This presentation is for educational purpose only prepared for the class presentation about the discussion

1. Oro-motor Rehabilitation
Presentar : Ashik Dhakal
Moderator : Mr. Sydney Roshan Rebello

2. Learning objectives
• Introduction to oromotor dysfunction and it’s rehabilitation
• Factors affecting oral motor function
• Brief discussion about speech and swallowing dysfunction
• Clinical conditions leading to OMD
• References

3. Introduction
• Oro-motor dysfunction refers to the disturbance in vital functions (drinking,
chewing, sucking, swallowing, speech) that are dependent upon the co-ordinated
interaction of a set of neural structures.
• It also involves language motor articulation and gestural communication by means
of facial expression.

4. • Oral-motor rehabilitation is use of variety of exercises to develop
awareness, strength, coordination and mobility of the oral muscles. e.g,
improve muscle tone of the face or to reduce tongue thrust.

5. Factors affecting oral motor function
• Presence of medical conditions affecting function
• Presence of seizures
• Cognitive level
• Hypersensitivity
• Positioning
• Gagging, coughing.
• Tongue thrust
• Food texture, temperature
• Time alloted for intake.

6. Major Oromotor dysfunction
• Speech pathology
• Swallowing difficulty

7. Speech pathology
• Speech is one of our most important human behaviour which sets us apart from
animals like tool making.
• Disruption in the ability to communicate may impact on a person’s daily life in
important way.
• Disruption can be caused by
1. Structural abnormality (e.g., cleft palate)
2. Neurological conditions (e.g., stroke, Parkinson’s disease)
3. Non organic conditions ( non organic articulatory disorder)

8. • The use of speech for communication involves fine motor coordination of
components of the oral-motor system.
• Gestures, pantomime and other non-verbal pragmatic language behaviours, are also
essential elements of communication.
• The common of speech language pathology involves, aphasia, dysarthria.

9. Epidemiology
• Communication disorders exact a large economy costing US economy an estimated
$30 billion a year.
• National institute on deafness and other communication disorders (NIDCD)
estimated, 14 million population with speech and language disorder.
• In population >65 of age, 10.8% have speech and language disorder, <45 of age ,
9.9%.
• The largest population of communication impaired are children with language
disorder (43.7%), and articulation disorder (32.1%), aphasia 15% of adult speech
language impaired population.

10. Aphasia

11. • Aphasia is an impairment of language, affecting the production or
comprehension of speech and the ability to read or write.
• Aphasia can be severe or very mild depending on the pathology.
• It is estimated that there are more than 1 million individual with aphasia in the
US alone, and approximately 84,000 new patients with aphasia each year.
• The majority are older than 65 years of age and acquired aphasia as a result of a
stroke.
• Smaller number are the consequences of head trauma and neoplasm.

12. Types of Aphasia

13. 1. Fluent Aphasia : speech output that is facile in articulation, produced at a
normal rate, with preserved flow and melody is referred to as fluent aphasia.

14. 2. Non- fluent Aphasia : speech output that is characterised as hesitant,
awkward, interrupted, and produced with effort.

15. 3. Global aphasia : a severe aphasia with marked dysfunction across all
language modalities and with severely limited residual use of all
communication modes for oral- aural interaction is referred as global
aphasia.

17. Evaluation of recovery
• If complete recovery from aphasia is to occur, it usually happens within a
matter of hours or days following onset.
• Once aphasia has persisted for several weeks or months a complete return to a
premorbid state is usually the exception.
• Two separate recovery dimensions
1. Objective : attempts to quantify the extent to which the patient has regained
language abilities.
2. Humanistic term : measures the recovery of functional communication

18. Treatment
• The primary assumption in treatment of aphasia is that language in the brain is not
“erased”, but that retrieval of its individual units has been impaired.
• Approaches to aphasia therapy have generally followed one of two models : a sub-
stitute skill model or a direct treatment model.
• Substitute skill model can be found in deaf individuals, some of whom use speech
reading, a visual input rather than an auditory input as an aid to comprehend spoken
language .
• In direct treatment model, specific exercise individually designed to ameliorate
specific linguistic deficits are the basis of treatment.

19. • The performance aspect of language — in which repeated practice and teaching
strategies — are assumed to help restore impaired skills through a task oriented
approach (i.e, naming practice.)
• Self-cueing and repetition exercise that manipulate component of grammar and
vocabulary.
• Stimulating the patient to use residual language by — encouraging conversation
— in a permissive setting where a patient’s responses are unconditionally
accepted and — topics are of personal interest.

