Tuesday, May 13, 2014

CTAR (Chin Tuck Against Resistance)

Yoon W.L., Khoo JKP, Liow SJR. Chin Tuck Against Resistance (CTAR):  New Method for Enhancing Suprahyoid Muscle Activity Using a Shaker-Type Exercise. Dysphagia (2014) 29: 243-248.

I was beyond excited to pick up my newest edition of the Dysphagia journal. I've never said I wasn't a nerd. There was an article in the journal about chin tuck against resistance. I've always used what I call Modified Shaker exercises. My patients are generally elderly. Most have heart conditions or COPD. They are unable to do the Shaker as it was intended.

Most of my patients either use the Neckline Slimmer (available on Amazon) which offers 3 different levels of resistance through springs. They complete exercises exactly as if they were completing the Shaker, but don't have to lie on the floor and struggle to get up.

This article looked at using Chin Tuck Against Resistance (what I would call a Modified Shaker) to improve activation of the suprahyoids.

Look at patients with dysphagia from Pharyngoesophageal Segment (PES) dysfunction, we look at strengthening the suprahyoid muscles. These muscles assist in hyolaryngeal excursion and therefore play a part in esophageal opening.

CTAR vs Shaker:  Both have a component of isometric versus isokinetic. The isometric portion fo the Shaker is holding the head up for 1 minute with a minute rest x 3 repetitions. The difference is, with CTAR, the patient is holding an inflatable rubber ball and performing a chin tuck against it while seated. The Shaker the patient is lying flat on the floor and lifting their head only as if they were looking at their toes.

The isokinetic portion is 30 repetitions of up and down head movement 3 times. 

This study used 40 healthy individuals (20 male, 20 female) 21-39 years of age. All participants completed the Shaker and CTAR both isometric and isokinetic as indicated above. Data was collected over one session.

What the researchers found:

CTAR:  The Chin Tuck Against Resistance was less strenuous than the traditional Shaker, with increased sEMG values during isometric and isokinetic movement. There was a significant increase for the isometric portion of the exercise. These patient had greater muscle activation using the rubber ball and a chin tuck!

Effort was required for the chin tuck, but not for the release.  The authors felt is might benefit to have the patient release compression of the ball slowly.

There was greater muscle activation for the isokinetic movement than for the isometric movement during the traditional Shaker. The Shaker also yielded considerable greater effort to lower the head to the mat.

“Clinical trials are now needed, but the CTAR exercises appear effective in exercising teh suprahyoid muscles and could achieve therapeutic effects comparable to those of Shaker exercises, with the potential for greater compliance by patients.”

Overall, CTAR was an effective in exercising suprahyoid muscles in healthy participants.

This looks promising in giving us an alternative for our patients for the Shaker exercise!!

Sunday, March 23, 2014

Guest Blog Post

Check out my guest blog post at http://graymattertherapy.com/dysphagia_apps/ about apps and dysphagia therapy!

Tuesday, March 11, 2014

Research Tuesday Post-Effects of Barium Concentration

I finally got back into the swing of things with Research Tuesday.

My article for the month is:  Stokely S., Molfenter SM, Steele CM.  Effects of Barium Concentration on Oropharyngeal Swallow Timing Measures.  Dysphagia (2014) 29: 78-82.

This study was completed as prior studies suggest that various aspects of the swallowing process, including timing measures may vary depending on the concentration of barium presented to the patient.

Subjects:  20 healthy adults

Given:  3 non cued swallows of 5 ml of barium ("thin" 40% concentration and "ultrathin" 22% concentration).
Longer stage transition durations ("the interval between the bolus head crossing the ramus of the mandible and the onset of hyoid elevation) with the 22% concentration.

Longer pharyngeal transit times ("the interval between the bolus head crossing the ramus of the mandible and closing of the UES") were observed with the 40% concentration.

Longer durations of UES opening with 40% concentration.

Results:  "For all temporal measures of interest (stage duration, pharyngeal transit time and duration of UES opening) significantly shorter duration were seen with the 22% concentration than with the 40% concentration."

"The 22% w/v "ultrathin: solution may act more like a true thin fluid such as water than a 40% w/v solution.  Although lower concentrations of barium appear less opaque on fluoroscopy, the study by Fink and Ross together with our own use of a 22% w/v concentration for several years, suggests that this concentration is adequate for visualization."

