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118 Cards in this Set

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Swallowing and degenerative disease - info. available.
Relatively little info available on progression of swallowing disorders in each diagnosis and whether progression is predictable in all pts w/ similar conditions.
p. 329
Swallowing problems associated with neurologic disease
Not good research. Those that have looked at homogeneous gorups of pts have found inconclusive results regarding association btwn. disease stage and severity or nature of dysphagia.
p. 329
Need for research re. neurogenic disease
Need to follow pts from onset of neurologic symptoms to determine progression of swallowing dysfunction in order to design optimum management programs at specific times in the disease process.
p. 329
What does management of swallowing problems in the pt w/ degenerative disease involve?
Progressively chaning strategies, shifting and restricting nature of diet (usually viscosity) and in some cases recommending a combo of oral and nonoral feeding or complete oral feeding.
p. 330
Pt w/ degenerative disease must have swallowing regularly evaluated so that...(3 things)
Progressively worsening function can be compensated for as much as possible; Pt is put at minimal risk of serious aspiration and pulmonary problems and optimal nutrition and hydration status is maintained by initiation of appropriate non-oral feeding methods when needed.
p. 330
Counseling of pt's w/ degenerative disease
Regarding their goals and general progress is critical. Pt should be informed of risks and benefits of all procedures recommended.
p. 330
Who is the ultimate decision maker regarding the nature and continued use or oral intake?
The patient
p. 330
Alzheimer's Disease
Progressive dementia that causes a number of feeding and swallowing disorders.
p. 330
Alzheimer's Disease - types of initial swallowing disorders
agnosia for food (can't visually recognize food as food), which makes it difficult for them to accept food into mouth - explains their difficulty with slowness in opening mouth and accepting food.
p. 330
Alzheimer's Disease - types of swallowing disorders as disease progresses
In addition to oral agnosia, often develop apraxia for both feeding and swallowing. May have difficulty determining how to use utensils, and with initiating oral stage of swallow. May move food around in mouth w/ no tongue motion.
p. 330
Physiologic changes in swallow with Alzheimer's
Reduction in lateral tongue motion for chewing, delay in triggering pharyngeal swallow, motor abnormalities in pharynx - bilateral pharyngeal weakness, reduced laryngeal elevation, reduced posterior motion of the tongue base.
p. 331
General progression of swallowing problems w/ Alzheimer's
OFten agnosia and swallowing apraxia present first and gradually worsen until they cause a significant delay in oral intake, threatening the adequacy of intake for nutrition and hydration.
p. 331
How long might some pt's w/ Alzheimer's take to initiate a single swallow?
3-4 minutes
p. 331
Critical aspect of feeding and swallowing assessment in pt's w/ Alzheimer's
Measuring length of time it takes then to accept food into mouth and initiate the oral stage of the swallow.
p. 331
Question to ask re. eval of how long it takes Alzheimer's pt to accept food and initiate oral stage of swallow
How long do caregivers spend feeding the pt? Time may be so severe it compromises nutrition and hydration.
p. 331
What to do for pt's with Alzheimer's and swallowing disorders?
Heighten sensation immediately before placing food in mouth to speech oral acceptance and initiation of oral stage of swallow. Good for these pts b/c caretakers can do sensory techniques
p. 331
Course of Alzheimer's Disease
Can be slowly progressing or can result in more rapid deterioration. In either case, must identify when the pt can no longer benefit from swallowing therapy and withdraw pt's care.
p. 331
Pts w/ dementia (organic brain stroke, multistroke) - common patterns
Often exhibit separation in cortical and brainstem controlled aspects of swallow (i.e. btwn. oral prep and oral stages of swallow and pharyngeal stages of swallow).
p. 331
Pts w/ dementia (organic brain stroke, multistroke) - common pattern
Initiate swallow on command, propelling bolus from oral cavity w/ good lingual motion, but lack of triggering of pharyngeal swallow. Pt. thinks they did swallow.
p. 331
Does a pharyngeal swallow ever trigger in Pts w/ dementia (organic brain stroke, multistroke)
Generally after several minutes w/ bolus resting in various locations in pharynx, swallow triggers.
p. 331
Pts w/ dementia (organic brain stroke, multistroke) - common pattern - why?
