Medical fair dysphagia talk 2011
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Medical fair dysphagia talk 2011

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Slide for my talk at the QSNCC ,on Swallowing Rehabilitation. 15 Sept 2011.

Slide for my talk at the QSNCC ,on Swallowing Rehabilitation. 15 Sept 2011.

Assistant Prof. Parit Wongphaet,M.D.
spine.clinic@yahoo.com

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Medical fair dysphagia talk 2011 Medical fair dysphagia talk 2011 Presentation Transcript

  • SwallowingRehabilitation Parit Wongphaet, MD.
  • “The catalogue”• Baic Positioning• Stretching Exercises• Massage• Strenghtening Exercise• Facilitation Technic• Compensatory Swallowing Technic• Neck Positioning• Food Adaptation• Special Utensils
  • “The catalogue” Comprehensive• Baic Positioning• Assessment Stretching Exercises• Massage• Strenghtening Exercise• Facilitation Technic• Compensatory Swallowing Technic• Rational Neck Positioning• Food Adaptation• Mangagement Special Utensils
  • “The catalogue”• Baic Positioning• Stretching Exercises•• So much Massage Strenghtening Exercise•• options…. Facilitation Technic Compensatory Swallowing Technic• Neck Positioning• Food Adaptation• Special Utensils
  • The Normal Swallowing(brief review)
  • Normal sequence of actionsBolus control : glossopalatal sealBegin of oral transition : tongue tip elevation to alveolar ridgeTongue propulsion : food bolus move toward tongue baseNasopharyngeal seal : velum elevationPharynx constricts & Tongue base move backwardsLaryngeal elevationEpiglottis invertsLarynx closesUpper Esophageal Spincter open
  • Less than one second !
  • “The catalogue”• Baic Positioning• Stretching Exercises• Massage• Strenghtening Exercise• Facilitation Technic• Compensatory Swallowing Technic• Neck Positioning• Food Adaptation• Special Utensils
  • Prerequisits to Swallowing Rehab.• Consciousness : Awake ,Oriented• Attention , Memory, Learning Ability• Sitting Balance & Endurance• Medical conditions
  • Ramathibodi Bedside Swallowing Assessment (Rama-BSAF)• Consciousness• Oro-pharyngeal sensory• Oro-facial & neck motor• Respiratory control• Reflexes test• Swallowing test
  • Ramathibodi Bedside Swallowing Assessment (Rama-BSAF)• Functional Outcome• History of pneumonia• Clinical Impression on type of dysphagia• Choice of treatment compontents
  • Basic Positioning
  • Stretching Exercises &Massage
  • Strenghtening& Co-ordination Exercises
  • Swallowing Pattern Speech Generator Breathing Protective Control Reflex
  • Facilitation Technic
  • Compensatory Swallowing Technic
  • Mendelsohn
  • Technique Goal Indication InstructionForceful swallow Increase force of Weak tongue Swallow(Popderoux tongue base retraction forcefully1995) posterior movementSupraglottic Closure of Delayed In hale & holdSwallow airway during triggering of breath(Larsen 1973) swallow swallowing reflex Swallowing Impair laryngeal Voluntary protection cough& swallowSuper Tight closure of Same as above As above , butsupraglottic airway during also pressingSwallow swalow during(Martin 1993) swallowingMendelsohn Prolonged Limited Upper E- Keep larynx(Mc connel 1989) elevation of spinctor opening elevated until larynx : inprove Limited laryngeal swallowing is CP opening elevation finished
  • Neck Positioning
  • positioning goal IndicationAnteflexion of neck Use gravity Impaired oral bolus(welch 1993) Expand valleculae control space Delayed swallowing Facilitate posterior reflex tongue movement Impaired tongue retractionNeck extension Use gravity Same as above(Logemann 1989)Neck rotation to weak Facilitate food bolus Hemiparesis ofside (kirchner 1967) transport to healthy pharynx side Unilateral vocal cord Tighten vocal cord ? paralysisImpairedCombined anteflexion Reduce tone in upper opening of CPand rotation ( esophageal spincterLogemann 1989)Lateral bending to Use gravity Combined unilathealthy side tongue and(Logemann 1983) pharyngeal muscle weakness or resection
  • Food Adaptation
  • Special Utensils
  • Screening for dysphagia in stroke• 50 cc water test (likelihood ratio = 5.7)• Impaired pharyngeal sensation (liklihood ratio = 2.5)• Screening seems to reduce incidence of pneumonia ( RRR ~ 80-40%) Martino R, Dysphagia 2000
  • Citric Acid Cough Test
  • VideofluoroscopicSwallowing Examination(VFSS) Assistant Prof. Parit Wongphaet,M.D. 19 April 2007
  • Overview of Lecture• Normal Swallowing (brief review)• Instrumentation for VFSS• Indications & Contraindications• VFSS versus FESS & Clinical Assessment• Principles & Protocol• Normal VFSS• Pathological VFSS & reporting
  • Indications• Find safe eating condition• Identify aspiration risk
  • Contraindications• Medically unstable• Cannot position• Poor cooperation
