Dysphagia Treatment: What are We Doing, and Why?

Transcription

1 Dysphagia Treatment: What are We Doing, and Why? ASHA Convention, 2014; Orlando James L. Coyle, Ph.D., CCC SLP, BCS S University of Pittsburgh jcoyle@pitt.edu 1

2 Treatment 2

3 Aims, targets and ingredients Aims: the clinical end point sought The old long term goals The end point we seek to attain in treatment Targets: specific elements of change The old short term goals or objectives The components of change leading to our aim Ingredients: what clinician does to hit targets The old methods 3

4 Aims & Targets 1. Eliminate aspiration 2. Train airway protection 3. Increase adherence 4. Speed recovery 5. Retest, modify independence 6. Etc. Target Target Target Target AIM HEALTHIER PATIENT 4

5 Treatment Attributes of Groupings Structural Tissue Properties Organ function Skilled performance Cognitive/ affective representations Targets Size, shape, flexibility Output, efficiency, etc. Speed, efficiency Knowledge, change attitude Mechanism of action Remodeling of tissue Habituation, substitution Learning Affective processing Essential ingredient Apply energy to tissues Change in output Facilitation of performance Facilitate acquisition Active ingredients Types of energy applied Patient effort, motivation Instructions, guidance, feedback How knowledge is organized, learned by patient Dosing parameters Amount, intensity, progression Methods to enhance effort, motivation Progression, schedule (intensity, dosage) Amount of information/time, repetition, rehearsal Examples Muscle enlargement Strengthening, plasticity Swallowing training, control Pt education, counseling, referrals Hart et al.,

6 Consequences of Dysphagia Aspiration Bolus mismanagement Pneumonia Malnutrition Premature mortality Targets Aims 6

7 Selecting aims/targets Treatment decisions require accurate diagnosis The observation always has a cause and if we miss it, we treat a symptom and not its cause Pneumonia is multifactorial Aspiration pneumonia incidence is relatively low! Perfect swallowing is often not feasible 7

8 Justifying Treatment Is there a reason to believe that: Dysphagia will cause/has caused health problems? Current function is worse than prior function? Selected intervention will likely improve health/function? Termination criteria? Would you pay for this out of pocket? Is patient a good candidate for selected behavioral interventions? 8

9 Some Common Interventions We choose them because research showed they do something Intended consequences Years later, many have been found to do other things Unintended consequences Sometimes good Sometimes not so good 9

10 Some Common Interventions compensate 1. Head rotation posture* divert bolus Developed for unilateral pharyngeal paresis Directs bolus to opposite side of pharynx BUT IT ALSO DOES THIS: Increases UESO diameter (to either side in normals) Reduces UES & PS pressure (to either side, normals) Increases intrabolus pressure THREE TARGETS WITH ONE METHOD! Logemann et al (1989); Takasaki et al.,

11 Some Common Interventions compensate 2. Chin down posture* reduce aspiration Patients with aspiration due to pharyngeal delay 50% did not aspirate with CDP Valleculae widened BUT IT ALSO: Reduces intrabolus hypopharyngeal pressure** Contraindicated in patient with weak constrictors CAUSES ASPIRATION from pyriform sinus*, *** *Shanahan et al. (1993); **Bulow et al (2002); ***Ra et al,

12 Some Common Interventions compensate 3. Increase duration of UES opening* Mendelsohn Maneuver Maintains/prolongs HLE BUT IT ALSO: Is difficult to teach, difficult to perform SEMG biofeedback training improves treatment effect* ** *Logemann et al (1990); ** Coyle (2008) 12

13 PLOTTING TREATMENT DATA TO TEST FOR TREATMENT EFFECTS p<0.05 p<0.05 First Visit Baseline (A-1) UES 2SD Test Opening A-1 --> B-2 SEMG MeanA ( V) Duration Second Visit Post-Treatment (B-2) Durations +2SD -2SD Baseline mean (1.6145) Amplitude ( V) seconds +2SD (1.9008) -2SD (1.3283) Trials 2 SD Band Test: p<0.05;c Statistic: p=

