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118 Cards in this Set
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Swallowing and degenerative disease - info. available.
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Relatively little info available on progression of swallowing disorders in each diagnosis and whether progression is predictable in all pts w/ similar conditions.
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p. 329
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Swallowing problems associated with neurologic disease
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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.
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p. 329
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Need for research re. neurogenic disease
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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.
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p. 329
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What does management of swallowing problems in the pt w/ degenerative disease involve?
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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.
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p. 330
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Pt w/ degenerative disease must have swallowing regularly evaluated so that...(3 things)
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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.
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p. 330
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Counseling of pt's w/ degenerative disease
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Regarding their goals and general progress is critical. Pt should be informed of risks and benefits of all procedures recommended.
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p. 330
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Who is the ultimate decision maker regarding the nature and continued use or oral intake?
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The patient
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p. 330
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Alzheimer's Disease
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Progressive dementia that causes a number of feeding and swallowing disorders.
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p. 330
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Alzheimer's Disease - types of initial swallowing disorders
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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.
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p. 330
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Alzheimer's Disease - types of swallowing disorders as disease progresses
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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.
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p. 330
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Physiologic changes in swallow with Alzheimer's
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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.
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p. 331
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General progression of swallowing problems w/ Alzheimer's
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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.
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p. 331
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How long might some pt's w/ Alzheimer's take to initiate a single swallow?
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3-4 minutes
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p. 331
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Critical aspect of feeding and swallowing assessment in pt's w/ Alzheimer's
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Measuring length of time it takes then to accept food into mouth and initiate the oral stage of the swallow.
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p. 331
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Question to ask re. eval of how long it takes Alzheimer's pt to accept food and initiate oral stage of swallow
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How long do caregivers spend feeding the pt? Time may be so severe it compromises nutrition and hydration.
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p. 331
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What to do for pt's with Alzheimer's and swallowing disorders?
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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
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p. 331
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Course of Alzheimer's Disease
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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.
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p. 331
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Pts w/ dementia (organic brain stroke, multistroke) - common patterns
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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).
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p. 331
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Pts w/ dementia (organic brain stroke, multistroke) - common pattern
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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.
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p. 331
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Does a pharyngeal swallow ever trigger in Pts w/ dementia (organic brain stroke, multistroke)
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Generally after several minutes w/ bolus resting in various locations in pharynx, swallow triggers.
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p. 331
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Pts w/ dementia (organic brain stroke, multistroke) - common pattern - why?
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Problem w/ continuity or speed of transimission of neural signals from cortex to brainstem.
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p. 331
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Pts w/ dementia (organic brain stroke, multistroke) - common pattern - what will help?
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Heightened sensory input via stronger tasting or larger bolus or TTS.
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p. 332
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Amyotrophic Lateral Sclerosis (ALS)
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Progressive disease, usually involves progressive upper and lower neuron degeneration, can affect predominantly corticobulbar tracts or the corticospinal tracts, or both.
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p. 332
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ALS - Swallowing problems for those w/ predominant corticobulbar involvement
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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.
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p. 332
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What are some natural changes people with ALS of the corticobulbar tract make in diet?
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Avoid eating thicker foods and foods requiring chewing.
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p. 332
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ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Lip closure
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Often reduced, causing drooling and spillage of food from the mouth.
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p. 332
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ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Velar function
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Anterior velar bulging to keep food in oral cavity while holding a bolus may be reduced, as well as reduced velar elevation.
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p. 332
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ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Laryngeal elevation
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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.
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p. 332
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ALS - Swallowing problems for those w/ predominant corticobulbar involvement: Changes in the early stages of disease
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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.
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p. 332
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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?
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TTS. 6-12 months, at some point effectiveness is reduced as the nervous system continues to deteriorate.
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p. 332
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When TTS is no longer helpful for ALS b/c of the progressive nervous system deterioration, can they still feed orally?
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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.
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p. 332
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Patterns exhibited in 20 ALS pts w/ corticobulbar involvement at NU (Followed from initiation of swallowing disorder to termination of oral feeding).
