The Second Big Quiz - Except Articles

Front 1

What do screening procedures give you?

Back 1

Indirect information abou thte presence of a swallowing disorder but NOT about physiology. They tend to identify some signs/symptoms (coughing, history of pneumonia, food coming back out trach)

Front 2

What is the purpose of a screening?

Back 2

To identify patients at high risk for aphasia who are in need of an in-depth physiological assessment

Front 3

What is the 3-Oz water test and the Timed Swallowing Test?

Back 3

They are screening procedures that require the patient to swallow larger amounts of water. Beware of these because the patient may be aspirating!?

Front 4

What are some statistical characteristics of screenings?

Back 4

Sensitivity - the procedure identifies those individuals who are aspirating or have residue (true positives) Specificity - the procedure identifies patients with none of the symptoms (true negatives) * The procedure should NOT have a lot of false negatives or positives. Unfortunately at this point the ones with more true positives also give more false positives - they overidentify.

Front 5

What are some red flags for individuals you can't interview? For example, if you are screening those with developmental delays…

Back 5

1. Rejection of food - the body protecting itself 2. Food selectivity - we cut out difficult foods 3. Gagging - oral hypersensitivity / abnormal sensation

Front 6

What are the twelve categories of information you can get from a Bedside/Clinical evaluation?

Back 6

1. Medical Information 2. Patient's Medical Status 3. Oral Anatomy 4. Respiratory Function 5. Labial Control 6. Lingual Control 7. Palatal Function 8. Pharyngeal Wall Contraction 9. Laryngeal Control 10. Ability to Follow Directions / Self-Monitor 11. Reaction to Oral Sensory Information 12. Reaction to Symptoms During the Swallow

Front 7

What types of information do you get from the clinical evaluation regarding MEDICAL HISTORY?

Back 7

The patient's current medical diagnosis, History of swallowing disorders.

Front 8

What types of information do you get from the clinical evaluation regarding the patient's MEDICAL STATUS?

Back 8

The patient's nutritional intake (oral? Feeding tube?), and respiratory status (trach?)

Front 9

What are the two parts of the bedside/clinical evaluation?

Back 9

The preparatory exam (no swallowing) and the initial swallowing examination

Front 10

What do you do during the preparatory exam in the bedside evaluation?

Back 10

Conduct a chart review to determine: respiratory status, history of swallowing problems, current and past medical problems, current and recent medications, history of the swallowing disorder, airway devices, nutritional intake

Front 11

What are you looking for when you check which medications your patient is on?

Back 11

Whether any of them cause dry mouth, reduced alertness, or delayed reaction time (and therefore likely to cause swallowing problems)

Front 12

What do you need to know about the history of the swallowing disorder?

Back 12

1) Time and nature of onset 2) Coughing, food "catching" 3) Difficult and Easy foods 4) Patient's general awareness / perception of problem

Front 13

What do you need to know about airway devices during the chart review?

Back 13

Presence, type, duration, and method of placement

Front 14

What do you need to find out about nutrition intake during the patient chart review?

Back 14

Is it oral or non-oral? If is it non-oral: type, duration, adequacy, and complications of feeding tube. If oral: any complications?

Front 15

What observations should you make when you enter the patient's room?

Back 15

1) Patient's posture in bed 2) Alertness/reaction to your presence 3) Is there a trach? (Is patient aware of it? How does the patient handle the tube/secretions?) 4) Does the patient follow directions well?

Front 16

What should you find out about the patient's respiration during the bedside/clinical eval?

Back 16

Is the patient in respiratory distress? Respiratory rate at rest? Timing of saliva swallows Timing of coughing in relation to swallowing/respiration Duration of comfortable breath hold Patients resting breathing pattern (oral or nasal?) If oral - CAN the patient breath nasally?

Front 17

What is the normal timing of swallowing in relation to respiration?

Back 17

Usually, 60-80% of people inhale, swallow, exhale. The swallow should NOT interrupt inhalation because if you inhale immediately after the swallow you may aspirate.

Front 18

What are the reasons for placement of a tracheostomy tube?

Back 18

1) Upper airway obstruction above or at VF 2) Potential airway obstruction due to edema following surgery 3) Provision of respiratory care

Front 19

Where is a trach usually placed?

Back 19

Between 3rd-4th tracheal rings. In emergencies it may be placed as high as the 2nd - can scar the larynx!

Front 20

What are the three parts of a tracheostomy tube?