Problem w/ continuity or speed of transimission of neural signals from cortex to brainstem.
p. 331
Pts w/ dementia (organic brain stroke, multistroke) - common pattern - what will help?
Heightened sensory input via stronger tasting or larger bolus or TTS.
p. 332
Amyotrophic Lateral Sclerosis (ALS)
Progressive disease, usually involves progressive upper and lower neuron degeneration, can affect predominantly corticobulbar tracts or the corticospinal tracts, or both.
p. 332
ALS - Swallowing problems for those w/ predominant corticobulbar involvement
Often begins w/ reduction in tongue mobility, so pts become less able to lateralize food to chew and less able to control material in the oral cavity. Unable to increase pressure generated by tongue as needed when viscosity increases, thus have increasing difficulty as thickness increases.
p. 332
What are some natural changes people with ALS of the corticobulbar tract make in diet?
Avoid eating thicker foods and foods requiring chewing.
p. 332
ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Lip closure
Often reduced, causing drooling and spillage of food from the mouth.
p. 332
ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Velar function
Anterior velar bulging to keep food in oral cavity while holding a bolus may be reduced, as well as reduced velar elevation.
p. 332
ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Laryngeal elevation
Often reduced later in the disease progression, complete closure of airway entrance is impaired, allowing penetration of food into the airway during swallow and aspiration of it after the swallow.
p. 332
ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Changes in the early stages of disease
Tongue base posterior movement and pharyngeal contraction reduced, so residual material remains in the pharynx after swallow and may be aspirated. Usually at same time tongue base retraction and pharyngeal wall contraction are affected,triggering of pharyngeal swallow also becomes delayed.
p. 332
What is helpful for pt's with ALS with corticobulbar involvement who have a delayed triggering of pharyngeal swallow. How long is it usually helpful for?
TTS. 6-12 months, at some point effectiveness is reduced as the nervous system continues to deteriorate.
p. 332
When TTS is no longer helpful for ALS b/c of the progressive nervous system deterioration, can they still feed orally?
As long as laryngeal function remains adequate to protect the airway, pt can feed orally by gradually changing viscosity of diet to liquids and thin pastes.
p. 332
Patterns exhibited in 20 ALS pts w/ corticobulbar involvement at NU (Followed from initiation of swallowing disorder to termination of oral feeding).
In all, disease began w/ involvement of oral musculature and later progressed to involve neuromuscular control of respiration and extremities.
p. 333
Progression of deterioration in 20 ALS pts w/ corticobulbar involvement at NU (Followed from initiation of swallowing disorder to termination of oral feeding).
Began w/ reduced oral lingual control, tongue base movement, and pharyngeal contraction, followed by a delay in triggering the pharyngeal swallow. A few pts developed CP disorders as a result of poor laryngeal movement.
p. 333
Are CP myotomies helpful in pts with ALS?
No, b/c CP problems usually related to poor laryngeal movement and b/c of severity of pharyngeal, laryngeal and oral aspects of the swallow. Unable to generate adequate pressure to propel food through upper digestive tract, even if UES is open.
p. 333
Swallowing disorders in patients w/ ALS with predominant corticospinal involvement
Often don't have swallowing changes until years after initial diagnosis. Usually then have reduced velar movement and pharyngeal wall contraction.
p. 333
Swallowing disorders in patients w/ ALS with predominant corticospinal involvement - what is the first sign?
Often it is slowly progressive weight loss. Pt is usually unaware of any swallowing problems.
p. 333
Treatment of swallowing disorders in patients w/ ALS
Use of compensatory procedures rather than active exercise (as this will cause fatigue).
p. 333
What may be the first sign of a motor neuron disease and what may accompany it?