20. • Visual communication therapy (VIC) is an experimental techniques designed for
global aphasia.
• VIC employs an index card system of arbitrary symbols representing syntactic and
lexical component that patients learn to manipulate so as to
1. Respond to a command
2. Express needs, wishes, or other emotions.
• Weinrich et al demonstrated application of the VIC system called Computer -
Aided Visual Communication system (C-VIC) can lead to improved spoken
language.

21. • Visual Action Therapy (VAT) is designed to train people with global aphasia to use
symbolic gesture representing visually absent objects.
• The task leading to this goal include associating pictured forms with specific
objects, manipulating real object appropriately, and— finally producing symbolic
gesture that represent the objects used (e.g., cup, hammer, razor).

23. Functional communication treatment (FCT):
• This treatment is designed to — improve information processing — in the
activities necessary to conducting ADL, social interactions, and self
expression of both physical and psychological needs.

24. Promoting Aphasics’ Communicative Effectiveness (PACE)
• PACE is a technique — intended to reshape structured interaction — between
clinicians and patients — into more natural communicative changes, includes several
pragmatic components common to natural conversation.

26. • Other interactive approaches
1. Communication partners approach of Lyon : This is a treatment plan designed to
enhance communication and well-being in setting where the — person with aphasia
and the caregiver live.
2. Supported conversation approach by Kagan : In this volunteers are trained as
conversation partners to facilitate conversation by using available modalities.
3. Social model of aphasia approach introduced by Simmons-Mackie : This focuses on
fulfilment of social needs and the encouragement of a greater conversational burden on
the part of communication partners.

27. Dysarthria
• The term dysarthria refers to an impairment of speech production resulting — from
damage to the central or peripheral nervous system, — which causes weakness,
paralysis, or incoordination of the motor-speech system (respiration, phonation,
articulation, resonance and prosody).
• The type and degree of dysarthria depends on the underlying etiology, — degree of
neuropathology,— coexistence of other disabilities, —and the individual responses
of the patient to the condition.
• When patient are totally unintelligent as the result of severe motor-speech system
impairment, they exhibit anarthria.

28. • Dysarthria is generally reflected in deficits occurring in multiple motor-speech
system, but may sometimes occur in a single system (i.e., an impairment of soft
palate movement resulting in cerebral palsy).
• It is notable prevalent in CP, TBI, cerebrovascular accidents, Parkinson’s disease,
ALS, neoplasm and demyelinating disease (e.g., multiple sclerosis).

29. Types of dysarthria :
• Spastic, flaccid, ataxic, hypo-kinetic, and hyperkinetic.
• When two or more types co-exist, it is called mixed dysarthria.

30. • Spastic dysarthria : affects strength, speed, precision, and coordination of
speech musculature movement

31. Treatment
• Treatment must be individually designed.
• Improve the intelligibility of speech, which can be negatively affected if the speaker
is in a dark, noisy place.
• As a patient’s overall physical coordination and precision of movement increases, —
corresponding improvement in the control of the motor-speech system, — hence in
speech intelligibility.
• To rehabilitate speech, use speech.

32. Dysphagia
• Generally refers to any difficulty in swallowing, including asymptomatic
impairments.
• It is a common problem affecting 1/3 to 1/2 of the stroke population and 1/6 of
elderly individual.
• It is common in head and neck cancer, degenerative disorder of the nervous
system, gastroesophageal reflux disease, and inflammatory muscle disease.

33. Types
• According to the location of the problem
1. Oropharyngeal : arises from abnormalities of muscles, nerves or structures of the oral
cavity, pharynx, and upper oesophageal sphincter.
2. Oesophageal : arises from abnormality of the body of the esophagus, lower
oesophageal sphincter, or cardia of the stomach, usually due to mechanical causes or
motility problem.
• According to
1. Mechanical - due to structural lesion of the foodway
2. Functional - by physiologic abnormality of foodway function

34. Symptoms and signs
1. Oral or pharyngeal Dysphasia
• Coughing or chocking with swallowing
• Difficulty initiating swallowing
• Sensation of food sticking in the throat
• Drooling

35. • Unexplained weight loss
• Change in dietary habits
• Recurrent pneumonia
• Change in voice or speech
• Nasal regurgitation
• Dehydration

36. 2. Esophageal dysphasia
• Sensation of food sticking in the chest or throat
• Oral or pharyngeal regurgitation
• Drooling (inability to swallow saliva)
• Unexplained weight loss
• Change is dietary habits
• Recurrent pneumonia
• Dehydration

37. Physical examination
• An examination of oral cavity and neck - structural abnormalities, weakness or
sensory deficits.
• The findings of Dysphonia or dysarthria is often associated with oropharyngeal
dysphasia.
• Changes in voice quality or spontaneous coughing after swallowing suggest the
presence of pharyngeal dysfunction.
• Neurological examination is necessary, as they commonly cause dysphagia.

