gsha convention, 2015, athens, ga - … 2015 convention; j. coyle, phd 01/09/2015 (c) james l coyle...

GSHA 2015 Convention; J. Coyle, PhD 01/09/2015

(c) James L Coyle except as noted 1

What’s wrong with my patient?Sepsis, Congestive heart failure, esophageal

function and disorders

James L. Coyle, Ph.D., CCC‐SLP, BCS‐SUniversity of Pittsburgh

[email protected]

GSHA Convention, 2015, Athens, GA

Disclosures

• I have a job and they give me a salary• University of Pittsburgh

• I see patients 2‐3 times per week• So I am biased toward their health

• NIH funds 25% of my time on an RO‐1

• I give several conferences lectures annually• Honorarium

• No products, no conflicts of interest

Patients with dysphagia

• Pulmonary diseases

• Neurological causes

• Digestive conditions• Severe illness and its effects on other systems

• CHF, Esophageal function/disorders, sepsis



Congestive Heart Failure

CHF

5© Connexions

Public domain

©Creative Commons license



Pulmonary edema

• Leakage of circulatory fluid into alveoli• Most common cause = congestive heart failure• Pulmonary hypertension “pushes” fluid out of capillaries

Pulmonary hypertension7

(R) heart

(L) heart

CHF and Pulmonary Edema

8

CHF & Pleural effusions• Fluid filling parts of pleural cavity• Preventing lung expansion during inspiration

• Gravity dependent “bag of water”

Pleural cavity9



CHF (transudative), Inflammatory (exudative)10

Pleural Effusion

© Nevit Dilman GNU free documentation license

effusions cardiomegaly

edema

CHF and dysphagia

• Pleural effusions, pulmonary edema• Reduce tidal volume increase respiratory rate

• Respiratory swallow incoordination

• RR > 30: each breath duration = swallow duration

• Tendency to overlap increases

• Inhale swallow exhale: REVERSED



CHF and dysphagia

•Assessment• Respiratory rate, SpO2

• At rest• During various assessment procedures

• Direction of airflow after swallows• <80‐90% expiration may indicate reversal

• Eg. Reversed post‐swallow exhalation in CVA, COPD

• Variability• Assess at different times of day; medication cycle

• Diuresis

Sepsis

Infection and sepsis (systemic infection)

• Infection• Pathogenic Organism…

• Organism that causes disease in host organ

• … enters and occupies host organ/tissue …• … draws nutrients from host and damages tissue …

• … reproduces and generates metabolic waste …

• … organism, offspring, waste, are all IRRITANTS …

• … blood organ barrier disrupted …

• … organism enters circulatory system = SEPSIS

• … process repeats in other organs …• Depending on organ … effects of infection … ???

15



Infection and sepsis

• Sepsis = septicemia = bacteremia (if bacterial)• Pathogen Damage to vascular structures, organs

• Leakage of fluid from blood vessels

• Hypotension • Organs need adequate blood pressure to function

• Organ metabolic failure

• Hypotensive shock• Multi‐organ hypotensive failure (high mortality)

• Organism infecting other organs• Example: UTI sepsis hematogenous pneumonia

16

Infection and sepsis

• Effects of sepsis• Depends on organs affected: Examples …• Brain and CNS

• Progressive lethargy reduced oral intake dehydration more lethargy more reduced intake more dehydration …

• Urinary system• Impaired filtration accumulated [organ] metabolic waste impaired nervous system and other organ function

• Metabolic acidosis

• Example to illustrate• E. coli, pneumococcus in blood culture

17

Sepsis

• The challenge in sepsis…• Acute mental status changes affect sensorimotor function

• Patient is impaired

• SLP examines patient• Patient performs poorly; diagnoses “dysphagia”

• Pulmonary infection now presumed to be ASPIRATION‐RELATED

• Association sticks and becomes a permanent part of the record

• Patient has permanent “history of aspiration pneumonia”

18



Sepsis• Assessment considerations

• Stage of recovery• Organs affected

• Pulmonary damage: alveolar noncompliance, debris from infiltrates ALL

• Increase respiratory rate

• Muscle damage• weakness, increased respiratory rate

• Brain damage• Cognitive impairments after sepsis

Sepsis

• Patient endurance• Weakness

• Effects of prolonged mechanical ventilation

• Depends on what organs suffered what damage…

• 40% survival … patient is not the same after surviving septic shock!