Swallowing disorders. May be accompanied by fasciculations in the tongue and concomitant changes in speech.
p. 333
Werdnig-Hoffmann Disease
Pediatric motor neuron disease/ Aggressive, usually diagnosed when infant begins missing motor milestones at 12 - 18 months. Essentially paralyzed by 3 to 3 1/2 years of age.
p. 333
Swallowing changes in Werdnig-Hoffmann Disease
Pharyngeal stage begins to be affected at about 18-24 months in the presence of normal oral function for speech and swallowing.
p. 333
6 pts followed longitudinally with Werdnig-Hoffmann Disease - characteristics
All maintained normal articulation and oromotor function for chewing and oral transit during swallowing, even when completely paralyzed from shoulders down and mechanically ventilated. Pharyngeal swallow completely nonfunctional b/c of delayed pharyngeal swallow, severely reduced pharyngeal wall contraction unilaterally and bilaterally, reduced laryngeal elevation.
p. 333
What is a common aspiration pattern in children with Werdnig-Hoffman disease?
Chronic aspiration after the swallow
p. 333
Management strategies for Werdnig-Hoffmann Disease
Compensatory, including postural changes and sensory enhancement techniques (TTS). Gentle supraglottic swallow may also be helpful.
p. 334
Should exercise be used as treatment for children with Werdnig-Hoffmann Disease?
No, it will cause fatigue.
p. 334
What is the long-term swallowing outlook for children with Werdnig-Hoffmann disease?
All strategies will eventually fail as the nervous system continues to deteriorate.
p. 334
What is helpful for kids with Werdnig-Hoffmann disease who are fed nonorally?
Head posture changes may help w/ management of secretions.
p. 334
Parkinson's Disease
May exhibit a number of swallowing disorders in all 3 stages of deglutition.
p. 334
Parkinson's Disease - Oral phase of swallow
Often exhibit typical repetitive anterior-posterior rolling pattern in lingual propulsion of the bolus. Bolus held in normal position when swallow begins, then midline of tongue rolls w/ bolus posteriorly but back tongue doesn't lower and bolus rolls back anteriorly.
p. 334
Parkinson's Disease - Lingual propulsion in the oral stage - how long may the back and forth rolling continue?
May be repeated a number of times until finally one single anterior-posterior movement propels bolus and back of tongue lowers to let bolus pass.
p. 334
Parkinson's Disease - Lingual propulsion in the oral stage - back and forth rolling
Called festination. May involve some degree of muscle rigidity if the pt is unable to lower back of tongue once it has been elevated to hold the bolus in the prep position.
p. 334
Parkinson's Disease - Delayed triggering of pharyngeal swallow?
Sometimes, but usually mild (2-3 seconds)
p. 334
Parkinson's Disease - Pharyngeal stage difficulties
Pharyngeal wall contraction and posterior motion of tongue base often reduced, resulting in residue in valleculae and pyriform sinuses after each swallow. Residue may increase as thickness increases.
p. 334
Parkinson's Disease - Difficulties in later stages
Laryngeal muscles may become involved, so may have reduced laryngeal elevation and closure, resulting in aspiration during the swallow.
p. 334
Parkinson's Disease - Most frequent timing and cause of aspiration
Caused by residue remaining in pharynx after the swallow b/c of poor tongue base and pharyngeal wall contraction. Residue falls into open airway when pt inhales after the swallow.
p. 334
Parkinson's Disease and CP dysfunction
Only occurs occasionally. Usually related to reduced laryngeal elevation and poor tongue base and/or pharyngeal wall motion. Some authors report higher incidence and problem with muscular portion of CP.
p. 335
Progression of swallowing dysfunction in pt with swallowing disease
Begins w/ reduction in tongue base retraction and the repetitive rocking-rolling motion of tongue. Then delayed triggering of pharyngeal swallow, with reduction in tongue base movement and pharyngeal wall contraction as disease progresses. Laryngeal elevation and closure may become inadequate and resulting CP dysfunction may occur.
p. 335
Do all patients with Parkinson's Disease exhibit severe swallowing problems?
