the blue line come first Ê After 8 weeks of treatment (twice daily for one week; once daily for one week; then twice weekly for six weeks), the patient was re-evaluated. Ê By Day 12 he was back on track and over the ensuing 2-4 weeks was able to consistently produce a clear superior to inferior pressure generation. Ê Discharged from treatment on full oral diet. Ê Of note..he can swallow correctly or mis-sequence swallowing on command. Impaired sequencing accomplished by swallowing hard. Dave: post-tx Dave: rehab Ê Peak to peak separation between the proximal and distal pharynx averaged 239 msec, only very slightly below the range of normal for age and gender (normal 258 msec, 95% CI ) Ê Manofluoroscopy : apparently unchanged hyolaryngeal movement, but only very slight pharyngeal residual of bread, likely consistent with age expectations, and no nasal redirection of the bolus. Ê Shortly after was DC d from treatment on normal diet exceptions due to anxiety Ê Continues to do well ML Huckabee: 2018, Auckland 9

10 Etiology Outcomes Post onset Pre Function Pre-tx peak to peak Post Function Post-tx peak to peak 40 F Medullary CVA 4 yrs Pureed diet; diffuse residual, nassal redirection no aspiration, 6 ms Near normal diet; persisting occasional redirection of liquids, no aspiration ms 28 F AVM hemorrhage 6 yrs Nonoral PEG; profound dysphagia, residual, aspiration, nasal redirection 8 ms (intensive week) persisting dysphagia, oral trials tolerated with some success ms 47 M CPA tumour resection 18 mths Moderate pharyngeal phase, intermittent aspiration nasal redirection; puree diet.5 ms Intensive week + weekly one year; return to full oral diet 239 ms 57 M CPA tumour resection 2 yrs Moderate pharyngeal phase, intermittent aspiration nasal redirection; puree diet 9 ms Intensive week + weekly 6 months; return to oral diet with some limitations; treatment not tolerated well 297 ms 72 M Bilateral pontine CVA 2 yrs Moderate to severe, int. asp., nonoral PEG 7 ms Intensive week-return to full oral unrestricted diet by 4 mths post 182 ms Patient reports Ê Sequencing of pharyngeal pressure most easily facilitated if relaxed Ê 11/16 patients resumed a full oral diet with thin liquids, including 6 patients with chronic dysphagia Ê Can volitionally stack waveforms by swallowing hard Ê Of the 5 patients who were unable to return to oral intake, 4 were unable to participate in continued treatment beyond an initial week of intensive treatment due to geographical constraints. ML Huckabee: 2018, Auckland 10

11 Next Step. Behavioural capacity for change Ê Can healthy participants mis-sequence through behavioural adaptation? Ê Method Ê 6 healthy participants (19-44 years) Ê Daily training for two weeks / 10 one-hour sessions Ê try to make red line come before the blue line or try to make the waveforms overlap Ê Analysis Ê 5 baseline swallows, random 20% of swallows in each session and 5 post tx swallows (without feedback) extracted for analysis Behavioural capacity to change Ê Results: Ê temporal separation of peak pressure between the proximal and distal pharyngeal sensors from a baseline median of 188 ms (IQR= 231 ms) to 68 ms (IQR = 92 ms; p = 0.002). Ê Although no significant change in overall swallowing duration during training (p = 0.41), there was a moderate correlation between peak to peak separation and total swallowing duration (0.44), suggestion there was a significant component of just swallowing faster to achieve separation. Ê Huckabee et al.: patients with mis-sequencing presented with longer swallowing duration Ê Lamvik et al data suggest that shorter duration to achieve pharyngeal mis-sequencing - not likely to be a behavioral maladaptive response, but a neurogenic feature of impaired motor planning ML Huckabee: 2018, Auckland 11

12 Key points: Wrapping up Ê Lack of diagnostic specificity hinders rehabilitative specificity Ê VFSS: movement of structures and bolus flow Ê No information regarding neuromuscular aetiology of impaired movement or bolus flow [Huckabee & Kelly, 2006] Ê Weakness, Spasticity, Dyscoordination Ê Need to look outside the box Key points Key points Ê Treatment should be physiology specific to be effective Ê If they are weak, strengthen them. Ê If they are not, DON T Ê Need refinement of diagnostic approaches Ê Emergence of skill training paradigms may hold much greater options for rehabilitation than our traditional course Ê We have evidence of the capacity to modulate the pharyngeal response Ê Swallowing reflex outdated concept for ingestive swallowing Ê Our challenge is to identify ways for patients to access pharyngeal response to modulate ML Huckabee: 2018, Auckland 12

13 Intervention is not benign Questions?? Ê Whether it be diet modification, compensatory techniques, or rehabilitation approaches: ÊIf an intervention is powerful enough to effect a positive change ÊIt is inherently powerful enough to effect a negative change. ÊIf you do nothing, intervention has no power to change.this may be the worst yet. Ê Ê Ê maggie-lee.huckabee@canterbury.ac.nz ML Huckabee: 2018, Auckland 13