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In all, disease began w/ involvement of oral musculature and later progressed to involve neuromuscular control of respiration and extremities.
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p. 333
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Progression of deterioration in 20 ALS pts w/ corticobulbar involvement at NU (Followed from initiation of swallowing disorder to termination of oral feeding).
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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.
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p. 333
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Are CP myotomies helpful in pts with ALS?
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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.
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p. 333
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Swallowing disorders in patients w/ ALS with predominant corticospinal involvement
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Often don't have swallowing changes until years after initial diagnosis. Usually then have reduced velar movement and pharyngeal wall contraction.
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p. 333
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Swallowing disorders in patients w/ ALS with predominant corticospinal involvement - what is the first sign?
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Often it is slowly progressive weight loss. Pt is usually unaware of any swallowing problems.
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p. 333
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Treatment of swallowing disorders in patients w/ ALS
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Use of compensatory procedures rather than active exercise (as this will cause fatigue).
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p. 333
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What may be the first sign of a motor neuron disease and what may accompany it?
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Swallowing disorders. May be accompanied by fasciculations in the tongue and concomitant changes in speech.
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p. 333
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Werdnig-Hoffmann Disease
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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.
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p. 333
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Swallowing changes in Werdnig-Hoffmann Disease
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Pharyngeal stage begins to be affected at about 18-24 months in the presence of normal oral function for speech and swallowing.
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p. 333
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6 pts followed longitudinally with Werdnig-Hoffmann Disease - characteristics
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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.
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p. 333
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What is a common aspiration pattern in children with Werdnig-Hoffman disease?
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Chronic aspiration after the swallow
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p. 333
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Management strategies for Werdnig-Hoffmann Disease
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Compensatory, including postural changes and sensory enhancement techniques (TTS). Gentle supraglottic swallow may also be helpful.
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p. 334
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Should exercise be used as treatment for children with Werdnig-Hoffmann Disease?
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No, it will cause fatigue.
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p. 334
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What is the long-term swallowing outlook for children with Werdnig-Hoffmann disease?
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All strategies will eventually fail as the nervous system continues to deteriorate.
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p. 334
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What is helpful for kids with Werdnig-Hoffmann disease who are fed nonorally?
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Head posture changes may help w/ management of secretions.
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p. 334
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Parkinson's Disease
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May exhibit a number of swallowing disorders in all 3 stages of deglutition.
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p. 334
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Parkinson's Disease - Oral phase of swallow
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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.
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p. 334
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Parkinson's Disease - Lingual propulsion in the oral stage - how long may the back and forth rolling continue?
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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.
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p. 334
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Parkinson's Disease - Lingual propulsion in the oral stage - back and forth rolling
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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.
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p. 334
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Parkinson's Disease - Delayed triggering of pharyngeal swallow?
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Sometimes, but usually mild (2-3 seconds)
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p. 334
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Parkinson's Disease - Pharyngeal stage difficulties
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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.
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p. 334
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Parkinson's Disease - Difficulties in later stages
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Laryngeal muscles may become involved, so may have reduced laryngeal elevation and closure, resulting in aspiration during the swallow.
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p. 334
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Parkinson's Disease - Most frequent timing and cause of aspiration
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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.
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p. 334
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Parkinson's Disease and CP dysfunction
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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.
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p. 335
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Progression of swallowing dysfunction in pt with swallowing disease
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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.
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p. 335
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Do all patients with Parkinson's Disease exhibit severe swallowing problems?
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No, not even at advanced stages. Variability in disorders and progression also exists.
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p. 335
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Parkinson's Disease pts and tremors at rest
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Often present in the head in neck. May occur in mandible, oral tongue or tongue base, soft palate or larynx.
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p. 335
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What should you do before beginning a MBS w/ a PD pt?
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Before placing food in pts mouth, turn on videofluoroscopy and observe pt's mouth and pharynx at rest, looking for any tremor.
