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89 Cards in this Set

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In degenerative diseases, swallowing problems will_
_worsen over time
Relatively little is known about swallowing disorders and degenerative diseases regarding what 2 things?
1. progression of SD for each diagnosis
2. whether progression is predictable
What two problems are associated with early studies of SD and degenerative diseases?
1. assessed pts with a number of diagnoses
2. assessed pts with one diagnosis, but with no regard to stage of illness
True or False

Current research offers the potential for designing optimum management programs according to diagnosis and disease process.
False

Further research is needed
Often, some oral intake for pleasure is possible under what circumstances?
When non-oral intake is introduced to supplement calories.
True or False

A common strategy with SD accompanying degenerative diseases is to restrict and modify diet (generally viscosity)
True
Is it important to regularly evaluate the swallowing of a pt with degenerative disease? Can you think of three reasons why or why not?
That would be a yes.
1. compensate as much as possible as function progressively worsens
2. put patient at minimal risk for aspiration/pulmonary problems
3. maintain optimal nutrition and hydration by initiating non-oral feeding methods as needed
Who is the ultimate decision maker regarding the nature and use of oral intake in the patient with a degenerative disorder.
The patient
Counseling the patient with a degenerative disease, as well as his or her SOs regarding _______ is critical. It is important they be informed of what?
goals and their general progress
risks and benefits of all procedures recommended.
What SD symptoms often present first in patients with Alzheimer's, say two?
agnosia for food, swallowing apraxia
What does swallowing apraxia make it difficult to do?
initiate the oral stage of swallowing (move food around in mouth with searching motions, or hold it with no motions)
True or False

In addition to a visual agnosia where they cannot recognize food, Alzheimer's patients often develop an oral tactile agnosia for food, where they cannot recognize it in their mouth.
True
How long might it take an Alzheimer's patient with agnosia and swallowing apraxia to inititate a single swallow? Why is this a problem?
3-4 minutes
threatens adequacy of nutrition and hydration
What physiologic changes in the swallow might one see with Alzheimer's?
reduction in lateral OT motion for chewing
DTriPS
bilateral pharyngeal weakness
reduced Lg elevation
reduced TB retraction
The swallowing therapist must be willing to identify the patient who_
_can no longer benefit from swallowing therapy and withdraw from the patient's care.
A critical aspect of feeding and swallowing assessment in patients with Alzheimer's disease involves what?
Measuring the length of time it takes them to accept food into the mouth and inititate the oral stage of the swallow.
___ can be used quite successfully for a time with patients who have dementia
sensory enhancement procedures
Some patients with organic brain syndrome or multistroke dementia exhibit what? How does it present?
A separation in the cortically and medullary (brainstem) controlled aspects of the swallow (oral v. pharyngeal stages)
Will initiate a swallow on command, but the pharyngeal stage does not trigger until minutes later
What might a patient with organic brain syndrome or multistroke dementia benefit from treatment-wise?
heightened sensory output via a stronger tasting bolus or a larger bolus
techniques to heighten sensation, e.g. TTS
True or False
ALS is a progressive disease usually involving upper and lower motor neuron degeneration and affecting both the corticobulbar and corticospinal tracts.
False

Can affect both CB and CS tracts, or either.
Swallowing disorders may be the first sign of what?
motor neuron disease
Swallowing disorders in motor neuron disease may be accompanied by ____ and ____.
fasciculations in the tongue
concomitant changes in speech
You see residue on the pharyngeal walls of a patient in the early stages of ALS that's affecting the CB tracts. What's going on? Is there any risk of aspiration?
TB retraction and pharyngeal contraction are reduced.
Yes, after the swallow when the patient inhales.
True or False

The progression of deterioration in neuromuscular control of deglutition observed in 16 ALS patients with predominantly corticobulbar involvement participating in a NUMS study began with reduction in oral lingual control and delay in triggering the pharyngeal swallow, followed by reduced tongue base movement and pharyngeal contraction.
False.

