Dysphagia and the MBSS: Disclosures. Instrumental Assessment. The Disorder Guides the Treatment

Transcription

1 Dysphagia and the MBSS: The Disorder Guides the Treatment Jennifer Jones, PhD, CCC-SLP, BCS-S C/NDT Board Certified Specialist in Swallowing and Swallowing Disorders Certified in Neurodevelopmental Treatment Disclosures My name is Jennifer Jones and I am here to discuss Interpreting the MBSS. I have authored a book As They Grow: Birth To Six, which is in it s 2 nd edition and sold by Talk Tools. I receive royalty when my books are sold by Talk Tools. However, I will be discussing only a minimal amount of information that is presented in that book. I lecture nationally for Talk Tools on the topic of Interpreting the MBSS for Adults and Pediatrics. I do receive financial compensation for those lectures. I am being compensated for my travel expenses by Talk Tools to lecture here today. I have no other financial disclosures. Instrumental Assessment First you must be able to determine what is truly a normal swallow across the age span as viewed on the instrumental assessment 1

2 Normal swallowing includes an integrated interdependent group of complex feeding behaviors emerging from interacting cranial nerves of the brainstem and governed by neural regulatory mechanisms in the medulla, as well as in sensorimotor and limbic cortical systems. (Groher, 1997) Normal and Elderly Prevalence of swallowing impairment increases with age Longer oral and pharyngeal transit times Longer duration of pharyngeal pressures Higher incidences of pharyngeal residue after the swallow Changes in the activity patterns of the suprahyoid muscles (Robbins, Hamilton, Lof, & Kempster, 1992; Nilsson, Ekberg, Olsson, & Hindfeldt, 1996) (Miyaoka et al., 2007) Normal and Elderly Eat less Sense of smell & taste Aguesia / Anosmia absence of taste /smell Hypoguesia / Hyposmia diminished taste / smell Dysguesia / Dysosmia distorted taste / smell (1/3 of elderly report dissatisfaction with taste / smell) Large decrease (~1200 cal.) between years old Eat slower 2

3 Instrumental Assessment MBSS is the most frequently performed instrumental assessment because it permits the determination of: Underlying physiologic or anatomic reasons for the dysphagia Analysis of bolus flow Direction, duration and clearance Bolus response to treatment trials How do we watch an MBSS? Watch the bolus? Watch the structures? What are we looking for? How do we know to stop the study? 3

4 Before the Swallow is Initiated Examine the anatomy for any abnormalities Cervical vertebrae & esophagus are there any bulges Valleculae is the epiglottis there? Tongue base is there a tongue? Airway entrance, larynx, trachea Dentition Velum, tongue, mandible, lips, VP port, hyoid, pharynx, PES, pyriform sinuses, PPW Watch for any movement disorders Normal Swallow As the swallow is initiated Watch the bolus movement Does the bolus move consistently or hesitate? If so, where? How long? Count the delay. Where is the bolus head when the pharyngeal swallow is triggered? Count the delay. Does any bolus enter the airway before, during or after the swallow? 4

5 Physiology and Coordination Labial closure Mandibular motion & mastication efficiency Onset of lingual bolus propulsion Lingual Range of motion & control during: Elevation of bolus to palate Bolus seal against palate A-P (anterior-posterior) propulsion of the bolus Oral Phase Timing Physiology and Coordination Tongue base retraction Velopharyngeal closure soft palate Epiglottic Inversion Initiation of the Pharyngeal Swallow & bolus location relative to timing Pharyngeal constriction stripping wave Laryngeal protection: supraglottic & glottic level Hyolaryngeal motion anterior excursion & elevation Physiology and Coordination Pharyngeal Phase Timing Pharyngo-esophageal opening Coordination of pharyngeal structural movement during swallow Presence or absence of upper airway and/or aerodigestive tract obstruction Movement of bolus through upper 1/3 of esophagus and esophageal clearance 5