The barium we use will and does effect timing events in the swallow.  If the barium solution is more concentrated, we can expect longer timing events in the swallow.  We need to be aware of the barium we use and mix it according to manufacturer's directions or use a standardized recipe when assessing the events of the swallow.

Wednesday, March 5, 2014

Some Days

Warning.......This may not be an entirely professional post.

Many of you know that I have switched to a school system as my primary employment.  I continue to work at the hospital, but needed a little change.  We have had a remarkable number of snow days this year and to make up 2 of those days, our school decided to tack an hour on to each school day for 12 days.  If you have never worked with kindergarten through third grade, that is like working a 12 to 16 hour day.

So after 2 weeks of off and on illness with my 4 year old, including long nights, some involving vomit I open my email to find a wonderful comment on one of my very old posts.  (I wish there was a sarcastic font for wonderful).

Professionally, I have often wondered what direction I need to pursue my career.  I've often considered a doctorate.  I love teaching.  I have been presenting professionally for some time now and love it, it's just not the right choice for my family at this time.

When I present, I have always had to realize that not every person in the audience will love my presentation.  I have received constructive criticism, which I welcome whole-heartedly and some downright mean comments.  There are also comments on factors which are beyond my control.   I have to be a professional and take those with a grain of salt, saying thank you or I'm sorry you feel that way, when sometimes I want to say, didn't you read the freaking brochure?!?!?!

I had another SLP accuse me recently of plagiarizing her website, when I had never been on her website.  After examining her website to see where the accusation of plagiarism arose, I realized it was not a site I will visit in the future either.  The most irritating fact is when I asked about this accusation and where it was believe I "stole" information, I received no reply.  Seems like an attempt to get more hits on a website to me.

Anyway, back to this email.  I am extremely proud of this blog.  It started as something that I thought would be fun and a way to share information with some people.  It became bigger than I thought it would ever become!

A while back, I posted an article from a friend and fellow SLP about acupuncture and dysphagia.

Today, I get this comment:

Your a typical College book worm with no forsite on anything but scientific proof. I ve had dysphagia for a few years now to where I was hospitalized every other month. After starting accupuncture ONE I repeat for your puniy little mind One hospital stay in a year. Don't be so closed minded with your sheep skin degree! Thats all is it is sheep skin. I have a Masters pursuing a Doctorate 

Spam?  Maybe.  Who knows.  It still got to me.  It was from an "anonymous" person.  If you're going to use poor grammar and misspell half the words while insulting me, please at least be a strong enough person to post your name.

I have no "forsite" on anything but scientific proof.  I hate to tell you but my profession is based on ethics and evidence based practice.  We have to be able to prove that something works.  As a professional, I cannot treat a patient using something that has no basis.  I need to have proof that what I do with my patient will work.  I do know from my scientific proof that dysphagia often involves weak musculature.  I have yet to hear that sticking needles in a person will increase the strength of the swallowing musculature.

My "sheep skin degree" has actually taken me far in life.  That is one piece of sheep skin that I am proud to have worked for and earned.   It seems that we both have the same degree.  Hmmmmmm........

While it's nice to hear that this technique has possibly worked for ONE person, I stand by my original post that until there is solid proof, I will neither endorse nor promote acupuncture for dysphagia.

While this is a post I actually would normally not post, but instead email the person, I find it difficult to email an anonymous person.

Any and all posts that attack me personally will no longer be tolerated nor acknowledged.  My "puniy" mind is done for the night.

Tuesday, January 14, 2014

Measuring Outcomes for Success.....What are You Using?

I have written about the Dysphagia Toolbox before, but I am planning on doing it again!  This site just simply can't get enough recognition as far as I'm concerned!


The one thing I can't help thinking is why we call it a toolbox.  Do most of you actually carry a toolbox full of your must-have dysphagia assessment/treatment equipment?  Mine is usually jammed in my lab coat pockets or on top of my clipboard, if I remember to even bring that with me!

Maybe saying our dysphagia "apron" would be more appropriate??


Anway, I digress...

There are several outcome measures that are freely available for us to use from the Dysphagia Toolbox.  There are questionnaires that the patient completes, indicating current symptoms when eating/drinking including:

Eating Assessment Tool-10 which has 10 areas where the patient rates their swallowing.

The Sydney Swallow Questionnaire has 17 areas that the patient rates from rarely to always by placing an "x" on a line drawn for them.

Clinicians may use:

The Functional Oral Intake Scale (FOIS) where they rate the patient's diet level on a scale from 1-7, with a description of each diet provided.