14 Some Common Interventions compensate 4. Self protection of airway Supraglottic swallow (SGS) Closes airway before swallow super SGS effortful vocal fold closure + tilts arytenoids BUT IT ALSO DOES THIS Earlier/longer UES relaxation and HLE* ** Increases intrabolus pressure* Reduces oral residue* ANOTHER THREE FOR ONE TREATMENT! *Bulow et al (2002); **Ohmae et al., 1996; 14

15 Some Common Interventions compensate HOWEVER It can be Dangerous!!! SGS and SSGS assessed in patients with stroke With or without coronary artery disease Both produced cardiac arrhythmias in most of these patients** Even healthy people showed BP increases *Bulow et al (2002); **Chaudhuri et al. (2001) 15

16 An alternative: Swallow respiratory coordination Healthy swallows are followed by exhalation Disordered swallows are followed by inhalation Training patients to coordinate breathing and swallowing? Inhalation before swallow Swallow Exhale after swallow Much easier to teach, less effortful, lower risk Gross et al, 2009; Leslie et al, 2002a,b; Leslie et al,

17 Some Common Interventions compensate 5. Tongue holding/tether Bulge in PPW during swallow Inhibits tongue motion BUT IT ALSO: Increases oral residue in healthy subjects, AND Is not intended for use by patients when swallowing! Fujiu & Logemann (1996) 17

18 Some Common Interventions compensate 6. Bolus modification Bolus size: Larger bolus Earlier onsets: HLE, tongue movement, UES opening* Bolus taste, temperature, consistency Earlier activation in some patients** BUT Will patient eat/drink it??? *Cook et al., 1989; Dantas et al., 1990; **Ding et al.,

19 7. Texture/Diet modification Is not the default intervention Should be the last compensatory method evaluated in testing (Logemann, 1993) Issues: What does texture modification do for patient? Is patient amenable to modification? Will patient eat the prescribed diet Malnutrition, dehydration 19

20 Do thickened liquids cause dehydration? 20

21 Thickened liquids Hydration and thick liquids Sharpe et al., 2007 >95% water absorbed from thick mixtures No difference between water, thick water Hydration and thick liquids Reduced fluid intake when thick prescribed Whelan, 2001: 24 stroke patients Mean fluid intake = 455 ml/day 21

22 Do thickened liquids prevent aspiration or pneumonia? Protocol 201 (Logemann et al., 2007; Robbins et al., 2008) In liquid aspirators, is chin down posture or thick liquids Superior at reducing aspiration during a VFS (Part 1:VFS) Superior at reducing pneumonia incidence (Part 2: 3 mo.) Parkinson s disease, dementia, both 22

23 Eligible, consent: VFS Aspirate thin liquids on VFS (711) VFS: 1. Thin/chin 2. Nectar 3. Honey PART 1: Do thick liquids or chin down posture prevent aspiration? Thin liquid Part 1 Results Thin liquidchin down Nectar Honey Aspiration 100% 68% 63% 53% Preference 1st 2nd 3rd last 23

24 PART 2: In liquid aspirators, which has lowest pneumonia incidence: Thin/CDP? Nectar? Honey? 3 month randomized study Aspirated none in Part 1 (10) Aspirated all 3 in Part 1 (42) Pneumonia Chin thin All thick liquid Nectar Honey 6 (7%) 4 (5%) 0 (0%) 4 (10%) 18 (9.8%) 24 (14%) 10 (11.5%) 14 (19%) 24

25 8. Water Protocol Evidence Results Becker, et al., 2008 Pneumonia: 1 patient in each group UTI: 2 patients in each group Death: 2 treatment deaths, no control deaths Independent patients consumed significantly less 25