6 After the Swallow Residue in the Oral Cavity poor oral tongue movement Residue in Valleculae Reduced tongue base retraction Unilateral pharyngeal paralysis Residue in Pyriform Reduced laryngeal elevation Reduced cricopharygneal opening (PES) Reduced hyolaryngeal excursion Residue on Posterior Pharyngeal Wall (PPW) Reduced pharyngeal wall contraction forward and lateral What You Should Know To treat Dysphagia it is VERY important to know when the aspiration occurred and why it occurred. If you don t have this information then you can NOT adequately treat the patient. When Is the Aspiration? 1. Before 2. During 3. After 6

7 Planning Treatment Remember, not all dysphagia patients have the same problem Therefore, you cannot treat them all the same Review your history Put the pieces of the puzzle together to determine the disorders Make your treatment plan based on the problems the patient is having, NOT only their Medical Diagnosis Goal of Feeding Program Acute medical status MUST be stable Swallowing evaluation must demonstrate: an adequate protective and productive cough reflex and laryngeal elevation during a swallow Be sure if you say NO to NG or G-tube that the patient is receiving adequate oral intake to meet nutritional requirements (consult dietician) Always recommend an oral care program for the patient before & after meal if possible Treatment Techniques Compensatory Treatment (Indirect) circumvents problem using indirect strategies to alter bolus flow Postures, Sensory procedures, Maneuvers, Combine postures and maneuvers, Diet changes Rehabilitative Treatment (Direct) Changing the swallowing physiology to restore fxn and directed at improving neuromuscular control Visual feedback, auditory feedback, sensory therapies, physiotherapeutic exercises (ROM & resistive) (Logemann, 1997; Sate of Colorado Dept of Labor and Employment, 2006) 7

8 Indirect Treatment Strategies 1. Postures 2. Maneuvers 3. Bolus Modifications 4. Sensory Enhancement 5. Other compensatory techniques 6. Diet changes See handout for maneuver/posture summary! Postures 1. Chin down / tuck 2. Head back 3. Head tilt 4. Head rotated / turned 5. Combinations Results: Narrows oropharynx Widens valleculae space Displaces tongue base & epiglottis posteriorly Reduces laryngohyoid distance But, may weaken pharyngeal contraction Chin Down 8

9 Chin Down Indication: improve airway protection Use with a patient who has: Reduced laryngeal vestibule closure Reduced laryngeal closure Reduced tongue base movement Delayed trigger of pharyngeal swallow (Logemann, 1993, Logemann et al., 1994, Rasley et al., 1993, Shanahan et al., 1993) Contraindicated for: neurogenic patients with pharyngeal constrictor weakness pharyngeal delay pyriform pooling cervical spine injuries Chin Down Head back / Chin up Indication: Propel bolus to back of mouth or pharynx Use with a patient who has: Poor anterior-posterior propulsion of the bolus Reduced oral tongue strength Abnormal labial strength / closure Reduced velopharyngeal closure (Logemann, 1998) 9

10 Results: Better oral transport Head back / Chin up Contraindicated for: Patients with poor airway protection Head Tilt Tilt the head to the stronger side by placing the ear over his shoulder Indicated for: Unilateral oral and/or pharyngeal disorder to channel bolus through stronger side of oral cavity and/or pharynx (Logemann, 1998) Head Rotated / Turned Turn head to right/left (weakened side) shoulder while swallowing Indication: reduce post swallow residue and aspiration to close off weaker side of pharynx Use with a patient who has: Unilateral pharyngeal paresis / weakness Unilateral laryngeal weakness Post-radio therapy Reduced CP opening (Logemann et al., 1989, Logemann, 1998, Logemann et al., 1994) 10

11 Results: Isolates damaged side from bolus path redirects bolus to stronger side of pharynx Reduces UES pressure increases opening Increases proportion of bolus swallowed Contraindications: Bilateral pharyngeal paresis Head Rotated / Turned Combinations Chin down and then chin up Reduced oral control Reduced tongue vertical or lateral range of motion Head turn and chin down at the same time Use for best airway protection for patient with reduced laryngeal closure at entrance or cords Airway Protection Maneuvers Requirements: Ability to learn cognition intact Motivation Praxis Respiratory reserve 11