DTriPS happened last.
In ALS patients with corticobulbar tract involvement, where do swallowing impairments usually begin?
With reduction in tongue mobility, notably lateralization (chewing and controlling material in oral cavity)
A patient with ALS (CB tract involvement) is avoiding thicker foods and foods requiring chewing. Why (2 reasons)?
Unable to increase pressure generated by tongue as food viscosity increases, reduced lateralization for chewing/controling bolus
List some problems seen in ALS patients (CB tract involvement)
reduced tongue lateralization
reduced lip closure
reduced velar function (anterior velar bulging)
reduced Lg elevation
reduced TB posterior movement
reduced Pg contraction
As long as _____(function), patients with ALS can feed orally. How?
laryngeal function remains adequate to protect the airway
By gradually changing the viscosity of the diet to liquids and thin paste consistencies.
ALS patients with predominantly corticospinal involvement begin experiencing swallow changes when? What's the first sign? What's the nature of the impairment?
a number of years after their initial diagnosis.
slowly progressive weight loss
reduced velar movement and reduced PW contraction
True or False

In patients with ALS, treatment includes compensatory procedures and active exercise.
False

Active exercise may simply cause fatigue. Avoid.
_____ is an aggressive form of pediatric motor neuron disease that is usually diagnosed when the infant begins missing motor milestones at approximately 12-18 months of age.
Werdnig-Hoffman Disease
With Werdnig-Hoffman disease, a child is essentially paralyzed from the shoulders down and mechanically ventilated by _____ years. When does the pharyngeal phase of the swallow become affected?
3 - 3 1/2
18-24 months
True or False

With Werdnig-Hoffman disease, patients maintain normal articulation and oromotor function for chewing but the oral transit during swallowing and the pharyngeal swallow are non-functional.
False

Oral transit is normal, but pharyngeal swallow is nonfunctional including DTriPS, uni/bi reduced PW contraction, rd Lg elevation.
Management for swallowing problems associated with Werdnig-Hoffman
Compensatory strategies, including postural changes and sensory enhancement techniques such as TTS. Aggressive exercise causes fatigue. SGS (gentle) can be helpful.
In the oral phase of the swallow, patients with Parkinson's disease often exhibit:
a typical repetitive anterior-posterior rolling pattern in lingual propulsion of the bolus. (festination!)
In patients with Parkinson's, the bolus is held ____(how) when the swallow begins. Then the ____(part) of the tongue rolls the bolus ____(where). However, the ____(part) often does not ____(what) and the bolus rolls back ______(where). What is this generally described as ?
in a normal position.
the MIDLINE OF THE TONGUE rolls the bolus POSTERIORLY. However, the BACK TONGUE often does not LOWER and the bolus rolls back ANTERIORLY.
Festination.
True or False

Patients with Parkinson's often exhibit a delay in triggering of the pharyngeal swallow, which is typically severe.
False

Typically mild (2-3 seconds). PW contractions and/or TB retraction reduced, residue in valleculae and pyriform sinuses after swallow, which may increase with successive swallows.
Patients with Parkinson's typically aspirate before/during/after the swallow (which one?). Pourquoi?
After
poor tongue base and pharyngeal wall function.
When performing a radiographic study with a patient who has Parkinson's, what should the clinician do first? Why?
observe the patient's mouth and pharynx at rest, looking for any tremor activity.
Patients with essential tremors exhibit no swallowing disorders.
_____ may be the first sign of parkinson's disease. _____ is a pathognomonic sign of this disease.

A pathognomonic sign is a particular sign whose presence means, beyond any doubt, that a particular disease is present.
Oropharyngeal swallowing problems
festination of the tongue (rocking-rolling tongue motion)
Before beginning swallowing therapy with a newly diagnosed patient with dysphagia resulting from Parkinson's disease, the clinician may wish to...
wait several weeks to determine the effects of medications on the patient's swallow.
Patients with parkinson's disease often respond well to what sorts of therapies? How often for how long?
active ROM exercises for the tongue, lips, and laryngeal elevation, as well as the effortful swallow, MM, effortful breath-hold and falsetto. 10-12 minutes twice a day (morning and night)
True or False

Swallowing problems seen during the initial bout of polio are a good indicator of swallowing problems later in life, particularly in those who suffer bulbar polio.
False

May have had no swallowing problems during initial bout.
BUT-are seen particularly in those who suffer bulbar polio
What are the characteristic disorders seen in patients with postpolio syndrome?
Uni/Bi PW weakness
rd TB retraction
rd Lg elevation (rd closure of Lg vestibule)
Even though postural changes are helpful in facilitating a better swallow with reduced risk of aspiration, many patients with postpolio syndrome do not use them. Why? What can be done?
Many of these patients do no perceive the improvements in their swallow efficiency as a result of the postural change and must be convinced of its worth by review of the videotape and discussion with the clinician.
True or False

Swallowing disorders exhibited by patients with multiple sclerosis are related to the cranial nerve/s affected.
True
What are the two most frequent swallowing disorders seen in patients with multiple sclerosis?
DTriPS
Rd PW contraction
True or False

MS patients who do not complain of swallowing difficulties still have swallowing disorders similar to those MS patients with swallowing complaints
False.