No, not even at advanced stages. Variability in disorders and progression also exists.
p. 335
Parkinson's Disease pts and tremors at rest
Often present in the head in neck. May occur in mandible, oral tongue or tongue base, soft palate or larynx.
p. 335
What should you do before beginning a MBS w/ a PD pt?
Before placing food in pts mouth, turn on videofluoroscopy and observe pt's mouth and pharynx at rest, looking for any tremor.
p. 335
Do pts with essential tremor typically have swallowing problems?
No, but may exhibit tremors in head and neck structures.
p. 335
What might be the first sign of Parkinson's Disease?
Oropharyngeal swallowing problems, specifically the rocking-rolling motion of the tongue. Refer to neurologist if you suspect. If not diagnosed, follow for 6 months - 1 year for possible change in symptoms.
p. 335
End-stage Parkinson's Disease - complications
May result in dementia, making feeding and swallowing management difficult. May not be able to follow directions or use some therapy strategies. Use of compensatory procedures may be most effective. May also have severe rigidity, making use of postural changes difficult. May nee4d to modify diet or go to nonoral feeding.
p. 335
Parkinson's Disease - improvement in swallowing function
May see when they are placed on new medications. When newly diagnosed, may want to wait several weeks to determine effects of meds before working on swallow. May reach functional swallowing levels until they reach optimal medication doses.
p. 336
What do Parkinson's Disease patients respond well to in therapy?
Active ROM exercises for tongue, lips and laryngeal elevation. Effortful swallow, Mendelsohn, effortful breath-hold and falsetto can all be used. Pts should do exercises in morning and at night for 10-12 minutes each time.
p. 336
Postpolio Syndrome
Pts who had polio in '50s are now often suffering increasing muscle weakness, including swallowing problems (Esp. those who had bulbar polio), even though they didn't always have swallowing problems when they had initial polio
p. 336
Postpolio Syndrome - Swallowing problems
unilateral and bilateral pharyngeal wall weakness, reduced tongue base retraction, reduced laryngeal elevation resulting in reduced closure of laryngeal vestibule.
p. 336
Postpolio Syndrome - Result of swallowing problems
Residue in various areas of pharynx with risk of aspiration after the swallow.
p. 336
Postpolio Syndrome - Treatment of Swallowing problems
Postural changes selected to match pt's swallow will facilitate a better swallow w/ reduced risk of aspiration. Many of the pts do not perceive the improvements in swallow as resulting from postural changes and must be convinced by review of video and discussion with clinician.
p. 336
Postpolio Syndrome - should aggressive exercise be used?
No, in most cases it will fatigue more than strengthen.
p. 336
Multiple Sclerosis (MS)
Usually have multiple plaques in neurologic system from cortex to brainstem and cerebellum to corticospinal tracts.
p. 336
Multiple Sclerosis (MS) - swallowing problems
disorders may relate to any of their neurologic lesions from the cortex to the brainstem and the cranial nerve innervated portion of peripheral nerves. Can have swallowing disorders of various types.
p. 336
Multiple Sclerosis (MS)- swallowing problems if hypoglossal nerve affected
Lingual control of bolus manipulation, chewing and oral transit will be reduced to some extent.
p. 336
Multiple Sclerosis (MS)- swallowing problems if CN X involved
Tongue base movement, pharyngeal wall movement and laryngeal function will be reduced.
p. 337
Multiple Sclerosis (MS)- swallowing problems if CN IX involved
Triggering of pharyngeal swallow may be delayed
p. 337
Multiple Sclerosis (MS)- swallowing problems if combo of CN's involved
Multiple swallowing problems
p. 337
Study of 150 MS pts had ______ and _______ as the most frequent problems.