Back 20

1) Outer canula - holds the airway open 2) Inner canula - taken out for cleaning 3) Obturator - only for initial insertion (surgeon)

Front 21

What are two options for weaning a patient off a trach?

Back 21

1) Place a smaller tube. From an 8 to a 4 or 6 which encorages a combination of oral/nasal breathing and breathing through the trach. 2) Then, once patient is tolerating smaller tube, plug entrance with obturator or cap for longer and longer periods of time so that patient has to breath through mouth/nose.

Front 22

Can you talk with a trach in place?

Back 22

Yes, if you plug the outer end it will force air around the trach and up through VF. It will be less air than normal so the patient's voice will likely be softer and more breathy.

Front 23

When is a cuffed trach placed?

Back 23

1) When there is a need for respiratory treatment 2) When there is potential for aspiration of secretions.

Front 24

What are the dynamics with an inflated cuff?

Back 24

1) The cuff contacts the tracheal walls 2) It keeps material from entering larynx from about the cuff 3) This is necessary for mechanical ventilation operating on positive pressure

Front 25

What can happen if the cuff is overinflated on the trach?

Back 25

1) If can irritate the tracheal wall and cause tracheal stenosis 2) Can prevent re-learning to swallow because it restricts laryngeal elevation, reduces laryngeal sensitivity, places pressure on the front wall of the esophagus.

Front 26

How can you ensure that the cuff of the trach is not overinflated?

Back 26

MINIMAL LEAK TECHNIQUE: 1) Inflate the cuff fully until no air comes out, the take 1-2 cc of air out, allows a minimal leak. 2) This will prevent tracheal stenosis but may allow some aspiration!

Front 27

If a cuffed trach is present for more than 6 months, what complications may result?

Back 27

1) Greater scar tissue 2) Reduced VF closure because of restricted sensory input to the underside of the VF. 3) Cuff may not protect against all aspiration due to a misfit.

Front 28

What are some reasons you may use a fenestrated trach?

Back 28

1) If patient has trouble voicing, it will allow for greater airflow. 2) May be used in patients who are close to weaning off the trach. 3) Not generally used in patients with cuffed trach but maybe if patient no longer need the cuff inflated.

Front 29

What are the things you need to find out about the patient's tracheostomy?

Back 29

1. Is it cuffed - if so, is the cuff inflated? 2. What is the size of the tube? 3. Is the tube fenestrated or not? 4. How long has the trach been in place? 5. Is it medically feasible to deflate the cuff - best to do this for MBS or bedside because it restricts laryngeal elevation.

Front 30

When a patient has a trach, what steps need to happen during swallowing?

Back 30

1. DEFLATE THE CUFF if medically feasible 2. Teach the patient to cover trach with gauze or gloved finger during swallow and a few seconds after. Can also use a one-way valve if the patient tolerates it.

Front 31

Why do you have the patient cover the outside end of the trach during a swallow?

Back 31

It is found to improve the swallow by redirecting air through the larynx - creates more normal level of subglottic pressure, stimulates underside of the larynx, patient exhaling through VF after swallow will help clear residue. SOME STUDIES have should that this reduces or eliminates aspiration - check it radiographically.

Front 32

IN ventilator-dependent patients, what considerations do you need to make?

Back 32

1) If OTT and PTT are slow, they may not fit into the exhalation time allowed by the ventilator 2) Be sure to present food at the start of exhalation 3) Vent. patients usually have cuffed trach - possibly reduces laryngeal elevation and reduced closure of airway entrance.

Front 33

What is the Blue-Dye Test?

Back 33

A screening test for the presence of aspiration in trach patients

Front 34

What are the steps of the blue-dye test?

Back 34

Give the patient food dyed blue, suction trach immediately to check for the presence of blue material. If so, then the patient has aspirated. Then you know to do an MBS!!

Front 35

Why are patients intubated? What things do you need to consider?

Back 35

Placed in an emergency situation to set up a more stable airway. If it is left in place for days or weeks, laryngeal pathologies may develop (edema, redness, nodules/polyps, unilateral adductor paresis or paralysis). TE fistula may develop around the bottom edge. You do NOT conduct swallowing therapy while a patient is intubated. Following removal, there may be reduced ROM for up to a week.

Front 36

What are some things you need to find out about the history of the swallowing disorder?

Back 36

1) Was the onset gradual or sudden? 2) Do difficulties vary with food consistency? 3) What happens when the patient tries to swallow? Does material catch? Coughing? Can patient indicate where the food is collecting? 4) Notes on patient reliability - does the patient know about he swallowing disorder? Patients who are aware are usually reliable in identification and description (oropharyngeal SD only) 5) Ask the patient to demonstrate swallowing

Front 37

When you watch the patient eat (assuming he or she is already eating…) what should you do?