The Esophagus



Digestive System

22© Conexions

Digestion

• Propulsion• Mechanical digestion

• Food is broken down to simpler form, mixed

• Chemical digestion• Broken down food is dissolved into nutrients

• Absorption• Nutrients absorbed into blood

23

Organization of the GI “Tube”

24© Conexions

After the pharynx…

(Vagus)



Esophagus

• Upper 1/3 striated muscle• Muscle diseases affect function

• Myositis, myasthenia gravis, myopathy/dystrophy

• Lower 2/3 progressive smooth muscle• Other disease mechanisms affect function

• Scleroderma

• Achalasia

• UES, LES differences

25

Anatomy of the gastroesophageal junction

26

Esophageal “peristalsis”

27Creative Commons 3.0, Gnu public



Esophageal disorders

28

Structural Disorders of Esophagus

• Hiatus Hernia• Stricture: Esophageal web, Schatzki ring

• + congenital, inflammatory, traumatic, reflux induced, narrowing of esophageal lumen

• Diverticulae• Pulsion• Traction

29

Hiatus Hernia

• A. Normal anatomy

• B. Flattened flexure

• C. Sliding hernia

• D. Irreducible hernia

30



Paraesophageal hernia

31©Copyright Science Press Internet Services

Hiatus hernia

Schatzki`s ring

32

on barium esophagogram

on endoscopy

‐ <13mm: always symptomatic‐ >20mm: rarely symptomatic

Esophageal web

33Creative Commons 3.0



Zenker Diverticulum

• Bulge in inferior constrictor

• Pulsion diverticulum

• Outpouching of mucosal envelope

• Superior to cricopharyngeal bar

• High pressure zone

34Coyle, 2009

Zenker’s Diverticulum

• Outpouching of mucosal tube of UES• Bulges through muscular layer• Pressure‐induced overstretching

• Incidence: 1 in 1,000 to 1 in 10,000• Subclinical signs present before diagnosis

• Excessive intraluminal pressure• Cricopharyngeal prominence or bar

• Elderly patients: about 1/3

• Typically left of midline

Coyle, 2009

Zenker diverticulum

36



Progression of symptoms

• Resistance multiple swallows regurgitation anorexia recurrent unexplained LRTI

Telltale observations on VFS• Unexplained pyriform sinus residue

• Barium filled defect rises into field

• Air‐fluid level

• Barium re‐enters pyriform sinuses from below

Coyle, 2009

Esophagitis

• Inflammation of esophageal mucosa

• Extrinsic• Irritants mucosal inflammation

• Intrinsic• Eosinophilic esophagitis

• Eosinophils infiltrate esophageal mucosa

• Stricture, impactions, dysmotility

• “Trachealization” of mucosa

39



Esophagitis

40Creative commons 3.0

Candida esophagitis (candidiasis)Herpetic esophagitis

Eosinophilic esophagitis

41Creative commons 3.0

Disorders of Esophageal Motility

• Gastroesophageal reflux• Esophageal dysmotility

• Mild dysmotility

• Diffuse esophageal spasm

• Achalasia

42



Disorders of Esophageal Motility

43

• Gastroesophageal Reflux• LES permits gastric contents to re‐enter esophagus

• food is normally reduced by acid, pepsin, bile

• all strong mucosal irritants

• mucosal injury, inflammation, re‐epithelialization, scarring

• Esophago‐laryngeal reflex (Shaker et al., 1992)

Gastroesophageal Reflux

44

Disorders Related to GER

45

• Esophagitis• Subglottic Stenosis

• Chronic laryngitis, hoarseness, cough• Aspiration Pneumonitis

• Chronic bronchitis, tracheobronchitis

• Globus‐relieved by swallowing• ? increased UES pressure in response to GER



Other Esophageal Motility Disorders

46

• Disordered peristalsis• disorganized esophageal clearance with residuals

• Reduced or absent peristalsis• stasis in esophagus

• increased esophagopharyngeal reflux risk• AKA extraesophageal reflux

• AKA L.P.R.