12 Maneuvers 1. Supraglottic 2. Super Supraglottic 3. Mendelsohn 4. Effortful Supraglottic Swallow Inhale, exhale slightly, valve glottis, swallow, clear pharynx, swallow again For Super add bear down / squeeze with swallow Indications: Pharyngeal delay Unilateral pharyngeal wall disorder Bilateral pharyngeal wall disorder Other populations: Head & neck irradiated patients Medullary stroke patients Others with pharyngeal dysfunction Supraglottic Swallow Indications & rationale: Promote earlier airway closure Promote increased subglottal air pressure Improve efficiency of cough Clear residual hypopharyngeal pooling Minimize aspiration before, during and after the swallow Intended to: Reduce aspiration by increasing glottal closure (Logemann et al., 1995; Bisch et al., 1994) 12

13 Supraglottic & Super Supraglottic Contraindications: Vocal fold paralysis = can t hold breath Restrictive lung disease = voluntary breath hold restricted Hx of cardiac arrhythmia or coronary artery disease What procedure tells the patient to: Place your finger on your voice box and feel it rise and fall as you swallow your saliva. This time when you swallow and feel it move up, try to hold it up and not let it fall back down. Hold it up for a count of about three. A.) Supraglottic Swallow B.) Double Swallow C.) Mendelsohn D.) Masako Maneuver Mendelsohn Indicated for: Reduced laryngeal elevation Reduced CP opening Discoordinated swallow Intended to: Improve swallowing coordination Increase UES opening width & duration Increase tongue base retraction Increase laryngeal elevation by increasing hyoid movement Increase anterior laryngeal excursion (Lazarus, Logemann, & Gibbons, 1993; Logemann & Kahrilas, 1990; Kahrilas et al., 1991) 13

14 Effortful Swallow The patient is asked to swallow harder What does that mean? Better description: as you swallow, squeeze hard with all of your muscles and push your tongue into the roof of your mouth. Indicated for: Reduced tongue base retraction Generation of higher intra-oral pressure Reduce valleculae residue Effortful Swallow Physiological changes: Increased tongue-palate pressures Increased duration of swallow Increased tongue base movement Studies show: Increased pressure exerted on the palate and tongue base Increase in tongue base movement Depth of airway penetration decreased Decreased residue (Logemann, 1993; Lazarus et al., 2002; Pouderoux & Kahrilas, 1995) Combine Postures and Maneuvers Supraglottic chin down, head rotated or both Super Supraglottic chin down or head rotated Effortful chin down Mendelsohn head rotated 14

15 Sensory Procedures Other ways to change the swallow: Bolus volume and viscosity Taste, texture and temperature changes To facilitate lingual motion To improve triggering of the pharyngeal swallow Change Bolus Volume Decrease the amount of intake Respiratory issues Poor bolus control Increase the amount of intake Decreased sensation in oral cavity change onset & duration of swallow by changing the bolus larger bolus moves faster increase bolus size = decrease pharyngeal transit times (Bisch et al., 1994; Lazarus et al., 1993; Logemann et al., 1995) Differences with Large Bolus 1. Anterior position of the velum 2. Widening of the PES 3. Increased closure time of the airway Therefore, large bolus would definitely be contraindicated for people with respiratory issues. (e.g. COPD) 15

16 Change of Bolus Viscosity Viscosity levels Thin, nectar, syrup, honey, pudding Up to 28% of residents in long term care receive thickened liquids Cost is $200 / month to drink (Castellanos, 2004) USDA Funded Project Components of taste Sweet, sour, bitter, salty, umami Change of Flavor May want to add materials to existing foods to increase the taste (e.g. spices) A lot of taste manipulation actually involves smell manipulation 16

17 Carbonation / Thin Liquids For patients with mild aspiration or bolus control issues Use carbonated beverages without thickener Reduces swallow time Therefore, reduces the misdirection and poor coordination of the bolus (Bülow, Olsson, & Ekberg, 2003) Other Sensory Procedures Pressure of spoon May trigger response Self-feeding Oral-preparatory assistance Chewing Stimulates saliva and swallow reflex Absence of chewing may also help Enhances taste!! Bolus Hold Double or multiple swallows Alternate liquids & solids Throat clearing Other Techniques 17

