Ch 10 - Overview Of Behavioral Treatment Strategies

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Evidence-Based Practice

Back 1

-Conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients
-Process of finding, evaluation and using the best available evidence to inform and improve individual practice
-Principles may apply to the entire spectrum of clinical practice, from accuracy of Dx tests to prognosis, to the efficacy and safety of rehabilitation and prevention efforts

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One Classification of Strength of Evidence in Clinical Research
Level I

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-systematic review of multiple randomized, controlled trials (RCTs)
-large RCT with clear-cut results

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One Classification of Strength of Evidence in Clinical Research
Level II

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-small RCT with uncertain results
-systematic review of cohort studies
-individual cohort study

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One Classification of Strength of Evidence in Clinical Research
Level III

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-systematic review of case-control studies
-individual case-control study

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One Classification of Strength of Evidence in Clinical Research
Level IV

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-case series with historical controls
-case series without historical controls
-poor case-control and cohort studies

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One Classification of Strength of Evidence in Clinical Research
Level V

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-expert opinion (eminence value)
-critical review based on physiology (biologic plausibility)

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Levels of Evidence

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Difference between information and evidence

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________ results from the controlled approach to the study of clinical questions

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evidence

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Strength of evidence directly relates to

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strength or degree of control in studies used to address clinical questions

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Most current evidence in support of behavioral Tx of dysphagia based on:

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-small cohort studies
-Case-controlled studies
-Historical-controlled studies
-Outcome research
-Randomized, controlled is emerging

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Case Series

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reports on number of patients receiving same treatment, may involve historical comparisons, which could be group of patients treated before treatment of interest available or historical performances of patients in series before receiving the treatment of interest

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Case-Control Study

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often a retrospective study of patients with specific disease or outcome of interest compared with group of -Similar patients without disease of outcome of interest
-This might involve looking at specific outcomes in group of patients who received a treatment compared with similar (indv matched) group of patients who didn't receive that treatment

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Cohort Study

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-observational study, group of similar patients may/may not receive treatment based on indv circumstances (natural selection)
-outcomes observed after treatment, usually over extended period

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Randomized, Controlled Trial

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-requires random assignment of patients into treatment group and control group
-both groups treated same with exception of treatment of interest

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Systematic Review

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-systematic eval of evidence across multiple clinical trials
-when review uses specific statistical methods to combine results of several studies, called metaanalysis

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Questions Related to Applying Evidence

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-Technique
-Patient Issues
-Outcome Issues
-Clinical Readiness

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technique questions when applying evidence

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-Is technique intended to change swallow physiology?
-To accommodate various bolus characteristics?
-Short or long term impact?
-Have other influences on the patient or swallow mechanism?
-Does clinician have skills necessary to apply technique?

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are patients in study similar to my patient?

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-clinical profile
-imaging studies (endoscopy/fluoroscopy)
-acute or chronic and clinical environment

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was the therapy technique adequately described?

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-stated purpose
-clear instructions
-how and when to apply and stop
-patient role vs clinician role

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do I have the clinical skills and technology to use this technique?

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-feasibility in my practice
-specific knowledge or technology
-specific training available

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were the outcomes similar to those that I want to achieve for my patient?

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-amount of oral intake
-type of food
-physiologic changes

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were failures reported?

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why did some patients fail with this technique?

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Which Techniques and What to Consider

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-postural adjustments (head posture and head posture)
-supraglottic swallow
-super supraglottic swallow
-Mendelsohn maneuver
-Effortful Swallow
-Tongue hold or Masko maneuver
-Isotonic/isometric exercise: Shaker Exercise
-Thermal-tactile application
-Adjunctive biofeedback

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General Postural Adjustment
-Entire body or only the head

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-May redirect bolus
-Change speed of bolus flow (Gives patient more time to adjust the swallow)
-Body posture changes involve lying down and/or side-lying (Reduce impact of gravity either during swallow or post swallow residue)
(Side-lying when one side of pharynx weaker, strong side needs to be lower) (May not be useful in non-compliant or cognitive patient)
-Maintaining upright posture, elevate head of bed
GERD
-Head Postural Adjustments

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Head Postural Adjustments

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-Head extension
-Head flexion
-Chin Tuck
-Head Rotation

Front 26

Head extension

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raise chin widens oropharynx and helps to move bolus posteriorly

Front 27

what may increase intraluminal pressure and decrease PES relaxation duration?

Back 27

head extension

Front 28

head extension may increase laryngeal closure T/F

Back 28

False

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should head extension be considered for those with airway closure issues?