26 Recent Evidence Karagiannis et al. (2011) Significant increase in lung complications (6/42) vs. controls (0/34) Carlaw et al. (2011) No complications in either group More fluid intake in protocol patients 26

27 9. Using the /k/ phoneme Modified Valsalva: make a /k/ as hard as you can and hold it for as long as you can, don t let any air escape. Hawk: say the word hawk, make the /k/ as hard as you can. Perlman et al,

28 Hawk, modified valsalva produced ~20% of muscle activity seen during swallow 28

29 10. Carbonated thin liquid * Order effects**? Command swallow effects***? Cued swallows significantly shorter duration *Bulow et al., 2003; ** Robbins et al, 1999; *** Daniels et al.,

30 Carbonated thin liquid Sdravou et al., 2012 Significantly less PEN/ASP Citric acid (strong acidic taste) + NaHCO3 Non carbonated liquid always deployed first Krival, 2007 No reduction in PEN/ASP scores with carbonation Same additives for producing carbonation Non carbonated liquid always deployed first 30

31 11. NMES Most studies contain flaws Most frequent No control for recovery Lack of blinded judges Subjective criteria for success Recent work with transoral NMES to pharynx Interesting, need more data Patient selection? What are we treating? 31

32 This preliminary meta analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing. Because of the small number of studies and low methodological grading for these studies, caution should be taken in interpreting this finding. These results support the need for more rigorous research in this area. Small = clinically insignificant Low grading = invalid results Carnaby Mann & Crary,

33 12. Feeding tubes? Unequivocal lack of benefit At end of life In advanced dementia Imposes additional (and unintended) risks Increased aspiration risk from stomach Does not mitigate oral aspiration 33

34 13. Exercise Testing/measurement Exercise protocol 34

35 Significant Differences Lingual Strengthening Exercise Reduced oropharyngeal residue Pharyngeal (p =.03), overall (p =.01.02) Improved PA scores (3mL, 10mL liquid) 4 weeks: p =.02; 8 weeks: p =.005 Increased isometric pressure Anterior 4 8 wk:(p =.001); posterior (p =.01,.001) Increased swallowing pressure All consistencies/volumes at 4, 8 weeks. 35

36 Restorative Methods Exercise Resistive expiratory exercise Increase force of expiratory effort Sapienza et al. 36

37 Restorative methods Shaker exercise* Head Neck flexion while supine Increase AP dimension of UES during swallow Eliminated tube feeding in stroke patients ** *Shaker et al (1997), **Shaker et al (2002); 37

38 Jaw Opening Exercise Fig 1 10 seconds, 5 repetitions with a 10 second rest period between each, 2 sets daily. Significant increases (p<.05): Vertical hyoid motion UES opening diameter, Pharyngeal transit duration Near significant (p=.05) anterior hyoid motion Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw Opening exercise for insufficient opening of upper esophageal sphincter. Archives of Physical Medicine and Rehabilitation, 93(11),

39 McNeill program Exercise based intervention specific to swallow activity Swallow hard in a single swallow Systematic increase bolus volume, consistency as eating rate increased Homework (eating what was used in treatment) Record keeping at home FOIS, MASA, patient self rating Kinematic analysis *Crary et al., 2012 (above); Carnaby Mann et al., 2010 (N=8); Lan et al. (2012) N=8 39

40 Statistically significant increases in all measures after treatment Marginal maintenance at 3 months in physiologic measures Clinical significance (Effect sizes Hedge s g) MASA 0.94 FOIS 1.42 VFS 0.18 VAS 1.26 N=9 40

41 Improved Health, Reduced Risk Goals Prior Evidence! Aims New Evidence! Target 1 Target 2 Target 3 Objectives 41

42 Summary Aims are determined based on many factors Targets are specific and lead to one or more aims Evidence is essential in generating them! Generate your own evidence! Evidence consumers are the customers! 42

43 Thank you. 43