Back 37

1) Look for signs/symptoms 2) Does the patient take too much food? 3) Does the patient position food correctly in the mouth?

Front 38

During the examination of oral anatomy, what do you examine?

Back 38

You observe: lip and hard palate configuration; soft palate and uvular dimensions (relative to posterior pharyngeal wall); anterior and posterior faucial pillars; lingual configuration; adequacy of anterior and lateral sulci; scarring/assymetry; status of dentition and oral secretions; whether mouth is moist or dry

Front 39

Following the anatomical examination, you conduct what?

Back 39

An Oral-Motor Examination

Front 40

What three things do you look at in the oral-motor examination? For what structures? What functions?

Back 40

RANGE, RATE, and ACCURACY of movement For the lips, tongue, soft palate, pharyngeal walls. You do this during speech, reflexive activity, and swallowing.

Front 41

What are the specific tasks you check during the oral motor examination?

Back 41

1) Ability to open mouth voluntarily 2) Bite reflex 3) Identification of optimal oral-sensory stimuli and bolus 4) Identification of and compensation for swallowing apraxia 5) Identification of and compensation for abnormal oral reflexes 6) Labial function 7) Lingual function (anterior and posterior tongue motion) 8) Chewing function 9) Soft palate function and oral reflexes 10) Oral sensitivity examination

Front 42

What can you do if the patient has trouble opening mouth?

Back 42

The patient may need oral massage - give a rotary massage of the cheek on one side and give firm downward pressure on the chin. Give continuous verbal reinforcement.

Front 43

How do you check the bite reflex? What should you do if it is present?

Back 43

Touch a gauze roll to the teeth and alveolar ridge. If needed, make sure to select utensils that will not break easily. Also avoid touching the spoon to teeth or alveolar ridge.

Front 44

In patients with cognitive impairments, oral activity may be in response to _________________

Back 44

Particular sensroy combinations - taste, temp., texture

Front 45

What is the purpose of checking oral-sensory stimuli?

Back 45

TO identify the combination of taste, temperature, and texture that elicits the most swallowing-like oral movements. Use this to compare with regular MBS materials in radiographic study.

Front 46

How can you check different oral sensory combinations?

Back 46

Use different textures - gauze, satin, burlap. Dip these in different tastes/temps.

Front 47

How do you identify and compensate for swallowing apraxia?

Back 47

1) The patient will perform best with no verbal instructions. 2) Patient may do better when not told what to do 3) You'll see severe difficulties on MBS 4) If patient shows ONLY apraxia and symptoms of no other swallowing disorder you don't have to do an MBS.

Front 48

How do you identify/compensate for abnormal oral reflexes?

Back 48

1) Hyperactive gag, tongue thrusting, tonic bite 2) Identify locations in the mouth where these are triggered as well as nature of stimuli that triggers it. Then avoid these during MBS.

Front 49

How do you test labial function during the oral motor exam?

Back 49

1) /i/ and /u/ - then rapid alternation 10x 2) Get a DDK rate using /pa/ 3) Repeat a sentence with many bilabial stops - put the papers by the back door. 4) Make sure the patient can maintain lip closure during chewing (make sure to check nasal breathing)

Front 50

How do you test ANTERIOR lingual function during the oral motor exam?

Back 50

1) Extend and retract tongue as much as possible 2) Tongue tip to either corner, then rapidly alternate 3) Show motion needed to clear lateral sulcus 4) Open mouth wide - elevate and depress tongue as much as possible. Then rapidly alternate. 5) DDK using /ta/ 6) Repeat sentence with tip-alveolar stops - take time to talk to Tom.

Front 51

How do you test POSTERIOR lingual function during the oral motor exam?

Back 51

1) Assume position for /k/ and hold it for a few sec. 2) DDK with /ka/ 3) Repeat a sentence with velar stops - Can you keep the kitchen clean?

Front 52

How do you assess chewing function during the oral motor exam?

Back 52

1) This is safer with GAUZE than food 2) Roll gauze in tastant and wring it out -ask the patient to simulate chewing with the gauze.

Front 53

How do you assess soft palate function in the oral motor assessment?

Back 53

Do a prolonged /a/ and rapid repetition of /a/ - should see it elevate. The muscles are: Levator muscle (elevation) and the Palatopharyngeus muscle (retraction)

Front 54

How do you test the palatal reflex in the oral motor exam?