  • VFSS versus FESS &Clinical Assessment
  • Fiberoptic Endoscopic Evaluation of Swallowing
  • VFSS FESS clinicalIntra yes no nodeglutative problemsRadiation exposure yes no NoVoluntary laryngeal +/- yes +/-controlLaryngeal sensory no yes +/-testing (cough reflex testing)
  • Instrumentation forVFSS• Same as Fluoroscopic Examinaitons• Additional Items • Video Recorder • Bare minimum 10 fps • VHS & DVD(25-29fps) • Freeze-Frame playback • Timer (milliseconds)
  • Principles & Protocol• Instrument check• Patient instruction & consent• Baseline anatomy review• Lateral • 3 ml liquid x2 • 5 ml liquid • Cup drink • 5 ml nectar • 5 ml pureed • Cookie• Addition repeated swallowing as needed• Special maneuvers as appropriate
  • Normal VideoFluoroscope study• No penetration• No aspiration• Fast and complete laryngeal movement• No retention
  • What to look for
  • Abnormal VideoFluoroscope study• penetration• Aspiration• Nasal regurgitation• Delayed triggering or decreased laryngeal excursion• Decreased or ineffective cough when aspirate• retention
  • Common positive findingsin patients withneurogenic dysphagia• Delayed swallowing reflex triggering 88%• Dysfunction CP 75%• Decreased tongue movement 74%• Drooling related problems 60%• Abnormal (hypo/hyper) gag reflex 42/10% Posiegel M. Nervenarzt 2002
  • Pre-deglutative
  • Intra deglutative with CP spasm
  • Before & after
  • Cp not open
  • Post deglutative
  • Additional SwallowingTry• Neck Positioning • Rotation,flexion,extension,lateral bending• Special Maneuvers • Mendelson • Supraglottic • Super-supraglottic • Forceful swallowing
  • positioning goal IndicationAnteflexion of neck Use gravity Impaired oral bolus(welch 1993) Expand valleculae control space Delayed swallowing Facilitate posterior reflex tongue movement Impaired tongue retractionNeck extension Use gravity Same as above(Logemann 1989)Neck rotation to weak Facilitate food bolus Hemiparesis ofside (kirchner 1967) transport to healthy pharynx side Unilateral vocal cord Tighten vocal cord ? paralysisImpairedCombined anteflexion Reduce tone in upper opening of CPand rotation ( esophageal spincterLogemann 1989)Lateral bending to Use gravity Combined unilathealthy side tongue and(Logemann 1983) pharyngeal muscle weakness or resection
  • Mendelsohn
  • Technique Goal Indication InstructionForceful swallow Increase force of Weak tongue Swallow(Popderoux tongue base retraction forcefully1995) posterior movementSupraglottic Closure of Delayed In hale & holdSwallow airway during triggering of breath(Larsen 1973) swallow swallowing reflex Swallowing Impair laryngeal Voluntary protection cough& swallowSuper Tight closure of Same as above As above , butsupraglottic airway during also pressingSwallow swalow during(Martin 1993) swallowingMendelsohn Prolonged Limited Upper E- Keep larynx(Mc connel 1989) elevation of spinctor opening elevated until larynx : inprove Limited laryngeal swallowing is CP opening elevation finished
  • Outcome of IPD swallowing rehabLevel of feeding Befor Afte e rFully normal 14 52With adaptation 5 42Limited food texture 24 8With adaptation and limited 8 35food texturePartial oral feed 26 25Enteral feed only 131 36 Posiegel M. Nervenarzt 2002
  • Screening for dysphagiain stroke• 50 cc water test (likelihood ratio = 5.7)• Impaired pharyngeal sensation (liklihood ratio = 2.5)• Screening seems to reduce incidence of pneumonia ( RRR ~ 80-40%) Martino R, Dysphagia 2000
  • Screening for dysphagiain stroke• 100 cc water test• Speed • Sensitivity 85% • Specificity 50 %• Choking or Wet voice • Sensitivity 45 % • Specificity 91 % Meng-Chun Wu,et al. Dysphagia 2004
  • Videofluoroscopy Swallowing Study (VFSS) Course & Workshop Spine.clinic@yahoo.com• 13 September 2007• Queen Sirikit National Conference Center• Key Note Lectruer – Professor Christian Hannig – Technical University Munich, Germany• Course Objective• “Enable Participants to Confidently Perform and Interprets VFSS”
  • A 63 year-old male, DM,HT,DLP - Lt MCA infarction 10 years ago, presented with loss of consciousness and fully recovery - Rt MCA infarction 8 months ago, presented with loss of consciousness and mild weakness of Lt side Now clinical was improved, but still has swallowing problem Clinical assessment at first time(Jan 2011) showed drooling, impaired lip and tongue movement and cannot trigger his larynx and cannot clear his secretion. NG tube was inserted. He also developed aspiration pneumonia 3 times and wt loss.Now showed normal lip and tongue movement, mildly apraxia,normal laryngeal triggering, 2 FB-excurtion, can clear secretion usually. Currently he can eat banana via oral tract. : Can he progress to more “advanced” feeding?
  • Banana กล้วยสุก
  • Soup-like
  • Water-like