38. • The findings of atrophy or fasciculation of the tongue or palate suggest LMN
dysfunction of the brainstem motor nuclei.
• Gag reflex is not strongly predictive of the ability to swallow, it may be absent in
normal individual and normal in severe dysphasia and aspiration.
• History and physical examination are limited in their ability to detect and
characterise dysphagia, so instrumental studies are usually necessary.

39. Swallowing trial
• Should be performed by different consistencies, not only by water.
• Always start with very small amount 1/2 of 1 teaspoon;
1. Smooth pudding consistency
2. Sorbet
3. Thickened liquid
4. Carbonated liquid

40. • Correct positioning of the fingers during the clinical or bed-side
swallowing examination

41. Observation during the swallowing
• Observe : avoidance of certain food and liquids
1. Lip closure - any leakage anterior or posterior
2. Tongue movement
3. Mastication
4. Feeding respiratory pattern

42. • Listen : voice quality
1. Cough
2. Wet voice - saliva
• Feel : finger positioning
1. Swallowing movement
2. Delayed pharyngeal swallow

46. • Morphological evaluation of dysphagic patient

48. • Evaluation for sensitivity and reflex

49. • Oral feeding test in dysphagia

50. Instrumental Diagnostic studies

51. 1. Videoflurographic swallowing

53. 2. Fiberoptic laryngoscopy : if vfss cannot be performed.
3. Esophagoscopy : in case of esophagial dysphasia, biopsy for mucosal
abnormality.
4. Manometry : detect motor disorders of the oesophagus.
• EMG : useful in detecting LMN dysfunction of the larynx and pharynx if
neuromuscular disease is suspected

54. Differential diagnosis
• Myocardial ischemia
• Globus sensation
• Heartburn due to gastroesophageal reflux disease.
• Indirect aspiration (aspiration of refluxed gastric contents).

55. Functional limitation
• Depends on nature and severity of dysphasia,
• Many individuals modify their diet, some may require inordinate amount of time
to consume meal.
• In severe cases tube feeding is necessary.

56. • These alterations in the ability to eat a meal may have profound effect on
psychological and social function.
• Difficulty in eating meal may disrupt relationship and result in social isolation.
• Some patient may require supervision during meals or feel unsafe when eating
alone, causing further disruption of social and vocational function

57. Complications
• Aspiration pneumonia
• Airway obstruction
• Dehydration/ starvation.
• Severe dysphasia : social isolation - depression - suicide (reported in severe
cases)

58. Treatment
• Tx depends on its cause and mechanism.

59. Rehabilitation
• Goal of therapy : reducing aspiration, increasing the ability to eat and drink , and
optimising nutritional status.
• Best therapy for activity is activity itself, swallowing (safe and effective) is the
best therapy for swallowing disorder.
• Diet modification - common treatment, behavioural techniques (modification of
posture, head position, and respiration as well as specific swallow manoeuvres).

60. • Exercise therapy : when problem is related to weakness of the muscles of
swallowing,
• Choice of exercise should be individualised according to the physiologic
assessment,
1. Tongue weakness - protrude and lateralise of the tongue are strengthened using
the manual resistance.
2. Upper oesophageal sphincter opens poorly : strengthening of the anterior supra-
hyoid muscle(supine, flex neck against gravity)

61. 1. Active exercise
• Targeted for : weakness and disrupted muscle tone
• Strength training : increases muscle strength and endurance.
2. Passive exercise
• Targeted : hypertonicity and spasticity
• Massage : relaxes muscle and reduce muscle tension
• Stretching : inhibit stretch reflex — decrease muscle tone — increase ROM

62. 3. Physical modalities
• Targeted : muscle spasm and dysphagia
• Physical agent : heat, cold, electricity & vibration

63. Surgery
• Cricopharyngeal myotome (effectiveness is controversial)
• Oesophagotomy : in case of oesophageal cancer or obstructive strictures.
• Percutaneous endoscopic gastoctomy (PEG)( feeding gastrotomy) : indicated
when the severity of dysphasia makes it impossible to obtain adequate
alimentation and/or hydration orally, although intravenous hydration or ng tube
feeding may be sufficient on a time-limited basis.