Back 54

1) Touch a cold instrument to the juncture between the hard and soft palate. (Or inferior edge of soft palate and uvula). 2) The reflex consists of an upward, backward movement of the soft palate but NO reaction in the pharyngeal walls. 3) The muscles are: afferent - glossopharyngeal (and maybe Vagus). Efferent - Vagus (and maybe glossopharyngeal). Trigeminal may be involved as well. 4) May require two strokes - the least stable of the oral reflexes.

Front 55

How do you test the gag reflex in the oral motor exam?

Back 55

1) Contact the tongue blade against the base of tongue or posterior pharyngeal wall. 2) The reflex consists of a strong, symmetrical contraction of the entire pharyngeal wall and soft palate. 3) Don't forget that the gag reflex is often absent in normal individuals! 4) Afferent is mainly X (IX may be involved)

Front 56

What do you suspect if the gag reflex is assymmetrical?

Back 56

Possible unilateral pharyngeal weakness (likely to affect swallowing)

Front 57

The gag is triggered by ________________ while the swallow is triggered by ____________________.

Back 57

(noxious stimuli - vomit, reflux, etc.) surface tactile receptors / deep proprioceptive receptors

Front 58

What is the gag reflex designed to do?

Back 58

Get foreign material out of the pharynx - designed to squeeze materials up and out of the pharynx.

Front 59

How do you assess oral sensitivity during the oral motor exam?

Back 59

Test light touch using a cotton swab - assess different areas of the tongue. Check patient awareness. If no gag is elicited - check posterior pharyngeal wall. All food should then be positioned in the area of maximum sensitivity. If the patient is not aware of touch, it suggests they may also be unaware of residue.

Front 60

Helpful information obtained during the oral motor examination…

Back 60

1) Labial assessment - facial paralysis or problems maintaining lip closure?? 2) Lingual function - limitation in functions needed to organize bolus or propel it backward? 3) Particular consistencies the patient can manage

Front 61

What things do you check during the laryngeal function examination?

Back 61

1) Voice quality 2) Laryngeal DDK - hahahah 3) Coughing and throat clearing 4) Sliding up and down vocal scale 5) Prolonged phonation, s/z

Front 62

What do you check regarding voice quality during the laryngeal function examination?

Back 62

1) Is the voice gurgly? RED FLAG!! Do an MBS 2) Is the voice hoarse? You should suspect reduced laryngeal closure during the swallow - careful laryngeal examination needed. Refer to an otolaryngologist!

Front 63

What will you see when you try to do a laryngeal DDK task with patients with neurologic impairment?

Back 63

Generally a continuous breathy /ha/

Front 64

What does inability to change pitch suggest?

Back 64

Reduced laryngeal sensation - these are served by the same nerve - Superior laryngeal nerve.

Front 65

If you suspect that the larynx is borderline/impaired, what should you do prior to initiating any swallows?

Back 65

Teach the supraglottic or super-supraglottic swallow!!

Front 66

What are you looking at for the pulmonary function portion of the bedside eval?

Back 66

Determining if the patient can tolerate any amount of aspiration - done by physician. Oral feeding regimens involve SOME aspiration!!

Front 67

Patients who aspirate on MBS are at higher risk for…

Back 67

Developing aspiration pneumonia in the next six months

Front 68

What information is collected form the preparatory exam?

Back 68

1) The posture that MAY result in the best swallow 2) The best position for food in the mouth 3) The potentially best food consistency 4) Some indication of the nature of the patient's swallowing disorder

Front 69

When considering whether swallows should be attempted at bedside, what should you think about?

Back 69

The risk:benefit ratio

Front 70

IF the patient is ALREADY eating, what should you watch for?

Back 70

1) Patient's reaction to food 2) Oral movements in food manipulation/chewing 3) Coughing, throat clearing, struggling behaviors, or changes in breathing (and TIMING) 4) Changes in secretion levesl throughout the meal 5) Duration of the meal and total intake 6) Coordination of breathing and swallowing

Front 71

Posture: When is tilting head down and then throwing it back the best posture?

Back 71

1) Poor tongue control - difficulty maneuvering bolus in mouth, premature spillage

Front 72

When is tilting head back a safe posture?

Back 72

When the patient has normal pharyngeal and laryngeal control - because you know the airway will be protected

Front 73

Posture: When is Chin-Tuck a good choice - what does it do?