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no, may increase problems in those who already have airway closure issues

Front 30

Head flexion

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shown to demonstrate improved airway protection in patients who demonstrate airway protection deficits during swallowing

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chin tuck narrows ________

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oropharynx

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chin tuck reduces distance between _______ and ________

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hyoid bone, larynx

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Chin Tuck

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considered compensatory, temporary adjustment to increase airway protection, functional benefit should be verified with image study

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physiologic effect of Chin Tuck is a weaker

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pharyngeal contraction during swallowing, may need to be combined with other strategies including bolus change

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Mat not be used in patients with

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pharyngeal weakness, and questioned in patients with swallow initiation problems and post swallow residue in piriform sinus

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Head Rotation

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used with unilateral pharyngeal deficit, patient turns head toward weaker side in cases of hemilateral impairment, physiological effect is a drop in PES pressure with increase in PES opening

-Allows for increase in the amount swallowed with less residue and risk of airway problems
-Considered compensatory technique, effectiveness may be reduced by cognitive or physical factors, or multiple swallow deficits,
-Checked easily with imaging

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Protecting the Airway techniques

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-Supraglottic
-Super supraglottic
-Supraglottic
-Super supraglottic
-Mendelsohn Maneuver
-Effortful Swallow
-Tongue holding or Masako Maneuver
-Isotonic/isometric Exercises: The Shaker Exercise
-Thermal-Tactile Application

Front 38

Supraglottic

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closing airway before swallow and cough immediately after swallow, closure at level of vocal folds

Front 39

Super supraglottic

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greater pre swallow breath hold with effort to ensure glottal closure, supraglottic areas are also closed, arytenoids move anteriorly to approximate the petiole of the epiglottis

Front 40

Supraglottic

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physiologic effects may demonstrate no difference with normal swallow, prolonged airway closure, increased anterior laryngeal movement, increased tongue-base movement, increased PES opening

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Super supraglottic

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increase degree of laryngeal elevation, positive impact on swallow coordination

Front 42

which maneuvers are considered compensatory in that they may contribute to improved swallow function when applied correctly?

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Supraglottic and Super supraglottic

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Mendelsohn Maneuver

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ask patient to suspend swallow at peak of hyolaryngeal elevation and pharyngeal contraction and to prolong this posture for a couple of seconds

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what is the intent of the Mandelsohn Maneuver?

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-Intent to prolong and extend hyolaryngeal elevation
-May prolong PES opening

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Mendelsohn Maneuver Compensatory function

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function-reduces post swallow residue and aspiration when using technique

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Mendelsohn Maneuver Rehabilitative function

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Improved swallow function using this technique without dependence on the technique

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the Mendelsohn Maneuver is easy to teach, coordination, cognition T/F

Back 47

False, it is difficult

Front 48

the Mendelsohn Maneuver may prolong apneic phase of swallow and not be appropriate for patients with respiratory disease T/F

Back 48

True

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Effortful Swallow

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Hard or Forceful swallow, increase force applied to bolus from within swallow mechanism

Front 50

(effortful swallow) With no PES deficits, increasing effort results in improved

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bolus flow, less residue post swallow and increased base of tongue movement

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(effortful swallow) Physiology reports indicate swallowing biomechanics were altered when

Back 51

swallowing effort was increased
degree of movement
oral pressures (tongue to palate), several measures of duration such as hyoid anterior excursion
laryngeal vestibule closure
PES opening were increased

Front 52

(effortful swallow) With pharyngeal dysfunction

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no impact on number of misdirected swallows or degree of pharyngeal residue, did reduce depth of penetration of material into larynx and trachea

Front 53

Tongue holding or Masako Maneuver

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Anterior tongue holding to increase posterior excursion of pharyngeal wall

Front 54

Tongue holding or Masako Maneuver Negatives

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-reduced duration of airway closure, increased post swallow residue, increased delay in initiation of the pharyngeal component of the swallow
-Could contribute to possibility of airway compromise
-Should not be used with a bolus
-No evidence re procedure

Front 55

Isotonic/isometric Exercises: The Shaker Exercise

Back 55

-Patient in supine position, raise head but not shoulders enough to see toes, maintain a prescribed period and repeat a prescribed number of times
-Contraindications include cervical spine deficits, reduced movement capability in the neck, cognition, physical limitations
-Not widely evidenced based

Front 56

what does the Isotonic/isometric Exercises: The Shaker Exercise target?

Back 56

to increase PES opening by increasing hyolaryngeal elevation and reduce post swallow residue and aspiration

Front 57

Thermal-Tactile Application

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-Possibly presentation of a sensory stimulus will alert nervous system and prepare swallow mechanism
-Cold tactile stimuli used to stroke facial pillars

Front 58

Thermal-Tactile Application outcome measures would be

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-a reduction in delay in the initiation of swallowing, particularly in the pharyngeal phase
-Not to be used in patients with airway compromise as it does not reduce aspiration
-Necessity for extensive repetition to obtain results may make it impractical

Front 59

Adjunctive Behavioral Therapies: Biofeedback

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-May enhance the amount of motor learning required and reduce Tx time
-Aids in teaching new movements, unfamiliar movements, movements otherwise difficult to monitor
-VFE, FEES, cervical auscultation, sEMG,