18 Pt. is asked to hold the bolus in the mouth until asked to swallow Intra-Oral Bolus Hold This technique teaches oral containment and control, while heightening sensory input of feeling the bolus Good procedure to use with a delayed pharyngeal swallow Double Swallow Simply ask the patient to swallow two times for every bolus taken into the oral cavity Good to use with a patient who has pharyngeal residue Direct Treatment Methods Visual Feedback VFSS Videofluoroscopic Swallow Study FEES Fiberoptic Endoscopic Eval of Swallowing Biofeedback IOPI Madison Oral Strengthening Therapeutic Most Device 18

19 Iowa Oral Performance Instrument (IOPI) hand-held, portable, battery-operated instrument that can accurately measure tongue strength and the relative fatigability useful for diagnostic and therapeutic purposes Madison Oral Strengthening Therapeutic Device Developed by JoAnne Robbins, PhD, Univ of Wisconsin and the VA in Madison She has pioneered research on tongue strengthening exercises - first with the IOPI MOST Device - now developing her own product that is undergoing a lot of research at this time. Direct Treatment Methods Auditory Feedback Cervical Auscultation Sensory Stimulation Thermal application Bolus positioning Electrical Stimulation 19

20 Cervical Auscultation What can we learn about swallow by listening? Easier to recognize sound than describe it Adds to the clinical examination Ongoing monitoring/feedback device Screening tool The Method Use cold mirrors, ice sticks, or lemon glycerin swabs Rub pillars and sides of tongue vigorously Have pt. swallow hard w/ or w/o a bolus All above constitutes one trial Time between trials individualized as is number of stimulations per trial Thermal Application Thermal-Tactile Stimulation Indicated for: Delayed initiation of pharyngeal swallow also no swallow response Mostly use with slowness and aspiration slowness = delay greater than 2 seconds But not always, As we age we need more time to adapt physiologically Therefore, slower swallows may sometimes be safer (Lazzara, Lazarus, & Logemann, 1986; Rosenbek, Roecker, Wood & Robbins, 1996) 20

21 Bolus Positioning Place the bolus on the unimpaired side of the mouth instead of midline The bolus will tend to go to the weak side if it is placed at midline This placement should help facilitate proper movement of the bolus to the pharyngeal area Electrical Stimulation Must have an intact nerve You set up electrodes around the nerve and the current between the electrodes stimulates the nerve Difficult to do because the sensory nerves are closer to the skin than the motor nerves Most muscles that we want to stimulate are very deep and questioned if electrical stimulation will even effect those muscles Electrical Stimulation Protocol the placement of surface electrodes on the neck using one of four different positions, as described by the developers of the technique (Wijting & Freed, 2003). The electrodes are simultaneously activated over the submental and laryngeal regions. The intensity level of the current is increased until the patient reports feeling a sensation of muscles grabbing. This is referred to as reaching motor levels of stimulation. The electrical current remains on, cycling off for 1 second every minute throughout 1 hour of therapy. Meanwhile, the patient is encouraged to repeatedly swallow hard using endogenous saliva. With progress, the patient is upgraded to swallowing ice chips and eventually solid foods. 21

22 Direct Treatment Strategies Exercises Shaker Masako Specific muscles targeted These are designed to give the patient more information to facilitate learning maneuvers These are performed WITHOUT FOOD Suprahyoid Exercises - Shaker Patient is asked to lay on your back and raise your head to look at your shoes, do not raise your shoulders. Intended to: Improve PES opening, anterior laryngeal excursion and reduce backflow aspiration Works to strengthen: Mylohyoid, geniohyoid and anterior belly of digastric Pharyngeal Wall Exercise - Masako Also known as the Tongue holding maneuver Patient is asked to hold tongue between the teeth while swallowing Intended to: Increase contact between tongue base and pharyngeal wall Physiological Effects: Increased anterior movement of posterior pharyngeal wall 22