I mean, they DO have swallowing disorders, but they tend to be milder than those in patients who complain of swallowing difficulty.
MS patients with bulbar involvement show what two additional symptoms (aside from DTriPS, rd TB contraction and rd PW contraction, leaving residue in the valleculae)?
rd lingual function
rd laryngeal adduction
What therapy procedures (compensatory strategies) work well with MS patients who have swallowing difficulty?
sensory enhancement procedures such as TTS
In patients with MS who develop cognitive impairments and dementia, _____ strategies are quite important, particularly ____ and _____
compensatory
postures
sensory enhancement procedures
Most frequently with myasthenia gravis, a neurologic disease that causes biochemical changes in the myoneural junction, the ____ are initially involved.
cranial nerves
True or False

The first cranial nerves affected by Myasthenia Gravis are those that control swallowing.
False

Nope, sorry. Ocular movement (ptosis). That said, reduced laryngeal function as a first symptom has been seen -- as well as the cranial nerves involved in chewing, talking, swallowing. Yeah, I know. It's a gray area. Good luck arguing that on the test.
Diagnostic evaluation for myasthenia gravis may involve a _______ test
tensilon

The "edrophonium test" is infrequently performed to identify MG; its application is limited to the situation when other investigations do not yield a conclusive diagnosis. This test requires the intravenous administration of edrophonium chloride (Tensilon®), a drug that blocks the breakdown of acetylcholine by cholinesterase and temporarily increases the levels of acetylcholine at the neuromuscular junction. In people with myasthenia gravis involving the eye muscles, edrophonium chloride will briefly relieve weakness.
Can an MBS be used to diagnose myasthenia gravis? If so, how?
Repeat the test before and after the patient eats for 15-20 minutes to assess the affects of fatigue (that's the hallmark symptom)
What's to be done for a patient with Myasthenia Gravis? I can think of three things...
1. Medication
2. compensatory strategies
3. diet changes
Use of _____ is usually best in patients with myasthenia gravis because ______ may only contribute to fatigue
compensatory strategies
active exercise
Patients with myasthenia gravis should be advised as to what sort of diet? What does it depend on? How often should they eat?
the diet they can swallow best
the particular muscles involved for that patient
more often, smaller meals (v. 3 large square a day)
If careful assessment reveals a ____(adjective) cricopharyngeal muscle in a patient with muscular dystrophy, _____(procedure) may be appropriate
hypertonic
cricopharyngeal myotomy
A muscular dystrophy affecting the ocular and pharyngeal muscles selectively. What's it called? What may it result in?
oculopharyngeal dystrophy
may result in reduced pharyngeal contraction and dysfunction.
What are the two disorders to watch for in patients with muscular dystrophy?
1. reduction in strength of the pharyngeal constrictors
2. hypertonic cricopharyngeal sphincter -- oops! Not a sphincter! Sorry. Just going by what the BOOK said (339)
True or False?

Dystonia is characterized by involuntary, regular, chronic contortions of the muscles of the head, neck, trunk, and extremities.
False

irregular contractions
With some forms of dystonia, _____ ____ times are slowed, with disorganized ____ ____ of the bolus. Once the ____ ____ ___ ______, the motor control of the pharyngeal stage is _______ ______.
oral transit
lingual propulsion
pharyngeal swallow is initiated
usually normal
______ and ______ are the two main swallowing problems observed in patients with dermatomyositis.
rd PW contraction
cricopharyngeal dysfunction
_____ is connective-tissue disease that is characterized by inflammation of the muscles and the skin. Its cause is unknown, but it may result from either a viral infection or an autoimmune reaction. Up to 50% of the cases may be a paraneoplastic phenomenon, indicating the presence of cancer.
X-ray findings include dystrophic calcifications in the muscles.
dermatomyositis.
think "collagen disease." Sigh.
What's "many muscle inflammation"? What disorder in this chapter is it related to?
polymyositis
dermatomyositis
A dystrophy characterized by prolonged contraction and difficulty in relaxation of involved muscles, frequently affecting the sternocleidomastoid, the muscles of mastication, and the UES (inhibiting laryngeal elevation)
Myotonic dystrophy
Patients with myotonic dystrophy can exhibit aspiration because why?
material cannot pass throught CP juncture, overflowing the pyriforms and entering the airway.
In some patients with progressive neurologic disease ____ is the first symptom. Name 4.
dysphagia
Parkinson's
myasthenia gravis
amyotrophic lateral sclerosis
Guillain-Barré
Patient presents rocking-rolling tongue motion alone or in combination with reduced tongue base movement and/or reduced lip closure and poor laryngeal elevation.
Possible neurogenic disease?
Parkinson's!
Patient presents with fatigue on use of selected muscles during swallowing.
Possible neurogenic disease? What's recommended to verify?
myasthenia gravis!
fatigue test during MBS
Patient presents with reduced lip closure, reduced fine tongue control, chewing with or without fasciculations in the tongue. Soft palate involvement may also be present.
Possible neurogenic disease?
amyotrophic lateral sclerosis!
Patient presents with generally weak swallow with reduced range of motion of all pharyngeal structures.
Possible neurogenic disease?
Guillain-Barré!
Patient presents with slowly progressive swallowing problems, usually affecting triggering of the pharyngeal swallow (yes, I can type it out), reduced laryngeal elevation, and reduced tongue base action.
Possible neurogenic disease?
Brainstem tumor!

