McNeill Dysphagia Therapy Program. Gwen Van Nuffelen en collega s Universitair Ziekenhuis Antwerpen

Transcription

1 McNeill Dysphagia Therapy Program Gwen Van Nuffelen en collega s Universitair Ziekenhuis Antwerpen

2 MDTP Therapieprogramma voor slikrevalidatie Benaderen van de normale slikbeweging Focus op bekrachtigen, bijsturen en heropbouwen van het corticale motorische programma voor slikken (corticale plasticiteit) progressieve spierkrachttoename & verbeteren van de coördinatie tussen verschillende spiergroepen (perifere plasticiteit)

3 MDTP MDTP is a systematic, exercise-based therapy framework for the treatment of dysphagia in adults Swallowing = treatment! you let the patient eat & drink during therapy! you let your patient aspirate! another approach! another way of thinking!

4 MDTP stap voor stap

5 Wie? able to engage in active therapy awake, comprehension, interactive guidelines MMSE 20 level 5 or below on FOIS (oro)pharyngeal dysphagia no restriction on dysphagia severity obstacles obstacles requiring surgery significant structural alterations

6 Pre-therapie-assessment

7 Inhoud MASA / MASA-C! score Functional Oral Intake Scale (FOIS) MMS score 23 = MDTP possible FEES / VFES

8 FOIS tube dependent total oral intake Diet level of safe oral intake meeting nutritional and hydratation needs Level 1: nothing by mouth (NPO) Level 2: tube dependent with minimal/inconsistent oral intake (attempts of food) Level 3: tube supplements with consistent oral intake Level 4: total oral intake of a single consistency Level 5: total oral intake of multiple consistencies requiring special preparation or compensations Level 6: total oral intake of multiple consistencies without special preparation, but with specific food limitations (avoidance) Level 7: total oral intake with no restrictions

9 Instrumental assessment Required to identify: Starting level (most advanced level of material that a patient can swallow without aspiration) Primary movement deficit in the swallow pattern Structural obstacles to therapy Patient response to the bolus and to any aspiration event/ residue Scoring system: C-VFE

10 Starting level the highest volume and consistency that can be swallowed by the patient without aspiration penetration allowed! residue allowed! in case of aspiration: repeat the same material at least once if not more (! except in case of very severe aspiration in a compromised patient)

11 Sessie 1 & 2

12 Sessie 1 Patient orientation to therapy technique: principes MDTP uitleggen -> power point dagboek overlopen (dieet: wat & hoeveel) belang huiswerk: thuis oefenen met hoogste niveau dat veilig is in therapie sliktechniek uitleggen en aanleren + oefenen met droge slik vragen van patiënt en omgeving beantwoorden! patiënt weet waar hij/zij aan begint, motivatie

13 Swallow technique 1. Keep your mouth closed and lips together 2. Try not to move the food/drink around in your mouth 3. When you are ready, swallow as fast and as hard as you can 4. Try to swallow it all in one swallow 5. (You might cough but try to suppress the cough. If you can t supress the cough that s OK). Cough if necessary but don t spit out. 6. Once you have swallowed, clear your throat gently. Inhale through your nose and keep your mouth closed. 7. Then, swallow as fast and hard as you can. 8. Continue to use gentle throat clear followed by hard, fast swallow until you think the food/drink is gone.

14 Sessie 2 review aims, diet progression (levels), and daily format address concerns & questions review the swallow technique limited trial of swallow technique on dry swallow establish 1 RM (repetition max) limited trial of swallow technique on the food hierarchy starting level review observations/ experience address concerns & questions request diet record & practice of technique for homework

15 Sessies 3-15

16 Therapy Intensive! 1 session = 1 hour (if possible) > swallowing attempts per session 2X10 bolussen/niveau op de food hierarchy 2 verschillende voedingswaren

17 Food hierarchy Level 11 Food avoidances and specific food difficulties Level 10 Patient preference Level 9 Hard masticated (tanden) cake, appel, vlees, Level 8 Soft masticated (tong) banaan, gestoomde vis, Level 7 Pudding (10 ml) Level 6 Pudding (5 ml) Level 5 Thin juice (10 ml) Level 4 Thin juice (5 ml) Level 3 Nectar (10 ml) Level 2 Nectar (5 ml) milkshake, roomsoep, Level 1 Ice chips

18 Monitoring the swallowing attempts Proper technique? Hard and fast Throat clear Repeat swallow Avoid bad habits : poor head position inappropriate breath holding (apnea) coughing excessively Spitting Negative faulty behaviors have to be unlearned before correct movements can be mastered

19 Monitoring the swallowing attempts Proper technique? Identify and break up the patterns interference activity e.g. introducing another bolus immediately into the swallow if unsuccessful: at the end of the therapy program (level 11) Correct form of movement & controlled speed of movement Initially: slow + focus on form (no heavy resistance!) Once correct form! increase speed & resistance In case of an oral problem, it may be impossible to normalize the form. Try to normalize it as much as possible.

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21 Control of fatigue Clinician must carefully monitor the patient throughout the program to maintain a balance between swallowing attempts and rest Early levels: rest periods of 1-2 minutes between sets (10 boluses) of swallows Later: bolus of a lower level instead of rest E.g.: working at level 9 (hard mast)! 1 bolus soft masticated

22 Residue Repeated swallows But! If the patient can not clear the mouth or throat: Add a new bolus Preferably of the target level If needed: bolus of a lower level E.g.: target level: soft masticated; use yogurt to clear mouth/throat

23 Use of compensatory strategies do not add any compensations! (e.g. chin tuck) try to remove habitual compensations (e.g. altered head position) as soon as posssible

24 Use of sauce The use of sauce is recommended at levels (8), 9 and 10 As normal as possible

25 Nectar en vloeibaar Repeated failure on nectar and/or thin liquids If the patient can not successfully achieve nectar and/or thin liquids after numerous attempts, you may progress to the next level on the food hierarchy. These materials must be re-introduced after successful completion of level 10

26 MDTP implies another approach Do not: talk too much let the patient talk too much: shut up and swallow be over cautiousness mothering mix treatments allow too much rests

27 Push the patient Do: verbally encourage, motivate and drive progression

28 End of each session 1) stretching Relaxing tight muscles balances the muscle and improves flexibility Static stretch: slowly elongate the muscles through its full range of motion, then hold it at a position where it is at full extension (but without pain). Hold for 15 to 30 seconds.

29 End of each session 2) determining which food you need next day enough! starting level = last complete successful level backward step(s) forward step(s)

30 End of each session continued 3) home practice a patient should consume/ practice any material already successfully passed in therapy sessions aim: to promote functional independence patients complete a daily diary of foods consumed outside therapy to monitor practice

31 Carnaby-Mann, G.D., & Crary, M.A.(2010). McNeill dysphagia therapy program: a case-control study. Arch Phys Med Rehabil, 91(5), Carneby-Mann, G., & Crary, M. (2008). Adjunctive neuromuscular electrical stimulation for treatment refractory dysphagia. Ann Otol Rhinol Laryngol, 117(4),