Back 73

1) Patients with slightly inadequate laryngeal closure, pharyngeal delay, hemi-laryngectomy, reduced tongue-base retraction. 2) The epiglottis is positioned more posteriorly, the airway entrance is narrowed, the valleculae will be widened. This means more food can rest there during the delay.

Front 74

Posture: When is head rotation a good choice? What does it do?

Back 74

1) Patients with unilateral pharyngeal paralysis such as in medullary stroke. 2) When you turn toward the affected side, it closes the pyriform sinus on that side, directing food to the functional side.

Front 75

Posture: When is head tilt a good choice? What does it do?

Back 75

1) Patients with oral and pharyngeal weakness on the same side. 2) When you tilt the functional side, it allows gravity to pull material to the side that works. NOTE: you should have the patient tilt before placing food in the mouth.

Front 76

When should you make decisions regarding posture?

Back 76

Based on chart and preliminary information - BEFORE INITIATING SWALLOWS

Front 77

How do you determine optimal food position in the mouth?

Back 77

1) Depends on oral sensitivity - position it on the side with best sensitivity and best function. 2) You can use a pipette, syringe, or tongue blade to place liquid or food in different places

Front 78

How do you select the best possible food consistency?

Back 78

1) Information from history 2) Oral control 3) Pharyngeal / laryngeal control NOTE: it is good to start with the easiest one to make the patient more comfortable

Front 79

In general, what consistency works well for patients with poor oral control?

Back 79

Thickened liquid and then transitioning to thinner

Front 80

In general, what consistency works well for patients with delayed pharyngeal swallow?

Back 80

Thicker material because thin liquids tend to splash in the airway during the delay

Front 81

In general, what consistency works well for patients with reduced tongue base or pharyngeal wall contraction?

Back 81

Best with liquids - easier to clear from the pharyx

Front 82

In general, what consistency works well for patients with reduced laryngeal elevation/reduced UES opening?

Back 82

Liquids - more likely to flow through a narrow UES. Thicker material is more likely to sit on top of it and fall into airway.

Front 83

In general, what consistency works well for patients with reduced closure of airway entrance?

Back 83

Thicker consistency - less likely to penetrate.

Front 84

In general, what consistency would work best for a patients with BOTH disturbed oral function AND delayed pharyngeal swallow?

Back 84

Something between a liquid and paste - gravity will help with bolus propulsion (easier than thick) but the material will still cling to the valleculae (instead of splashing into airway as thin liquid would)

Front 85

List six materials you need to use in the initial swallowing evaluation

Back 85

Size 0 or 00 laryngeal mirror; tongue blade; cup; spoon to present liquids/pastes; straw (as pipette); syringe

Front 86

During the initial swallowing evaluation, what do you need to do to manage the trach?

Back 86

1) Deflate the cuff - get clearance from doc 2) SUCTION WELL orally and via trach 3) Tell pt. to occlude trach tube during each swallow

Front 87

What are some advantages to initiating swallowing therapy while patient has a trach?

Back 87

1) Can observe aspiration more directly - expectoration through tube 2) Elimination of aspirated material is easier - coughing or suction

Front 88

What are some possible problems initiating swallowing therapy with a patient who has a trach?

Back 88

1) Restriction of upward laryngeal movement - trachea is anchored to the strap muscles and neck 2) Compression of esophagus by tube pushing posteriorly on common wall 3) Change in intratrachial pressure because of the tube

Front 89

A trach becomes more of a problem, if…

Back 89

It is in place for 6 months or more

Front 90

Prior to a trial swallow at bedside, what should you do…?

Back 90

1) Review and write down instructions 2) Give the patients several dry swallows to practice sequence of instructions 3) Coach the patient through them 4) When patient is successful with instructions - assure them the amount of liquid will be very small. Encourage the patient to COUGH when needed. 5) Use 1/4 teaspoon of material - not sufficient to block airway and should cause minimal difficulty.

Front 91

Where do you palpate during a trial swallow at bedside (finger placement)?

Back 91

1) Index finger - Directly behind mandible 2) Middle finger - hyoid bone 3) Third finger - top of thyroid cartilage 4) Fourth finger - bottom of thyroid cartilage

Front 92

What do you feel with your fingers in place during the trial swallow?

Back 92

1) Index finger - submandibular movement 2) Middle finger - hyoid movement 3) 3rd and 4th fingers - laryngeal movement Notes - looking for the strength of movement and you can get a rough estimate of OTT and PTT. You can also follow a normal swallow with one preceded by TT stim - to see the difference in timing. BUT, no information on the pharyngeal stage is obtained.