•Achalasia • absent peristalsis with absent LES opening

Achalasia

47

Other Esophageal Motility Disorders

48

• Diffuse Esophageal Spasm

• Nonspecific esophageal motility disorder

• 25‐50% of abnormal motility study results performed for chest pain and dysphagia

• Presbyesophagus• diminished peristalsis

• distal findings more prevalent

• impaired LES distension with proximal dilatation



49

Tertiary contractions Diffuse esophageal spasm

Signs and symptoms

• Pharyngeal globus sensation• Stricture (web, ring)

• CP bar

• Diverticulum

• Achalasia

• Esophagitis

• Hiatus hernia

• Esophageal varices

50

Signs and symptoms

• Early satiety• Achalasia

• Stricture

• Gastroparesis

• Hiatus hernia

51



Signs and symptoms

• Cough• Esophagitis (esophagolaryngeal reflex)

• Achalasia• Filling of esophagus aspiration

• Zenker diverticulum• Regurgitation from pouch pharynx aspiration

52

Signs and symptoms

• “a funny squirting sound in my throat…”• Zenker diverticulum

• Need to swallow several times…• Zenker diverticulum

• Esophageal motility disorder

• Cricopharyngeal bar

• Esophageal varices

• Of course, oropharyngeal dysphagia

53

Signs and symptoms

• Postprandial burning

• Gastroesophageal reflux

• Nocturnal awakening with cough

• Gastroesophageal reflux

• Zenker diverticulum

54



Esophageal disorders

• Symptoms often mimic oropharyngeal dysphagia

• Negative oropharyngeal exam with persistent symptoms refer to GI

• Need to know when to refer!

Summary

• Diseases produce changes in patient function• They also explain what is wrong with my patient

• Dysphagia is a symptom!

• Assessing more than swallowing is essential!

Thank [email protected]



Dysphagia Treatment: Expected and Unexpected Results of Common

Interventions

58

James L. Coyle, Ph.D., CCC‐SLP, BCS‐SUniversity of Pittsburgh

[email protected]

GSHA Convention, 2015; Athens, GA

Disclosures

• I have a job and they give me a salary• University of Pittsburgh

• I see patients 2‐3 times per week• So I am biased toward their health

• NIH funds 25% of my time on an RO‐1

• I give several conferences lectures annually• Honorarium

• No products, no conflicts of interest

What is treatment?

• Are we treating the bolus, the patient, or something else?

60



TreatmentAttributes 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., 201461

Goals and objectives

• Goals: the end point we seek to attain in treatment

• What is our Goal?• Eliminate aspiration?• Cause patient to swallow “better”?• Least restrictive diet without aspiration?• Improve biomechanics?

62

Selecting goals/objectives

• 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

63



• Objective measure of change(+ or ‐) ?

• Incremental reassessment

• Data collection – are we doing it?

• Termination criteria?

• Would you pay for this out of pocket?

• Is patient a good candidate for selected behavioral interventions?

64

Justifying Treatment

Some Common Interventions…

• They are designed for this…• Intended consequences

• But they also do this…• Unintended consequences

• Sometimes good…

• Sometimes not so good…

65

Some Common Interventions… compensate…

1. Head rotation posture* ‐ divert bolus Directs bolus to opposite side of pharynx Compensate for unilateral noncompliance

BUT IT ALSO: Increases UESO diameter (rotation to either side in normals)

Reduces UES pressure (either side, normals)

Increased intrabolus pressure Reduces contralateral pyriform sinus pressure**

66*Logemann et al (1989); **Takasaki et al., 2012




• 2. Chin‐down posture*‐ reduce aspiration• Patients with aspiration due to “pharyngeal delay”

• 50% did not aspirate with CDP (OR = 0.5)• Continued aspirators: pyriform sinus residue aspirated• Valleculae widened

• Anterior bolus position (phar. delay, oral containment)

• BUT IT ALSO:• Reduces intrabolus hypopharyngeal pressure**

• Contraindicated in patient with weak constrictors

67*Shanahan et al. (1993); **Bulow et al (2002)

Oral containment vs. delay?

• Pharyngeal delay• Abnormally long pause between volitional oral transit of an organized bolus and onset of hyolaryngeal excursion

• Oral containment impairment• Loss of posterior bolus containment (tongue & soft palate); unorganized material enters pharynx before hyolaryngeal excursion

68

Pharyngeal Delay

Impaired oral containment

69




•3. Head/neck lateral flexion posture

• oral flow diversion toward side of flexion

• unilateral lingual, oral/facial motor, sensory deficits

• It does not affect pharyngeal physiology

70


• 4. Increase duration of UES opening*• Mendelsohn Maneuver

• maintains prolonged HLE

• BUT IT ALSO:• Is difficult to teach, difficult to perform

• SEMG biofeedback training improves treatment effect* **

71*Logemann et al (1990); ** Coyle (2008)

