Sunday, October 5, 2014

Measuring Lingual Range of Motion

For so long, we have focused on lingual strength and range-of-motion.

The Iowa Oral Performance Instrument (IOPI),  the SwallowStrong and the Tongue Press have all been developed to give us visual and numeric strength measurements of the tongue.

We finally have a measurement scale for lingual range of motion.

C.L. Lazarus, H. Husaini, A.S. Jacobson, J.K. Mojica, D. Buchbinder, K. Okay, M.L. Urken.  Development of a New Lingual Range-of-Motion Assessment Scale, Normative Data in Surgically Treated Oral Cancer Patients.  Dysphagia (2014) 29:489-499.

This study compared results in treated surgical patients vs. healthy patients.   36 patients s/p oral tongue surgery with significantly decreased tongue range-of-motion and 31 healthy individuals.

The scale was validated by correlating range-of-motion with performance status, oral outcomes and patient-related Quality of Life.

The scale was made to define lingual deficits.  This is a tool that can be used for baseline and post surgery tongue range-of-motion and to track changes over time with recovery and therapy.

Lingual protrusion was measured using the Therabite jaw range-of-motion measurement discs.

Protrusion Scores:  (100) Normal:  > or = 15 mm past the upper lip margin
                              (50)   Mild-mod:  >1mm but <15mm lip="" margin="" p="" past="" the="" upper="">                              (25)   Severe:  Some movement but unable to reach upper lip margin
                              (0)     Total:  No movement

Lateralization Scores:  based on ability of the tongue to touch the commissures of the mouth.  Measure both right and left side.
                              (100)  Normal:  able to fully touch the corner of the mouth.
                              (50)    Mild-Moderate:  50% reduction of movement to corner of the mouth in either                                               direction.
                              (25)    Severe:  >50% reduction in movement.
                              (0)      Total:  No movement.

Elevation Scores:    (100)  Normal:  complete tongue tip contact with the upper alvoelar ridge.
                              (50)    Moderate:  tongue tip elevation but no contact with the upper alvoelar ridge.
                              (0)      Severe:  No visible tongue tip elevation

Total Scores were assigned by adding the protrusion score+ right lateralization score + left lateralization score + elevation score divided by 4.

Scores were 0-100:        0=severely impaired/totally impaired
                                      25=Severly impaired
                                      50=mild-moderate impairment

During this study, tongue strength was measured using the Iowa Oral Performance Instrument.

Jaw range-of-motion was measure using the Therabite jaw range-of-motion measurement discs.

Saliva flow was measured using the Saxon test where the patient was asked to chew a sterile 4x4 piece of gauze for 2 minutes then spit the gauze in a cup.  The gauze was weighed before and after mastication.

The Performance Status Scale was used to determine diet type, speech uderstandability, impact of surgery on ability to eat socially.

Quality of Life was measured using the Eating Assessment Tool-10 (EAT-10), MD Anderson Dysphagia Inventory (MDADI) and Speech Handicap Index (SHI).

The study found that lingual range-of-motion can negatively affect all aspects of a patient's life and correlates with performance and quality of life.

Wednesday, September 10, 2014

Stand Up for Ethical Treatment

This is re-posted with permission from Gray Matter Therapy:

Join us on October 2, 2014 for an event organized by American Association of Rehabilitation Therapists (Janet Mahoney, PT) and Gray Matter Therapy (Rachel Wynn, SLP). Therapists across the country and of all disciplines will stand together to advocate for our patients and our professions. We will politely but firmly put patients first.
This might look different for everyone – educating colleagues and your company, providing care in a patient-centered manner versus profit-centered system, calling your company’s compliance hotline, reporting via the False Claims Act, or calling the Medicare fraud hotline – but for everyone the goal is the same. We need to act together if we are to affect bottom-up change.

Risk of civil resistance

Is there risk in acting together? Yes. But what is the risk if we don’t act?
Civil resistance works for countries. In fact, only 3.5% of people need to act in order to affect change. If it can work for countries, it can work for healthcare.

Request a FREE media kit

Media kits contain the following
  • Poster
  • Lapel buttons
  • Wrist bands
  • T-shirt
  • Supporting documentation
Contact Janet Mahoney with American Association of Rehabilitation Therapists to request media kits. Message her on Facebook or email Janet. This is a grassroots movement, without external funding. Please be conservative with your media kits request. Submit requests prior to September 15th. Digital packets will be available also.

Tuesday, August 5, 2014

Slo Drinks

I was excited to have recently discovered a new thickener company called Slo Drinks.  You may ask how I discovered this company since they're based out of the UK.  I found them on Twitter.

The company has been great to work with and were more than willing to send me samples.  Twice.

After some delays, I received both sample packages!

Slo Drinks is a xantham based thickener, which comes in packets specified for specific drinks including soda, tea, wine, coffee, juice and beer.  The packets also have a number 1 or 2, indicating the consistency.  1 is syrup consistency (nectar) and 2 is custard consistency (honey).

Slo Drinks come with a sheet of information that says:

"Slo Drinks flow slowly so they are safer to swallow.  To make Slo Drinks, we deposit individual sachets with doses of our thickeners which dissolve quickly and are tasteless.

Our thickener works with alcoholic drinks and only requires mixing with the specified amount of fluid to reach the prescribed consistency Stage 1:  Syrup, 2:  Custard and make it flow slowly enough for the drinker to cope with.

As a result, you simply add the contents of the relevant sachet into a glass, add a favorite drink and change it into Slo Wine, Slo Cider, Slo Lager, Slo Beer, Slo Bubbly or Slo Mixer.

They will taste the same as ordinary glasses of wine, cider etc., but flow slowly."

I wanted to try these for myself.

The only difficulty I had was the packages are made to add to ml of the fluid.  There was no easy conversion to cups (that I found), so I converted as close as possible!

First up was the Lager.  I stole one of my husband's Samual Adams and mixed away.  I put the Slo Lager in the glass, then added the Sam Adams and stirred.

The lager fizzed quite a bit, not the volcanic explosion of soda with corn starch based thickener.  The fizzy went away after a few minutes.  The lager then had to sit for 5 minutes.  

It was definitely thick.  It was smooth however and maintained most of the flavor and some of the fizz.  I'm not a beer or lager fan, so I actually found the taste to be disgusting both before and after thickening!

It was the time for juice.  I had orange juice in the house, so that's what I used.  This packet is nectar consistency.  

I had to stir a little more vigorously with the juice.  It was definitely not as thick as the lager.  

I left both drinks sitting out for quite a while and the consistency never changed.

Then it was time for wine and tea.

I mixed both in a mixer bottle this time.  I added the liquid and then added the thickener and shook both.

After sitting for 5 minutes per instructions:

Both were thick, honey consistency, but both maintained flavor.  The consistency was smooth as most of the xantham gum based thickeners I have used.  Both maybe lost a little bite, but not much.

I also tried the soda.  I used Sprite and did the same as with the tea and wine.  I added Sprite to the shaker bottle, then added the thickener.  (There was no volcanic eruption!)  I shook the Sprite.  Unfortunately, I forgot to take pictures!!  

I waited the 5 minutes and tasted the Sprite.  It maintained flavor, but really had no fizz.  Again, the liquid did maintain it's consistency over time, even several hours later.

While I'm not a fan of the consistency of thickened liquids, the flavor of Slo Drinks was definitely one of the best that I have tried.  They are worth looking into!!

You can follow Slo Drinks on Twitter and find them on Facebook!!

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 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.