Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
Neurogenic Dysphagia: 
Role of SLP in Dysphagia 
Management of ALS Patients 
Denise H. Epps, MS, CCC-SLP, 
CBIS 
Hilary Ma...
Learning Objectives: 
 Participants will learn/understand: 
◦ 1. Normal vs. Disordered Swallowing 
in ALS patients 
◦ 2. ...
Overview 
 Amyotrophic Lateral Sclerosis (ALS) is 
the most common adult onset 
neurodegenerative disease that cause 
dys...
Overview 
 The disease is classified into three 
types according to the region of onset 
of initial symptoms: 
◦ Bulbar- ...
Overview 
◦ Bulbar- (brainstem nerves) 
 Most rapidly progressive form of ALS and 
involves the speech and swallowing mus...
Overview 
 Bulbar muscle weakness in ALS is 
associated with a worst prognosis due to 
the high risk of pulmonary aspirat...
Overview 
 The resulting paralyses from the loss of 
the UMN/LMN are rapidly progressive 
and the mean survival is less t...
Normal vs. Disordered 
Swallowing in ALS Patients 
 Swallowing is characterized into three 
stages: 
◦ Oral Preparatory S...
Normal vs. Disordered 
Swallowing in ALS Patients 
Copyright © 2014 University of Maryland ALS Clinic (Center of Excellenc...
Normal vs. Disordered 
Swallowing in ALS Patients 
 Dysphagia 
◦ is one of the most important clinical 
problems encounte...
Normal vs. Disordered 
Swallowing in ALS Patients 
Typical clinical signs and symptoms of Dysphagia in the ALS patients 
S...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia  Standardized assessment protocols 
used to assess s...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia 
 ALS FRS-R 
◦ Swallowing Sub-score 
 4 Normal eati...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia 
◦ ALSSS (ALS Severity Scale)- 
A 10-point scale to d...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia  Normal Eating Habits 
◦ 10= Normal Swallowing: Pers...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia  Dietary Consistency Changes 
◦ 6= Soft Diet: Diet i...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia  Needs Tube Feeding (Continued) 
◦ 3= Tube Feeding w...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia 
 The Clinical Examination for ALS 
Organizes the cl...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia 
◦ Stage 3: Dietary Consistency Changes 
 Soft Diet-...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia  Instrumental Evaluations- 
◦ MBS (Modified Barium S...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia 
MBS FEES 
Copyright © 2014 University of Maryland AL...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia  Dysphagia management is a matter of 
trial and erro...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia  Provide Information on First Aid 
 Non-oral feedin...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia 
 A critical concern in dysphagia 
management is the...
SLPs Role of the Evaluation and 
Treatment Strategies for 
Dysphagia 
 To use oral motor/laryngeal 
strengthening exercis...
How Respiratory Function 
Affects Swallow Function in ALS 
Patients  Cardiopulmonary factors are the primary 
cause of de...
How Respiratory Function 
Affects Swallow Function in ALS 
Patients  Respiratory muscle weakness is defined as 
the inabi...
How Respiratory Function 
Affects Swallow Function in ALS 
Patients 
 Respiratory complication in ALS 
patients in ALS pa...
How Respiratory Function 
Affects Swallow Function in ALS 
Patients 
 Eating, swallowing, and breathing are tightly 
coor...
How Respiratory Function 
Affects Swallow Function in ALS 
Patients  This passage/channel is separated from 
the lower ai...
How Respiratory Function 
Affects Swallow Function in ALS 
Patients  During the swallow process, the pharynx is 
used onl...
How Respiratory Function 
Affects Swallow Function in ALS 
Patients 
ALS 
Inspiratory 
Muscles 
Expiratory 
Muscles 
Vocal...
Bibliography 
1. Bedore, B. (2013). Management of Dysphagia In 
Individuals with Amyotrophic Lateral Sclerosis. ASHA 
Pers...
Bibliography 
6. Kidney, D., Alexander, M., Corr, B., O’Toole, O., & 
Hardiman, O. (2004). Oropharyngeal dysphagia in 
amy...
Bibliography 
9 Matsu, K. & Palmer, J.B. (2009). Coordination of 
Mastication, Swallowing and Breathing. Jpn Dent 
Sci Rev...