The FOIS is actually much the same as the ASHA NOMS, which can be used to give a numeric patient rating by the diet they are currently consuming.

The Penetration Aspiration Scale gives numbers regarding how deep penetration/aspiration occurs and if it was cleared or not.

The Modified Barium Swallow Impairment Profile is a standardized means to modifieds with rating scores given to each of 17 physiological events during swallows of multiple consistencies.  Training is required to become a registered user of the MBSImP.

The Mann Assessment of Swallowing Ability (MASA) is completed the the SLP as they complete a bedside or clinical swallow evaluation.  This gives a numeric score (up to 200) and provides a rating scale (mild, moderate severe) for both dysphagia and aspiration.  The MASA is also available in a version for patients with cancer called the MASA-C.

This is a small list of some of the outcome measures available to us.  You want to look for measures that are both valid and reliable.  Outcomes give us a way to measure progress by stating where the patient began and ended therapy.  It is crucial in this day and age with Medicare to measure your outcomes in a clear and precise manner.

Sunday, January 12, 2014

Yoga and Dysphagia? The missing link?

I recently took a course on speechpathology.com about Yoga and Learning by Christina Ristuccia.  It was directed towards more Speech Therapy type activities, but it seemed like a good topic to discuss with our Dysphagia patients.  Of course I immediately started thinking about all my patients with dysphagia.

Not that we're going to attempt to have people doing a Downward Dog pose and drinking water.


I'm also not thinking that your entire therapy session would be a yoga session.  Try billing insurance for that when you have a patient with a dysphagia diagnosis!

Yoga can be used in other ways.  Similar to the ways that we use Myofascial Release in our therapy.  A few minutes here and there to get the maximum benefit during the session.

Yoga can be either relaxing or energizing.

Yoga can help with breath support and help to activate the vocal folds when you pair sounds with the movement.

Yoga can also help to increase a patient's posture with increased head and neck posture.


This may be a great way to start your session.

What do you think?

Wednesday, January 8, 2014

The Dysphagia Buy-In.........Selling Your Services.

My colleague Jonathon Waller, over at the Dysphagia Cafe posted recently.  I LOVE his post.  If you haven't read it yet, you definitely need to.  Dysphagia Therapy:  More Rehabilitation and Less Compensation.

I think the reason I love this post, and asked him if he minded if I expanded on it, was because THIS IS MY LIFE!

I have definitely had the buy-in aspect.  I live and work in Smalltown, Nowhere.  People typically have not heard about this "dis-fay-gee-ah" thing.

I go into a room to work with a patient or they come to see me as an outpatient and they have NO idea why they're there.  They swallow just fine and have no problem speaking.  Even though they cough and choke with every sip of water.


I find the majority of my evaluation is getting the person to "buy-in" to therapy.   They're not going to continue to come in for therapy if they don't know what I'm doing.

Let's face it, we've given ourselves a bad name at times.  Have you ever had that patient that actually comes to you from another SLP with a 10 page list of exercises that they need to complete 10 times each, 3 times a day, including, but not limited to:  stick your tongue out, up, side to side, say every /k/ and /g/ word known to man, stick out your jaw and hold it tensed for 5 hours......you get the picture.  Now ask these people why they do these exercises and they have no idea.

I explain the swallowing system to the patient.  These are muscles that we work with and when we don't use those muscles or don't use them as we're supposed to, we lose the ability for those muscles to perform the way they are meant.

I often teach my patients, it's like when you hurt your leg or ankle and limp for several days.  You then create other problems because you are walking in a manner you were not meant.

I then teach them how I'm going to help.  There's homework.  You don't do your homework, you may not get better.  There's work to be done in my room.  However, I can't fix this in one session.  Much like you can't expect to go to the gym and after one day of lifting weights look like Arnold Schwarzenegger from the 80's.



I ask them to give me 4-8 weeks along with the home-exercise program.

We use NO compensation in the therapy room.  By using those compensations 100% of the time, we're not teaching them to swallow without and building pathways FOR those compensations.   (After all, who wants to tuck their chin, stand on their head and count to 25 when they swallow).


My patients EAT and DRINK in my therapy room.  They don't stick out their tongue at me or say "cook" with an emphasized /k/ sound.  They SWALLOW.


Happy Swallowing Rehabilitation.  P.S.  I'm all for Swallow Pathologists, Dysphagiologists, anything that distinguishes us by what we do!!  Maybe Dysphagia Rehabologists??  I say we put it to a vote!