delayed pharyngeal swallow, reduced pharyngeal wall contraction
p. 337
Study of 150 MS pts revealed pts w/ complaints and w/o complaints ____ had swallowing disorders
Both. Those w/o complaints more mild, including delayed pharyngeal swallow and reduced tongue base retraction and pharyngeal wall contraction. Pts w/ bulbar involvement tended to have reduction in laryngeal function and adduction as well.
p. 337
Treatment for pts w/ MS
Respond well to sensory techniques, including TTS. Improvements also often seen when pts placed on new meds. Some pts develop dementia - postures and sensory enhancement important.
p. 337
Myasthenia Gravis
Neurologic disease causing biochemical changes in myoneural junction. Generally presents as a fatiguing of the involved musculature with repeated use.
p. 337
Myasthenia Gravis - How is starts
CN's usually initially involved. Ocular muscles most often affected first, causing ptosis, but any other muscle innervated by CN's could be the initial symptom.
p. 337
Myasthenia Gravis and laryngeal dysfunction
Sometimes is the first symptom. Pts w/ initial pharyngeal wall involvement during meals - pharyngeal wall contraction progressively reduced w/ use until no pharyngeal contraction seen. Rare as the sole initial symptom.
p. 337
How to determine Myasthenia Gravis from fluoroscopy
Complete fluoroscopy at beginning of feeding and after 15-20 minutes of consecutive swallowing.
p. 338
What are Myasthenia Gravis pts sometimes misdiagnosed with?
Emotionally based swallowing disorders. Referred for psychotherapy or psychotherapeutic treatment. KEEP IT IN MIND as a potential etiology for swallowing disturbance, esp. if swallow worsens w/ use and improves with rest.
p. 338
Can Myasthenia Gravis affect only the tongue? How about muscles of mastication?
Yes!
p. 338
Can Myasthenia Gravis affect only the velum?
Yes. Often results in nasality during speech and backflow of food into nasal cavity in swallowing.
p. 338
Diagnostic eval for Can Myasthenia Gravis
Tensilon test. Evaluate functions before and after administration of tensilon.
p. 338
What can help Myasthenia Gravis?
medication, compensatory strategies
p. 338
Should active exercise be part of the treatment of Myasthenia Gravis?
No! Will contribute to fatigue.
p. 338
What diet changes may be made for a pt w/ Myasthenia Gravis?
Advise as to the diet they can swallow best depending on particular muscle involvement. Eating more small meals per day may be better than 3 large meals.
p. 338
Muscular Dystrophy - myotonic
Prolonged contraction and difficulty in relaxation of involved muscles, frequently affects the sternocleidomastoid, muscles of mastication and UES (cricopharyngeal muscle won't relax adequately to allow larynx to move and open the sphincter.
p. 338
Muscular Dystrophy - myotonic: aspiration
Aspirate b/c material that can't pass through the UES overflows the pyriform sinuses and enters the airway.
p. 338
Muscular Dystrophy - myotonic: Is a CP myotomy appropriate?
If careful assessment reveals a hypertonic cricopharyngeal muscle.
p. 338
Muscular Dystrophy - oculopharyngeal dystrophy
Affects ocular and pharyngeal muscles selectively. May result in reduced pharyngeal contraction and dysfunction of the muscular portion of the UES.
p. 338
Muscular Dystrophy - oculopharyngeal dystrophy - problems swallowing
Often can't propel material through pharynx b/c of reduced strength of pharyngeal constrictors and can't move material through UES b/c muscular portion doesn't relax and allow the larynx to move up and forward and open the sphincter.
p. 339
Most common swallowing dysfunction in patients w/ muscular dystrophy of any type
Reduction in strength of pharyngeal constrictors.
p. 339
Treatment for swallowing disorders resulting from various forms of muscular dystrophy
Compensatory Strategies
p. 339
Dystonia
Relatively rare chronic disease characterized by involuntary, irregular chronic contortions of muscles of the head, neck, trunk and extremities which may affect speech and swallowing.
p. 339
What may worsen dystonia?