23 Physiotherapeutic Approaches Muscles of the mouth, suprahyoid and pharyngeal are striated muscles and they need resistive exercise Resistive exercise = strengthening the muscles Range of motion = mobility You should have ROM and resistance exercises for every muscle group that is affected Labial musculature Mandible Intrinsic & extrinsic lingual musculature Suprahyoid muscles Yawning Gargling Masako Pulling tongue back Tongue base exercises Muscle Specific Exercises Lingual (straws, horns, z-vibe) Labial (button pull, tongue dep., straws, horns) Mandible (jaw exerciser, bite blocks, bite tubes) Sara will have a book published soon on Adult Oral Placement Therapy 23

24 Decision Making Process 1. The first step in deciding the disorder: SIGNS AND SYMPTOMS These are obtained with a good: a. history b. clinical examination Decision Making Process 2. Now establish or hypothesize if the signs and symptoms are related to: the swallowing structure (s), to other variables such as poor dentition, vision loss, cognitive impairment, lapses in attention, fatigue, etc. 3. If a sign or symptom seems to be related to abnormality within the swallowing anatomy then establish or hypothesize what structure (s) are involved. Decision Making Process 4. Establish whether the structure itself is involved as in Zenker s, fibrosis, tumor, surgical wound, etc. or whether movement of the structures are impaired or if both are occurring in combination. 5. Establish why the structure(s) or movement(s) are involved. 24

25 Decision Making Process Two possible variables: 1. movement variables: range, rate, timing 2. control variables: strength, tone, coordination Decision Making Process 6. Establish the treatment targets based on: interaction of the various signs (e.g. residual in the pyriform sinuses spills over after the swallow and is aspirated) impact on safety & adequacy pleasure of nutrition and hydration (QOL) Decision Making Process 7. Next, decide if the target (s) and its variables (movement or control) are modifiable YES: then the next step is to pick a method or set of methods (e.g. lingual weakness modifiable with IOPI or other strengthening methodology) NO: (or if effects can be expected to take some time) then the full range of compensations need to be considered. 25

26 Decision Making Process 8. Finally, decide: the intensity and duration of treatment the expected outcomes Neurogenic Mechanical Developmental Categories of Dysphagia See page in resources for examples Neurogenic Dysphagia Swallowing dysfunction due to movement & control variables Due to neurologic disease or insult Results in impaired motor and sensory functions of the oral and pharyngeal phases 26

27 Neurogenic Difficulties - Oral Abnormal oral containment Out of the lips Over the base of the tongue Abnormal / difficult mastication Abnormal / difficult bolus formation Abnormal A-P propulsion of bolus Saliva production (amount & sensation of) Abnormal lingual strength and movement Oral residual (anterior & lateral sulcus, palate, tongue) Neurogenic Difficulties - Pharyngeal Abnormal / Poor tongue base retraction Abnormal / Poor laryngeal elevation NP regurgitation Ineffective airway protection Ineffective airway clearance Abnormal / Poor pharyngeal contraction Diminished displacement of the hyoid bone and/or epiglottis Abnormal opening of the P-E segment Delay triggering the pharyngeal swallow Mechanical Dysphagia Due to muscle loss and loss of the motor and sensory innervations to those muscles. Muscles to perform acts are not intact Results in impaired motor and sensory functions of the oropharyngeal mechanism (similar to neurogenic dysphagia) Most mechanical dysphagia patients have had oral, pharyngeal, laryngeal, or esophageal structures removed or reconstructed during surgery for cancer. 27

28 Mechanical Difficulties - Oral Poor oral containment (anterior & posterior) Abnormal / Difficult mastication Abnormal / Difficult initiation of the swallow Abnormal Saliva production (amount & sensation) Abnormal / Decreased lingual strength Mechanical Difficulties - Pharyngeal Abnormal / decreased laryngeal elevation Abnormal opening of the P-E segment Abnormal / Decreased pharyngeal contraction Increased swallow transit times Ineffective closure to laryngeal vestibule Ineffective closure of the vocal folds 28

29 Complications Dehydration Malnutrition Aspiration pneumonia Asphyxia Loss of pleasurable eating Social difficulties Developmental Dysphagia Central nervous system injuries associated with: Infection Anoxia Trauma Vascular accident Hydrocephalus Mental retardation Cerebral palsy Cranial nerve palsy Muscular disorders (e.g. Myasth. Gravis) Variations May let the patient feed themselves May allow the patient to determine the size of the bolus to see what size they are commonly using May use different types of spoons, cups or straws May alternate liquids & solids 29