64. Treatment complication
• VFSS is very safe and well tolerated
• Substituting thick for thin fluids — reduce fluid intake — dehydration —
malnutrition
• Failure to re-evaluate in timely manner — unnecessary prolongation of dietary
restriction — increase risk of malnutrition — adverse psychologic effects of
dysphagia.
• PEG : direct sequel-pain, infection, and obstruction of the feeding tube are
common. May promote aspiration pneumonia in individuals with severe
gastroesophageal reflux disease.

65. Clinical conditions leading to OMD

66. 1. Stroke
• Symptoms vary with lesion location and size.
• Subcortical as well as right and left hemispheric strokes : pharyngeal and laryngeal
sensory deficits may occur.
• Subcortical stroke (paralytic dysphagia) : mild oral transit delays and a delay in
triggering the swallow.

67. • Right hemispheric stroke (pseudobulbar dysphagia) : mild oral transit delays and
some delay in pharyngeal trigger and laryngeal elevation.
• The pharyngeal stage lasts longer, and there may be penetration of the larynx and
aspiration, there may also be reduced upper esophageal sphincter opening.

68. 2. Traumatic brain injury
• Type and severity depends on the cause of the injury and location and size of
brain lesions.
• Diffuse brain damage, closed head injury — impaired cognition, information
processing, and attention — communication disorder.
• Behavioural and cognitive problems — affect — self-feeding and swallowing,
and abnormal pathological reflexes — can affect — oral and pharyngeal control.

69. • Increased or reduced muscle tone — may cause decreased mouth opening,
decreased lip closure, drooling, decreased tongue control, and pocketing of the
bolus in the cheek.
• Delayed pharyngeal swallow trigger, nasal regurgitation, decreased base of tongue
movement, and decreased laryngeal elevation with resulting pharyngeal residue
may be seen.
• Overall mealtime may be slow.

70. 3. Alzheimer’s Disease : Pseudo-bulbar Dysphagia
• Decreased attention span and apraxia for swallowing and self-feeding may be seen.
• Oral and pharyngeal responses slow — need for physical and verbal cues to self -
feed are needed.
• Difficulty with self-feeding is common, and challenges with initiating the meal
may be present.

71. • Agitation and behavioural challenges can hamper the eating process.
• Patient prefer sweet-flavored and pureed foods.
• Patients are prone to aspiration in later stages of the disease.

72. 4. Developmental disabilities.
• Cerebral palsy and mental retardation — together or in isolation — may present
deficits of bolus formation and transit — delayed swallow reflex, pharyngeal dys-
motility, esophageal disease, and aspiration.
• Abnormal oral reflexes and oral hyposensitivity or hypersensitivity may be
observed.

73. • Poor postural, head, neck, and limb control can affect swallowing.
• Behaviours such as eating too quickly and putting too much food in the
mouth can affect efficiency and safety of swallowing.

74. 5. Multiple sclerosis
• Dysphagia symptoms vary with location of plaques in the central and peripheral
nervous systems.
• Weakness of the oral structures and the neck muscles may be seen.
• Delayed pharyngeal swallow and weakness of pharyngeal contractions may be
seen.
• Dysphagia worsens with disease progression.

75. 6. Parkinson disease
• Impulsiveness and poor judgment can affect swallowing.
• Jaw rigidity, abnormal head and neck posture, impaired coordination of tongue
movements, mastication and orofacial motions are affected along with tongue
control.
• Alterations in the pharyngeal aspect of the swallow occur including pharyngeal
residue and delayed pharyngeal elevation.

76. • Abnormal head, neck, and trunk posture along with difficulty coordinating
upper extremity movements for self-feeding are seen.
• Feeding and swallowing may be too slow and laborious
to allow sufficient nutritional intake.
• Orofacial fatigue may make eating and swallowing more
difficult as a meal progresses.

77. References
• Manual of physical medicine and rehabilitation, Hanley and Balfus
• Susan B. Sullivan
• Occupational therapy for physical Dysfunction, Trombly Latham
• Dysphasia rehab manual, Masami Akai
• Braddom’s Physical Medicine and Rehabilitation

78. Thank You