Bibliography 
12. Teismann, I.K., Warnecke, T., Suntrup, S., 
Steinstrater, O., 
Kronenberg, L., Ringelstein, E.B., Dengle...
Upcoming SlideShare
Loading in …5
×

Presentation 228 denise epps neurogenic dysphagia- role of slp in dysphagia management of als patients

2,449 views

Published on

The ALS Association 2014 Clinical Conference Phoenix, AZ

Published in: Education
  • Gym guru exposes fat burning secret! I'm going to reveal to you the secret method that allows you to get the equivalent exercise of 45 minutes at the gym, in just a few minutes per day! Just watch this short video explaining how it works, JUST CLICK HERE ★★★ http://ishbv.com/1minweight/pdf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • The 3 Secrets To Your Bulimia Recovery ▲▲▲ http://scamcb.com/bulimiarec/pdf
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • I recovered from bulimia. You can too! learn more... ◆◆◆ http://tinyurl.com/bulimia2recovery
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
  • Suffer from Kidney Disease? how his patients avoid dialysis? Aussie Naturopath tells all... click here to find out how ▲▲▲ https://tinyurl.com/y5392ufy
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here

Presentation 228 denise epps neurogenic dysphagia- role of slp in dysphagia management of als patients

  1. 1. Neurogenic Dysphagia: Role of SLP in Dysphagia Management of ALS Patients Denise H. Epps, MS, CCC-SLP, CBIS Hilary May, BA, Graduate Intern
  2. 2. Learning Objectives:  Participants will learn/understand: ◦ 1. Normal vs. Disordered Swallowing in ALS patients ◦ 2. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia ◦ 3. How Respiratory Function Affects Swallow Function in ALS Patients Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  3. 3. Overview  Amyotrophic Lateral Sclerosis (ALS) is the most common adult onset neurodegenerative disease that cause dysfunction and loss of upper motor neurons (UMN) and lower motor neurons (LMN) in the primary motor cortex, brainstem, and spinal cord (7). Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  4. 4. Overview  The disease is classified into three types according to the region of onset of initial symptoms: ◦ Bulbar- (brainstem nerves) ◦ Spinal- (nerves of the spinal cord) ◦ Mixed- (combination of brainstem and spinal) (1) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  5. 5. Overview ◦ Bulbar- (brainstem nerves)  Most rapidly progressive form of ALS and involves the speech and swallowing musculature ; Controlled by cranial nerves ◦ Spinal (nerves of the spinal cord)  Progresses more slowly than bulbar form; Involves the upper/lower extremities; Controlled by spinal nerves ◦ Mixed (a combination of brainstem and spinal nerves)  Progresses at a rate that is determined by the predominant bulbar or spinal systems (1) Copyright © 2014 University Of Maryland ALS Clinic (Center of Excellence)
  6. 6. Overview  Bulbar muscle weakness in ALS is associated with a worst prognosis due to the high risk of pulmonary aspiration and malnutrition.  The incidence of ALS is approximately 2.4 per 100,000 with an onset occurring in the mid to late fifties. (12) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  7. 7. Overview  The resulting paralyses from the loss of the UMN/LMN are rapidly progressive and the mean survival is less than three years and death is often due to respiratory failure.  This disease results in a constellation of problematic symptoms: respiratory failure, dysarthria, weight loss and dysphagia (disordered swallowing). (2) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  8. 8. Normal vs. Disordered Swallowing in ALS Patients  Swallowing is characterized into three stages: ◦ Oral Preparatory Stage- the food is chewed (masticated), mixed with saliva, and formed into a cohesive ball (bolus) ◦ Oral Stage- the food is moved back through the mouth with a front-to-back squeezing action, performed primarily by the tongue ◦ Pharyngeal Stage- begins with the pharyngeal swallowing response:  The food enters the upper throat area (above the voice box)  The soft palate elevates  The epiglottis closes off the trachea, as the tongue moves backwards and the pharyngeal wall moves forward
  9. 9. Normal vs. Disordered Swallowing in ALS Patients Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  10. 10. Normal vs. Disordered Swallowing in ALS Patients  Dysphagia ◦ is one of the most important clinical problems encountered in ALS ◦ typically appears several months after the onset of disease (13) ◦ Causes considerable distress may lead to altered ingestion patterns that can cause malnutrition and dehydration (13) ◦ Dysphagia is present in more than 81% of the patients with advanced ALS (13). ◦ One critical issue in dysphagia management is saliva (11) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  11. 11. Normal vs. Disordered Swallowing in ALS Patients Typical clinical signs and symptoms of Dysphagia in the ALS patients Symptom Swallowing Stage Inability to remove food from spoon Oral Stage Absent/weak labial seal Oral Stage Chewing Fatigue Oral Stage Poor Bolus Manipulation Oral Stage Absent or inefficient Bolus Transfer Oral Stage Reduced hyoid bone elevation Pharyngeal Stage Uncoordinated respiration and swallowing Pharyngeal Stage Weakened ability/inability to protect airway Pharyngeal Stage Pharyngeal Weakness Pharyngeal Stage Typical Signs and Symptoms of Dysphagia in ALS Patients from M. Palovcak et al. (2007). Diagnostic and therapeutic methods in the management of dysphagia in ALS population.