30 Effectiveness of Intervention Fatigue Patient motivation Patient alertness, judgment, & distractibility Level of cueing and assistance necessary to perform techniques Ability to repeatedly & consistently perform techniques Language and cultural influences Possible Adverse Reactions Agitation Changes in breathing pattern Changes in level of alertness Changes in color Nausea and vomiting Changes in overall medical status MBSS Report Should Explain Problems by occurrence Sensory vs. motor Symptoms: residue, penetration, aspiration Physiologic / anatomic causes of symptoms Effects of therapy strategies or why therapy not needed / attempted during the study Recommended feeding strategies Recommended therapy procedures & goals 30

31 Description of the Swallow If swallows of all consistencies exhibit the same disorders, this can be indicated at the beginning of the report If the disorders vary by food consistency, the report sequence should be repeated for each food consistency Compensatory Strategies If no effect is seen a simple sentence can be used, such as Postural techniques and supraglottic swallow were unsuccessful in eliminating aspiration. Compensatory Strategies If techniques are successful, the conditions under which the patient can eat successfully should be defined, for ex. With the chin down and head rotated to the left, aspiration is eliminated on all volumes and food consistencies. Recommend eating orally only with the chin down and head rotated. Using the Mendelsohn maneuver, laryngeal movement and cricopharyngeal opening are improved enough so that a spoonful of thin liquid can be given orally in therapy only. 31

32 Recommended Therapy Depends on the nature of the swallowing motility disorders & the underlying cause of the patient s swallowing disorder Tx strategies should focus on the purpose of the therapy, for ex: To improve laryngeal elevation, closure at the airway entrance, or triggering of the pharyngeal swallow Recommend Re-evaluation Depends on the: patient s medical diagnosis, anticipated rate of recovery Prognosis For the neurologic patient in the process of recovery 3-4 weeks is appropriate For a patient w/ a degenerative neurologic condition 3-6 months is adequate unless swallowing worsens Recommend Re-evaluation Typical statement for recommendation of reevaluation Re-evaluation is suggested when clinical improvement is seen. Or Re-evaluation is suggested when swallow degeneration is suggested by... 32

33 Recommendations Oral vs. Non-oral delivery Specific oral intake modifications Therapeutic interventions required during meals Safe feeding / aspiration precautions Positioning Diet consistent with ethnocultural preferences and practices Need for thorough & consistent oral hygiene Dysphagia Treatment Plan consistent with exam findings Other consultations or assessments Identify & Interpret Penetration: cause, timing, & approx. % / severity Aspiration: cause, timing, & approx. % / severity Residue: cause, approx. % and location Sensory Awareness: Reaction to residue Reaction to penetration Reaction to aspiration (e.g. cough, throat clear) Effectiveness of Reaction to: Residue, penetration, aspiration (e.g. reduction of % residue, productive cough, & expectoration of material from airway) Aspiration: Before the Swallow Limited / Uncoordinated Lingual Movement Limited Mandibular Movement Delayed or absent swallow Poor Pharyngeal Motility 33

34 Aspiration: During the Swallow Reduced laryngeal elevation Inefficient / absent closure of laryngeal vestibule (vocal cords) Decreased anterior movement of the hyoid bone Decreased closure of true or false cords Aspiration: After the Swallow Residue in the oral cavity poor oral tongue movement Residue in valleculae Reduced tongue base retraction Unilateral pharyngeal paralysis Residue in pyriform Reduced laryngeal elevation Reduced CP opening Reduced hyolaryngeal excursion Residue on PPW Reduced pharyngeal wall contraction forward and lateral Jennifer Jones PhD, CCC-SLP, BCS-S, C/NDT Board Certified Specialist in Swallowing and Swallowing Disorders Certified in Neurodevelopmental Treatment TalkTools 1852 Wallace School Road, Suite H Charleston, SC Tel: info@talktools.com 34