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p. 335
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Do pts with essential tremor typically have swallowing problems?
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No, but may exhibit tremors in head and neck structures.
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p. 335
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What might be the first sign of Parkinson's Disease?
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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.
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p. 335
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End-stage Parkinson's Disease - complications
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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.
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p. 335
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Parkinson's Disease - improvement in swallowing function
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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.
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p. 336
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What do Parkinson's Disease patients respond well to in therapy?
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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.
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p. 336
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Postpolio Syndrome
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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
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p. 336
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Postpolio Syndrome - Swallowing problems
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unilateral and bilateral pharyngeal wall weakness, reduced tongue base retraction, reduced laryngeal elevation resulting in reduced closure of laryngeal vestibule.
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p. 336
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Postpolio Syndrome - Result of swallowing problems
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Residue in various areas of pharynx with risk of aspiration after the swallow.
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p. 336
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Postpolio Syndrome - Treatment of Swallowing problems
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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.
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p. 336
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Postpolio Syndrome - should aggressive exercise be used?
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No, in most cases it will fatigue more than strengthen.
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p. 336
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Multiple Sclerosis (MS)
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Usually have multiple plaques in neurologic system from cortex to brainstem and cerebellum to corticospinal tracts.
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p. 336
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Multiple Sclerosis (MS) - swallowing problems
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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.
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p. 336
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Multiple Sclerosis (MS)- swallowing problems if hypoglossal nerve affected
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Lingual control of bolus manipulation, chewing and oral transit will be reduced to some extent.
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p. 336
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Multiple Sclerosis (MS)- swallowing problems if CN X involved
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Tongue base movement, pharyngeal wall movement and laryngeal function will be reduced.
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p. 337
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Multiple Sclerosis (MS)- swallowing problems if CN IX involved
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Triggering of pharyngeal swallow may be delayed
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p. 337
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Multiple Sclerosis (MS)- swallowing problems if combo of CN's involved
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Multiple swallowing problems
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p. 337
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Study of 150 MS pts had ______ and _______ as the most frequent problems.
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delayed pharyngeal swallow, reduced pharyngeal wall contraction
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p. 337
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Study of 150 MS pts revealed pts w/ complaints and w/o complaints ____ had swallowing disorders
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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.
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p. 337
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Treatment for pts w/ MS
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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.
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p. 337
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Myasthenia Gravis
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Neurologic disease causing biochemical changes in myoneural junction. Generally presents as a fatiguing of the involved musculature with repeated use.
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p. 337
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Myasthenia Gravis - How is starts
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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.
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p. 337
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Myasthenia Gravis and laryngeal dysfunction
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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.
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p. 337
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How to determine Myasthenia Gravis from fluoroscopy
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Complete fluoroscopy at beginning of feeding and after 15-20 minutes of consecutive swallowing.
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p. 338
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What are Myasthenia Gravis pts sometimes misdiagnosed with?
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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.
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p. 338
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Can Myasthenia Gravis affect only the tongue? How about muscles of mastication?
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Yes!
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p. 338
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Can Myasthenia Gravis affect only the velum?
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Yes. Often results in nasality during speech and backflow of food into nasal cavity in swallowing.
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p. 338
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Diagnostic eval for Can Myasthenia Gravis
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Tensilon test. Evaluate functions before and after administration of tensilon.
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p. 338
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What can help Myasthenia Gravis?
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medication, compensatory strategies
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p. 338
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Should active exercise be part of the treatment of Myasthenia Gravis?
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No! Will contribute to fatigue.
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p. 338
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What diet changes may be made for a pt w/ Myasthenia Gravis?
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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.
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p. 338
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Muscular Dystrophy - myotonic
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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.
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p. 338
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Muscular Dystrophy - myotonic: aspiration
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Aspirate b/c material that can't pass through the UES overflows the pyriform sinuses and enters the airway.
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p. 338
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Muscular Dystrophy - myotonic: Is a CP myotomy appropriate?
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If careful assessment reveals a hypertonic cricopharyngeal muscle.