Hmm
When a patient with no identified medical diagnosis exhibits any significant oropharyngeal dysphagia on videofluorographic study, the ______(function) of the _____ and _____(structures) during the oropharyngeal swallow should be carefully observed. Why?
movement patterns
mouth and pharynx
So they can be compared with patients who have specific diagnoses.
When a patient with no identified medical diagnosis exhibits any significant oropharyngeal dysphagia on videoflurographic study, who should the swallowing therapist refer the patient to?
neurologist
What two things should the swallowing therapist do in addition to the swallow study for a patient with no identified medical diagnosis who exhibits any significant oropharyngeal dysphagia on videoflurographic study (really fun to type) and why?
observe posture, gait, fine motor control (reflect changes critical to neurologic diagnosis)
take a case history to determine if illness is progressive.

Oh! and refer to a neurologist...maybe...
Is there any sort of neurogenic dysfunction that might result in only swallowing dysfunction, and if so, what?
stroke, particularly a small brainstem stroke.
____ is traditionally considered a chronic, inflammatory autoimmune disorder that causes the immune system to attack the joints. It is a disabling and painful inflammatory condition, which can lead to substantial loss of mobility due to pain and joint destruction. ____ is a systemic disease, often affecting extra-articular tissues throughout the body including the skin, blood vessels, heart, lungs, and muscles. About 60% of patients are unable to work 10 years after the onset of their disease.
Rheumatoid Arthritis
Can RA affect several structures involved in swallowing? If so, what are they?
Yup
cricoarytenoid joint
cervical vertebrae
TMJ
A flareup of rheumatoid arthritis can cause swelling in the CA joint and in the arytenoid cartilage resulting in what?
collection of food around the arytenoid and/or in the airway entrance, with aspiration after the swallow
Because the ____(structure) rotate to bring the vocal folds into adduction, and ____(function) to contribute to the closure of the airway entrance, movement of the ____(structure) on the ____(structure) is critical to normal swallowing. Which patient population might have trouble with this and how?
arytenoid cartilages
tilt anteriorly
arytenoid cartilage
cricoid cartilage
a flareup of rheumatoid arthritis can cause swelling in the CA joint and in the arytenoid cartilage
What can a swallowing therapist do for a person with rheumatoid arthritis?
Introduct compensatory strategies when possible to facilitate oral intake until the inflammation in involved structures is eliminated using medication.
A group of diseases characterized by limitation of airflow in the airway that is not fully reversible. An umbrella term for chronic bronchitis, emphysema and a range of other disorders. It is most often due to tobacco smoking but can be due to other airborne irritants such as coal dust, asbestos or solvents, as well as preserved meats containing nitrites.
Chronic Obstructive Pulmonary Disease (COPD)
Patients with COPD have been found to have a difficulty with ___ and ___
airway closure and aspiration during the swallow
True or False

Airway closure problems is a contributing cause of pulmonary disease.
False

whether the airway closure problem results from COPD or is the contributing cause is unknown.
True or False

Compensatory strategies are best for patients with COPD because other types of exercises may put further stress and work on the respiratory system and be unproductive.
True
What sorts of compensatory strategies could you use with a patient who has COPD, say three of them? Anything you wouldn't use? Why?
postural changes
diet changes
sensory enhancements
Wouldn't use swallow maneuvers because they increase muscular effort and duration of airway closure -- can't prolong airway closure in a patient who has difficulty breathing...
Is fasciculation the same as festination?
No.
A fasciculation (or "muscle twitch") is a small, local, involuntary muscle contraction (twitching) visible under the skin arising from the spontaneous discharge of a bundle of skeletal muscle fibers. Fasciculations have a variety of causes, the majority of which are benign, but can also be due to disease of the motor neurons. It's common with Werdnig-Hoffman disease.
Festinations of the tongue are repetitive tongue elevations (pumping) and prolonged 'ramping' of the tongue in an attempt to initiate a swallow. It's seen with Parkinson's patients.