72

First VisitBaseline (A-1)

Second VisitPost-Treatment (B-2)

2‐Standard Deviation Band Sample Graphic

2 SD Band Test: p<0.05;C Statistic: p=0.00001.

p<0.05

UES OpeningDuration

seconds




• 5. Self‐protection of airway• Supraglottic swallow (SGS)

• Closes airway before swallow• “super SGS”

• “effortful” vocal fold closure +Tilts arytenoids

• Earlier/longer UES relaxation and HLE* **

73*Bulow et al (2002); **Ohmae et al., 1996;

• Does the work of 3 other interventions• Increased intrabolus pressure*• Increase UES Opening and laryngeal closure*• Reduced oral residue*

• And can be Dangerous!!!• Produces arrhythmia in certain patients**

74*Bulow et al (2002); **Chaudhuri et al. (2001)

BUT IT ALSO:


Swallow respiratory coordination

• Healthy swallows followed by exhalation• Disordered swallows followed by inhalation

• Training patients to coordinate breathing and swallowing?

75Gross et al, 2009; Leslie et al, 2002a,b; Leslie et al, 2005



• 6. Tongue holding/tether• Bulge in PPW during swallow

• Inhibits tongue motion

• Increases oral residue in normals

• BUT IT ALSO:

• Is not intended for use by patients when swallowing!

76

Fujiu & Logemann (1996)


• 7. Bolus modification• Larger bolus

• Earlier HLE, tongue movement, UES opening*

• Taste, temperature, consistency• Earlier activation in some patients**

• Will patient eat/drink it???

77*Cook et al., 1989; Dantas et al., 1990; **Ding et al., 2003


• And when we combine maneuvers we treat multiple problems

• …but we need evidence that each is appropriate for the impairment

78



What about texture modification and Water?

79

Diet modification

• 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

80

Diet modification

• Assuming that behavioral/compensation fails

• Increasing friction and reducing flow rate (thick)• When pharyngeal stage is delayed and dangerous

• Oral containment cannot be otherwise managed

• Some times when laryngeal closure is incomplete

• Decreasing friction and increasing flow rate (thin)

• Inability to propel bolus• UES does not distend adequately• Need good airway protection

81



Thickened liquids

• Reduces aspiration of thin liquids• Kuhlemeier et al., 2001; Logemann et al., 2008

• Swallow apnea later/longer with thick liquids• Hiss et al., 2004; Butler et al., 2004

• More effort needed to clear thick• Nicosia et al., 2001

82

Thick liquids

• Thin liquids aspirated most frequently• Compared to other viscosities

• Spawned experimentation with thick liquids

• Theory for dysphagia use:• Slowing the flow

• Compensates for mistimed airway closure

• What do we know about them?

83

Water

• Intake of water: ~2300 mL per day• 2100mL through intake• 200 mL synthesized by body (CHO metabolism)

• Variations in water intake• Climate, habits, physical activity

84



Thickened liquids

• Patients do not like thick liquids• Garcia, 2005: prepackaged vs. mixed

• Prepackaged better : Whelan, 2001

• Great variability in thick liquids• Prepackaged & mixed: UW/VA Swallowing Research Lab, 1999

• Prepackaged: Garcia, et al., 2005; Steele, 2005

85

Do thickened liquids cause dehydration?

86

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

87

Whelan, 2001,Finestone et al, 2001



Thick liquids

• Protocol 201 (Logemann et al., 2007; Robbins et al., 2008)

• Problem: Thin liquid aspiration

• Chin Down Posture vs. Thick liquids• Nectar, honey

• Parkinson’s disease, dementia, both

88

89

Aspirate thin liquids on VFS (711)

VFS: 1. Thin/chin 2. Nectar

3. Honey


VFS: 1. Thin/chin 2. Nectar

3. Honey

Eligible, consent: VFS

PART 1:Do thick liquidsor chin‐down

posture preventaspiration?

Thin liquid Thin liquid‐chin‐down

Nectar Honey

Aspiration 100% 68% 63% 53%

Preference 1st 2nd 3rd last

Results

Some aspirated on 1Some aspirated on 2

Some aspirated on ALL 3

90

Thin/Chin259

Nectar133

Honey123

Pneumonia, death

Dehydration, UTI, compliance,

etc.