Volitional attempts to manipulate food in prep for the swallow.
p. 339
What swallowing problems occur w/ dystonia.
As it worsens, labial seal worsens and food is lost from the mouth. Collecting bolus to initiate swallow may be severely impaired, material may fall over tongue base prematurely. OTT slowed w/ disorganized lingual propulsion of bolus.
p. 339
How is the pharyngeal stage of swallowing w/ dystonia?
Once pharyngeal swallow initiated, motor control of pharyngeal stage usually normal.
p. 339
Dermatomyositis
Collagen disease in which polymyositis or multiple muscle involvement is one distinguishing characteristic. Usually causes dysphagia.
p. 339
Dermatomyositis and swallowing problems
Reduced pharyngeal contraction and dysfunctioning of cricopharyngeus muscle
p. 339
In what neurologic diseases might dysphagia be the first symptom of the disease?
PD, myasthenia gravis, ALS, Guillain-Barre
p. 339
Dysphagia as the first sign of PD
rocking-rolling tongue motion alone or in combo w/ reduced tongue base movement and/or reduced lip closure and poor laryngeal elevation
p. 339
Dysphagia as the first sign of myasthenia gravis
Presents w/ fatigue on use of selected muscles during swallowing. Use fatigue test during MBS (repeat test before and after eating).
p. 340
Dysphagia as the first sign of ALS
Reduced lip closure, fine tongue control and chewing w/ or w/o fasciculations in the tongue. Soft palate involvement may also be present.
p. 340
Dysphagia as the first sign of Guillain-Barre
Generally weak swallow w/ reduced range of motion of all pharyngeal structures.
p. 340
Dysphagia as the first sign of brainstem tumor
Slowly progressive swallowing problems, usually affecting triggering of pharyngeal swallow, reduced laryngeal elevation and reduced tongue base action
p. 304
What to do when a pt. w/ no identified medical diagnosis exhibits significant dysphagia on MBS?
Movement patterns in mouth and pharynx should be carefully observed and compared to swallow movement patterns seen in pt's w/ specific neurologic diagnoses. Also observe posture, gait and fine motor control and take careful hx to determine if pt. is progressive. Refer to neurologist and let them know the nature of the pt's dysphagia and neurologic indicators.
p. 340
Rheumatoid Arthritis
Can affect several structures involved in swallowing. Can invade cricoarytenoid joint, restricting arytenoid movement during swallowing thus reducing airway closure.
p. 340
What can happen with a flare up of rheumatoid arthritis?
Can cause swelling in cricoarytenoid joint and in the arytenoid, resulting in collection of food around arytenoid and/or in airway entrance, w/ aspiration after the swallow.
p. 341
What might happen with rheumatoid arthritis and cervical vertebrae?
May cause swelling in cervical vertebrae, which may impinge on posterior pharyngeal wall. May make postural changes more difficult.
p. 341
Rheumatoid Arthritis and temporomandibular joint
Can damage it and make chewing painful
p. 341
Treatment of swallowing related to rheumatoid arthritis
Medication treats problems, reduces edema and improves swallowing. Our job is just to introduce compensatory strategies until the inflammation involved is eliminated through meds.
p. 341
Chronic Obstructive Pulmonary Disease (COPD)
Changes in respiration may result in swallowing problems. COPD is a generic term for pysiologic abnormalities causing chronic airflow limitation.
p. 341
Is the incidence of swallowing problems w/ COPD well defined?
Nooooo
p. 341
What are the known problems w/ COPD related to swallowing?
Difficulty w/ airway closure and aspiration during the swallow. Don't know if the airway closure problem results from COPD or causes it.
p. 341
Treatment for COPD pts w/ dysphagia
Compensatory changes, such as postural, diet and use of sensory techniques best as they don't stress the respiratory system.
p. 341