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p. 338
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Muscular Dystrophy - oculopharyngeal dystrophy
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Affects ocular and pharyngeal muscles selectively. May result in reduced pharyngeal contraction and dysfunction of the muscular portion of the UES.
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p. 338
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Muscular Dystrophy - oculopharyngeal dystrophy - problems swallowing
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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.
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p. 339
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Most common swallowing dysfunction in patients w/ muscular dystrophy of any type
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Reduction in strength of pharyngeal constrictors.
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p. 339
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Treatment for swallowing disorders resulting from various forms of muscular dystrophy
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Compensatory Strategies
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p. 339
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Dystonia
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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.
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p. 339
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What may worsen dystonia?
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Volitional attempts to manipulate food in prep for the swallow.
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p. 339
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What swallowing problems occur w/ dystonia.
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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.
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p. 339
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How is the pharyngeal stage of swallowing w/ dystonia?
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Once pharyngeal swallow initiated, motor control of pharyngeal stage usually normal.
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p. 339
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Dermatomyositis
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Collagen disease in which polymyositis or multiple muscle involvement is one distinguishing characteristic. Usually causes dysphagia.
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p. 339
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Dermatomyositis and swallowing problems
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Reduced pharyngeal contraction and dysfunctioning of cricopharyngeus muscle
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p. 339
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In what neurologic diseases might dysphagia be the first symptom of the disease?
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PD, myasthenia gravis, ALS, Guillain-Barre
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p. 339
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Dysphagia as the first sign of PD
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rocking-rolling tongue motion alone or in combo w/ reduced tongue base movement and/or reduced lip closure and poor laryngeal elevation
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p. 339
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Dysphagia as the first sign of myasthenia gravis
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Presents w/ fatigue on use of selected muscles during swallowing. Use fatigue test during MBS (repeat test before and after eating).
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p. 340
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Dysphagia as the first sign of ALS
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Reduced lip closure, fine tongue control and chewing w/ or w/o fasciculations in the tongue. Soft palate involvement may also be present.
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p. 340
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Dysphagia as the first sign of Guillain-Barre
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Generally weak swallow w/ reduced range of motion of all pharyngeal structures.
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p. 340
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Dysphagia as the first sign of brainstem tumor
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Slowly progressive swallowing problems, usually affecting triggering of pharyngeal swallow, reduced laryngeal elevation and reduced tongue base action
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p. 304
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What to do when a pt. w/ no identified medical diagnosis exhibits significant dysphagia on MBS?
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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.
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p. 340
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Rheumatoid Arthritis
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Can affect several structures involved in swallowing. Can invade cricoarytenoid joint, restricting arytenoid movement during swallowing thus reducing airway closure.
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p. 340
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What can happen with a flare up of rheumatoid arthritis?
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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.
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p. 341
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What might happen with rheumatoid arthritis and cervical vertebrae?
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May cause swelling in cervical vertebrae, which may impinge on posterior pharyngeal wall. May make postural changes more difficult.
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p. 341
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Rheumatoid Arthritis and temporomandibular joint
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Can damage it and make chewing painful
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p. 341
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Treatment of swallowing related to rheumatoid arthritis
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Medication treats problems, reduces edema and improves swallowing. Our job is just to introduce compensatory strategies until the inflammation involved is eliminated through meds.
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p. 341
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Chronic Obstructive Pulmonary Disease (COPD)
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Changes in respiration may result in swallowing problems. COPD is a generic term for pysiologic abnormalities causing chronic airflow limitation.
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p. 341
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Is the incidence of swallowing problems w/ COPD well defined?
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Nooooo
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p. 341
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What are the known problems w/ COPD related to swallowing?
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Difficulty w/ airway closure and aspiration during the swallow. Don't know if the airway closure problem results from COPD or causes it.
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p. 341
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Treatment for COPD pts w/ dysphagia
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Compensatory changes, such as postural, diet and use of sensory techniques best as they don't stress the respiratory system.
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p. 341
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