  12. 12. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  Standardized assessment protocols used to assess swallowing in ALS patients are as follows: ◦ ALS FRS-R- (ALS Functional Rating Scale- Revised) A rating scale designed specifically to measure the clinical effects of neuromuscular dysfunction of swallowing (6). This scale also assesses bulbar function, fine motor function, gross motor function and respiratory function using a 5- point scale rated from 0 (complete dependence for the specific function) to 4 (normal function) (11).
  13. 13. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  ALS FRS-R ◦ Swallowing Sub-score  4 Normal eating habits  3 Early eating problems; occasional choking  2 Dietary consistency changes  1 Needs supplemental tube feeding  0 Nothing by mouth (exclusively parental or enteral feeding (11) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  14. 14. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia ◦ ALSSS (ALS Severity Scale)- A 10-point scale to determine the severity of dysphagia. Scores cover a two point range and each range has a Group Name describing the functional feeding status of the patient .(11) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  15. 15. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  Normal Eating Habits ◦ 10= Normal Swallowing: Person denies difficulty chewing or swallowing. Examination demonstrates no abnormality. ◦ 9= Normal Abnormality: Only the individual with ALS notices slight indicators such as food lodging in the recesses of the mouth or sticking in the throat.  Early Eating Problems ◦ 8= Minor Swallowing Problems: Complains of some swallowing difficulties. Maintains a regular diet. Isolated choking episodes. ◦ 7= Prolonged Time or Small Bite Size: Mealtime has significantly increased and smaller bite sizes are necessary. Must concentrate on swallowing liquids.
  16. 16. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  Dietary Consistency Changes ◦ 6= Soft Diet: Diet is limited to soft foods. Requires some special meal preparation ◦ 5= Liquefied Diet: Oral intake adequate. Nutrition limited primarily to liquid diet. Adequate thin liquid intake usually a problem. May force self to eat.  Needs Tube Feeding ◦ 4= Supplemental Tube Feedings: Oral intake alone is no longer adequate. Person uses or needs a tube to supplement intake. Person continues to take significant nutrition (>50% of nutrition by mouth). Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  17. 17. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  Needs Tube Feeding (Continued) ◦ 3= Tube Feeding with Occasional Oral Nutrition: Primary nutrition and hydration accomplished by tube. Receives <50% of nutrition by mouth  Nothing By Mouth ◦ 2= Secretions Managed with Aspirator/Medication: Cannot safely manage any oral intake. Secretions managed by aspirator or medication. Swallows reflexively ◦ 1= Aspiration of Secretions: Secretions cannot be managed non-invasively. Rarely swallows. (11)
  18. 18. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  The Clinical Examination for ALS Organizes the clinical evaluation into three general areas: history, physical examination, and assessment of speech and swallowing function. ◦ Stage 1: Normal Eating Habits  Normal Swallowing - a score of 10  Normal Abnormality -a score of 9 ◦ Stage 2: Early Eating Problems  Minor Swallowing Problems- a score of 8  Prolonged Time or Smaller Bite Size- a score of 7
  19. 19. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia ◦ Stage 3: Dietary Consistency Changes  Soft Diet- a score of 6  Liquefied Diet- a score of 5 ◦ Stage 4: Needs Tube Feeding  Supplemental Tube Feedings- a score of 4  Tube Feeding with Occasional PO Nutrition- a score of 3 ◦ Stage 5: Nothing by Mouth  Secretions Managed with Aspirator/Medication-a score of 2  Aspiration of Secretions- a score of 1 Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  20. 20. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  Instrumental Evaluations- ◦ MBS (Modified Barium Swallow Study)  Visualizes the oral and pharyngeal stage of swallowing. ◦ FEES (Fiberoptic Endoscopic Evaluation of Swallowing)  Assesses the preswallow anatomy and physiology, diagnosis of pharyngeal dysphagia and providing objective data for therapeutic interventions for safer po intake (1)  Provides direct visualization of vocal cord adduction and abduction. The visual feedback provides the detection of pooling of liquids, secretions, or residue of solids.(11) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  21. 21. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia MBS FEES Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  22. 22. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  Dysphagia management is a matter of trial and error on an individual basis. (5)  Management includes the following: ◦ Education ◦ The modification to the texture and consistency of food (i.e. blending food; adding thickener to drinks) (5) ◦ The modification on consumption (taking smaller bites and sips; more frequent small meals throughout the day; crushing or taking pills in pudding ◦ Advisement of the change in positive or head positions (i.e. chin tucks)(5). Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  23. 23. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  Provide Information on First Aid  Non-oral feedings to maintain caloric intake and hydration  Non-oral Feeding Management can be achieved by gastrostomy. The two main options are: ◦ Percutaneous Endoscopic Gastrostomy (PEG) ◦ Radiologically Inserted Gastrostomy (RIG/PRG). (5)
  24. 24. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  A critical concern in dysphagia management is the saliva (sialorrhea). ◦ Two different problems:  Thickened tenacious secretions that cannot be easily cleared or swallow  The goal is to thin the secretions by increasing the amount of free water ingested; eliminating caffeine (diuretic) from diet; use of enzyme papian or an expectorant (Guuaifenesin)  Excessive thin saliva that leads to drooling  Patients reduce fluid intake or take medications) that have dramatic mucus drying effect (Robinul or Elavil) (10)
  25. 25. SLPs Role of the Evaluation and Treatment Strategies for Dysphagia  To use oral motor/laryngeal strengthening exercises or not?….that is the question ◦ At this time…there is no clear answer ◦ To date, no significant published studies on ALS and the effect of swallowing exercises ◦ (i.e. Mendelsohn Maneuver; Tongue-Hold (Masako); Lingual Protrusion) (1) ◦
  26. 26. How Respiratory Function Affects Swallow Function in ALS Patients  Cardiopulmonary factors are the primary cause of death for 96% ALS patients (11)  A triad of interrelated factors may prematurely predispose affected individuals to respiratory insufficiency, excessive disability, and distress.  Factors include: ◦ Impaired ventilation ◦ Inability to clear lower airway secretions ◦ Dysphagia
  27. 27. How Respiratory Function Affects Swallow Function in ALS Patients  Respiratory muscle weakness is defined as the inability of respiratory muscles to generate normal levels of pressure and airflow during inhalation and expiration. This leads to respiratory insufficiency.  Respiratory insufficiency is defined as inadequate pulmonary ventilation resulting in impairment of gas exchange causing carbon dioxide retention and eventually respiratory failure (4). Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  28. 28. How Respiratory Function Affects Swallow Function in ALS Patients  Respiratory complication in ALS patients in ALS patients result from: ◦ Diaphragmatic weakness ◦ Difficulty clearing secretions ◦ Ineffective coughing ◦ Inability to handle oropharyngeal secretions ◦ Sleep disordered breathing due to nocturnal hypoventilation (4) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  29. 29. How Respiratory Function Affects Swallow Function in ALS Patients  Eating, swallowing, and breathing are tightly coordinated  Swallowing is dominant to respiration in normal individuals (8)  Breathing air may flow through either the nose or mouth and always through the pharynx  The pathway for air and food cross in the pharynx  During the swallow process, the pharynx changes from an airway to a food channel