Randomization515 patients 3 months


VFS

Aspirate on 1 or 2 interventions

Excluded from Part 2: cannot randomize to a

condition

(166) (345)

Aspirate on NOinterventions (all

worked)

Aspirate on ALL 3interventions (all

failed)

PART 2:What is pneumonia

incidence in aspirators of thin

liquid randomized to drink:

nectar thick,honey thick,

chin‐down/thin for 3 months?



91

Results of Part 2


Aspirate on NO interventions

Aspirate on ALL interventions


Aspirate on NO interventions

Aspirate on ALL interventions

Thin/ Chin

Nectar HoneyThin/ Chin

Nectar Honey

Pneumonia(52)

166(aspirated on NONE

on VFS)

345(aspirated on ALL 3

on VFS)

4210

11% of all patients

Pneumonia

Chin‐thin All thick liquid Nectar Honey

All patients (52)

24 (10%) 28 (11%) 10 (8%) 18 (15%)

Aspirated none in

Part 1 (10)6 (7%) 4 (5%) 0 (0%) 4 (10%)

Aspirated all 3 in

Part 1 (42)18 (9.8%) 24 (14%) 10 (11.5%) 14 (19%)

Patients who aspirated on ALL 3, drinking honey thick liquids,had twice as many pneumonias as those drinking thin liquids

Overall, patients drinking thin or thick liquids had similar pneumonia incidence

Pneumonia

92

Thick liquids

• Other results• Dehydration: Thin: 2%, Thick: 6%

• UTI: Thin: 3%, Thick: 6%

• Median hospital stay with pneumonia

• Honey (18 d.), nectar (4 d.), CDP (6 d.)

93



Thick liquids

• Do thick liquids reduce aspiration?• Yes

• Do thick liquids reduce pneumonia risk?• No

• Are aspirators more likely to get pneumonia?• Yes

• Do patients like thick liquids?• No

• Will they drink it if they don’t like it?• Probably not

94

Thick liquids

• So, what are we doing when we prescribe thick liquids???

• We think we are reducing risk…

• Are we just shifting risk to a different place?• Hydration kidneys? QOL?

95

Evidence Summary for using Free Water Protocols

“Free Water” Protocols

96



• Rationale of protocol per developers:• 1. Need for hydration – self evident

• 2. Poor compliance with thick liquids

• We have reviewed that data

• 3. Safety of water aspiration

• One study published before 2008!!!

97

“Free Water Protocol” Principles

Safety of water aspiration

• Bronchoalveolar lavage

• Whelan et al. (2001) reduced fluid intake in patients prescribed thick liquids

• Numerous citations on dehydration in dysphagia

• Animal studies of water aspiration

98

Evidence: one study before 2008

• Garon et al., 1997• 20 aspiration‐documented CVA patients

• Aspirated liquid only on VFSS

• Randomized to free water or no free water

• Duration: treatment + 30 day follow up

• Small and underpowered study• Yet the main evidence for protocol

99



• Results• No patient in either group developed pneumonia

• No dehydration, complications

• Intake of fluids comparable between groups

• 1210 mL (C) ‐ all thick• 1318 mL (E): 855mL thick, 463mL thin

• “Much less water than expected” by investigators (“we were surprised…”)

100

Half of daily needs

Water Protocol Evidence

• Randomization to water protocol or prescribed dietary fluid (26 patients)

• 17 patients requiring feeding assistance• 8 assigned to control, 9 to treatment

• 9 independent feeding patients• 3 assigned to control, 6 to treatment

• All received oral care four times per day

• Outcomes: pneumonia, death, UTI, FIM, LOS, intake

Becker, et al., 2008

101

• Results• Pneumonia: 1 patient in each group

• UTI: 2 patients in each group

• FIM: no significant difference

• FCM: no significant difference

• Length of stay: 29.1 days (control) vs. 15.8 (tx)


102Becker, et al., 2008




• Death: 2 treatment deaths, no control deaths

• Both patients that died had chronic pulmonary conditions

• Other findings:

• Independent patients consumed significantly less fluid than dependent patients (p<.01), regardless of group

103

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

104

Using the /k/ phoneme

105

Perlman et al, 1989

Modified Valsalva:“make a /k/ as hardas you can and holdit for as long as you can, don’t let anyair escape.”

Hawk:“say the word ‘hawk’,make the /k/ as hardas you can.”



106

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

Carbonated thin liquid

• Order effects**?• Command swallow effects***?