  30. 30. How Respiratory Function Affects Swallow Function in ALS Patients  This passage/channel is separated from the lower airway and nasal cavity during the pharyngeal swallow to prevent aspiration of foreign materials into the trachea before or during swallow.  During this period the pharyngeal space is shared by feeding and breathing. (9) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  31. 31. How Respiratory Function Affects Swallow Function in ALS Patients  During the swallow process, the pharynx is used only for the food phase and completely separated from the airway in healthy individuals. (9)  Breathing ceases briefly during swallowing due to the following: ◦ The elevation of the soft palate ◦ Tilting of the epiglottis ◦ Neural suppression of respiration in the brainstem (8) Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  32. 32. How Respiratory Function Affects Swallow Function in ALS Patients ALS Inspiratory Muscles Expiratory Muscles Vocal folds & Other Upper Airway Muscles Ventilation Cough Aspiration &/or Aspiration Pneumoni a Respirator y Failure Motor Neuron Damage Functional Limitation Functional Effects of MND on the Respiratory System. From Management of Speech and Swallowing Disorders in Degenerative Diseases, Third Edition (p. 13) by K. Yorkston, R Miller, E. Strand and D. Britton, 2013, Austin, TX: PROED, Inc.. Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  33. 33. Bibliography 1. Bedore, B. (2013). Management of Dysphagia In Individuals with Amyotrophic Lateral Sclerosis. ASHA Perspectives, Vol. 22, No.1, 26-31. 2. Britton, D., Cleary, S., Miller, R. (2013). What is ALS and What is the Philosophy of Care?. ASHA Perspectives, Vol. 22, No.1, 4-11. 3. Cleary, S. & Richman-Eisenstat, J. An Overview of Respiratory Treatment for Individuals with Amyotrophic Lateral Sclerosis. 17-31. 4. Goyal, N.A. & Mozaffar, T. (2014). Respiratory and Nutritional Support in Amyotrophic Lateral Sclerosis. Current Treat. Options Neurology, 16:270, 1-12. 5. Johnson, J., Leigh, N., Shaw, C.E., Ellis, C., Burman, R., & Al-Chalabi, A. (2012). Eating-derived pleasure in amyotrophic lateral sclerosis as a predictor of non-oral feeding. Amyotrophic Lateral Sclerosis; 13: 555-559. Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  34. 34. Bibliography 6. Kidney, D., Alexander, M., Corr, B., O’Toole, O., & Hardiman, O. (2004). Oropharyngeal dysphagia in amyotrophic lateral sclerosis: neurological and dysphagia specific rating scales. ALS and other motor neuron disorders, 5, 150-153. 7. Korner, S., Hendricks, M., Kollewe, K., Zapf,A., Dengler, R., Vincenzo, S., & Petri, S. (2013). Weight loss, dysphagia and supplement intake in patients with amyotrophic lateral sclerosis (ALS): impact on quality of life and therapeutic options. BMC Neurology 2013, 13:84. 8. Matsu, K. & Palmer, J.B. (2008). Anatomy and Physiology of Feeding and Swallowing Normal and Abnormal. Phys Med Rehabil Clin. Nov 19(4): 691- 707.
  35. 35. Bibliography 9 Matsu, K. & Palmer, J.B. (2009). Coordination of Mastication, Swallowing and Breathing. Jpn Dent Sci Rev. May 45(1): 31-40. 10 Miller, R.M. & Britton, D. (2007). Experience with Amyotrophic Lateral Sclerosis: Incidence, Pathology, and Treatment Consideration. Gerontology. October 17-22. 11 Palovcak, M., Mancinelli, J.M., Elman, L.B., & McClusky, L. (2007). Diagnostic and therapeutic methods in the management of dysphagia in the ALS population: Issues in efficacy for the out-patient setting. NeuroRehabilitation 22, 417-423. Copyright © 2014 University of Maryland ALS Clinic (Center of Excellence)
  36. 36. Bibliography 12. Teismann, I.K., Warnecke, T., Suntrup, S., Steinstrater, O., Kronenberg, L., Ringelstein, E.B., Dengler, R., Petri, S., Pantev, C., & Dziewas, R. (2011). Cortical Processing of Swallowing in ALS Patients with Progressive Dysphagia- A Magnetoencephalographic Study. PLoS One. Volume 6, Issue 5, 1-9. 13. Traynor, B., Codd, M., Corr, B., et al. Incidence and prevalence of ALS in Ireland, 1995-1997: a population- based study. Neurology. 1999; 52(3): 504-509. Yorkston, K.M., Miller, R.M., & Strand, E.A. (2004).

×