• Cued swallows significantly shorter duration

107

*Bulow et al., 2003; ** Robbins et al, 1999; *** Daniels et al., 2007

*

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?

108



• “This preliminary meta‐analysis revealed a smallbut 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

109

Carnaby‐Mann & Crary, 2007

End of life intervention

• What is the goal?

• Medicine tries to achieve the best balance of risks and benefits to achieve the goal

• Patient comfort vs. adverse outcomes?

110

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

111



What’s going on in the research?

• Exercise• Plasticity

• Diagnostic methods to assist with treatment

112

Restorative methods

• Emerging efficacy in the literature

• Exercise‐Preventive, Restorative, beyond?• physiologic logic, predicted baseline, target

• muscle strengthening requires repetition to modify contractile properties (hundreds, thousands…)

• Do range of motion exercises do anything?

113

Exercise

Tongue Press exercise

• AKA tongue press exercise• Device assisted with biofeedback

Lingual Strengthening Exercise

114



Testing/measurement Exercise protocol

115

Significant Differences

• 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.

Lingual Strengthening Exercise

116

Restorative Methods

• Exercise• Resistive expiratory exercise

• Increase force of expiratory effort

Sapienza et al.

117



• “Shaker” exercise*• Head‐Neck flexion while supine

• Increase AP dimension of UES during swallow

• “Eliminated tube feeding in stroke patients”**

118

*Shaker et al (1997), **Shaker et al (2002);

Restorative methods

• Sham (7) vs Real (11)• No significant difference in any biomechanical measures

• 11 real exercise pts. Pre‐ Post Real Exercise• AP UESO, anterior laryngeal excursion (ALE), all significantly increased from own baseline

119

Jaw Opening Exercise

120



Fig 1 10 seconds, 5 repetitions with a 10‐second rest period between each, 2 sets daily.

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), 1995‐1999.

http://dx.doi.org/10.1016/j.apmr.2012.04.025

Jaw Opening Exercise

Significant increases (p<.05): ‐Vertical hyoid motion‐UES opening diameter, ‐Pharyngeal transit duration

Near significant (p=.05)‐anterior hyoid motion

121

• “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

122*Crary et al., 2012 (above); Carnaby‐Mann et al., 2010 (N=8); Lan et al. (2012) N=8

McNeill program

• 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

123



Measure Baseline Post‐treatment

Post tx 3 months

Significance measure

g P g P

MASA 0.94 <0.02 0.13 0.67

FOIS 1.42 0.01 0.74 0.17

VFS 0.18 0.37

VAS 1.26 <0.01 ‐0.21 0.38

LP pressure 0.05 NS124

• Thermal Tactile Stimulation

• Thought to stimulate afferent pathways *

• No evidence supports sustained effects• High dosage over long term produced momentarily quicker onset of HLE (reduced DST)**

• Taste‐sour bolus (50% lemon juice/barium)

• Reduced aspiration in neuro patients***

• Reduced DST in stroke patients***

125*Fujiu et al. (1994); **Rosenbek et al (1991, 1996, 1998); ***Logemann et al (1994)

Facilitative Methods

Facilitative Methods• Interest in manipulating other sensory modalities

• Taste, vibratory sense, electrical stimulation (?)

• Can the brain be rewired in adults?• Emerging evidence that “something” is happening upstream

• MEG, EEG (record the effects), MRI

• TCMS (stimulate motor effects)

• Direct current stimulation

• Exercise

• Implantable intramuscular ES

Jayasekeran et al., 2010, 2011; Pelletier & Lawless, 2003; Malandraki et al., 2011 126



• What is plasticity?• Alteration in the outcome

• Motor learning theory?• Mass practice

• Dosage, intensity, progressive resistance + (other increments)

• Task specificity• Neural adaptation

127

Diagnostic methods

• High speed MRI imaging

• Still crude

• Patient must be supine

• Screening• Accelerometry and acoustics

128

Hype & enthusiasm

129



Evidence. What is Evidence?

Smith et al., 2003130There is no evidence that parachutes prevent injury or death

“… significant inverse relationship between pirates and global temperature.”

p<0.05!!!

A Little Data Can Be a Dangerous Thing…

131

132



133

134

Tactic 1 Tactic 2 Tactic 3

Strategies

Objectives

Improved Health, Reduced Risk

Goals

NewEvidence!

PriorEvidence!

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• Treatment is guided by accurate diagnosis

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• Evidence is essential• Generate your own evidence!

• Evidence consumers are the customers!

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