Front 93

After the trial swallow in the clinical exam - how can you assess aspiration?

Back 93

1) Prolong /a/ - is it gurgly? Indicates material on VF 2) Panting - will loosen material in valleculae and pyriform sinus. Then ask patient to voice - gurgly? 3) Turn head to each side and vocalize - will squeeze any residue from pyriform sinus again making voice gurgly. 4) If voice is clear, ask patient to tilt head back - clears residue from valleculae. 5) If any task makes voice gurgly, aspiration can be expected.

Front 94

What percentage of patients are silent aspirators?

Back 94

50-60%

Front 95

Clinicians don't identify aspiration at bedside in ________ of patients who are actually aspirating

Back 95

40%

Front 96

Conduct a radiographic study to assess…

Back 96

1) Pharyngeal physiology 2) Presence of aspiration 3) Cause and amount of aspiration

Front 97

Pros and Cons of cinefluoroscopy…

Back 97

1) Pros - permits a frame by frame analysis 2) Cons - radiation exposure greater, can't make voice recordings

Front 98

Pros and Cons of videofluoroscopy…

Back 98

1) Pros - less radiation exposure, can patch VCR easily to fluoroscopy monitor 2) Cons - more difficult to frame - need to use a video counter timer. These numbers are placed at a rate or 30 or 60 per second.

Front 99

How does a MBS differ from a traditional upper GI barium swallow?

Back 99

1) Purposes - info on structural competence of the esophagus. Especially lower 2/3. Little attn. paid to oral/pharyngeal physiology. 2) Type and amount of material used - much more 3) Procedures used - don't introduce rehabs strategies as you do in MBS

Front 100

Purposes of the MBS

Back 100

1) Define abnormalities in anatomy and physiology causing the patient's symptoms. 2) Identify/evaluate treatment strategies that may enable patient to eat safely/effectively 3) Measure OTT and PTT 4) Assess valve function - VP, laryngeal, UES 5) Observe cervical esophagus peristalsis 6) Not only if but WHY patient is aspirating

Front 101

During MBS, how is food placed in patient's mouth?

Back 101

Generally a disposible spoon is used - unless patient has a bite reflex…then use something more sturdy. *For infants - Bottle or nipple - hold bottle with lead gloved hand.

Front 102

What did Weathers, Becker, and Genieser (1974) create to help place material in the patient's mouth?

Back 102

1) A tube with the nipple on one end and a 50cc syringe or a 450cc plastic bag on the other end. This way your hand doesn't enter the field of exposure.

Front 103

What are the three consistencies used for the MBS?

Back 103

1) Thin liquid barium 2) Barium paste = pudding + Esophatrast 3) Material required mastication = Lorna Doone cookie coated with pudding + Esophatrast

Front 104

In addition to the three typical materials used during the MBS, how else do you select material?

Back 104

Based on: patient complaints of what is difficult; food consistencies regularly given to patient; if the patient responded well at bedside to particular consistencies, tastes, temps

Front 105

If the patient does well with all volumes and consistencies during MBS, what do you do next?

Back 105

Allow the patient to self-feed and observe normal feeding

Front 106

How do you alter volume in the MBS?

Back 106

1) Increase it until the patient aspirates. Then determine cause and introduce intervention strategies. 2) You don't increase the volumes of pudding or cookie because it is natural for the amount to decrease as viscosity increases.

Front 107

We introduce intervention strategies in what order?

Back 107

Postures then sensory heightening then voluntary maneuvers then LAST - viscosity

Front 108

Why do we start MBS with a very small volume?

Back 108

1) Patients in MBS are ill - using more than 1 teaspoon of barium, if patient aspirates they could go into respiratory arrest. This is different from traditional barium swallows because the goal for that is to fill up esophagus and look for structural abnormalities.

Front 109

Why do we start with liquids in MBS?

Back 109

1) It ensures the material won't block the airway if aspirated 2) There is evidence the pneumonia is less likely from liquid than thicker foods 3) Lungs may be better able to clear thinner material back out of aspiration does occur

Front 110

GO BACK TO CHAPTER FIVE - POSITIONING THE PATIENT

Front 111

Following the evaluation, what four questions should be answered?

Back 111

1) What type of nutritional management is needed? 2) Should therapy be initated and what type? -Direct or indirect? -Compensatory or therapeutic? 3) What specific therapy strategies should be used? 4) And as therapy progresses, does the patient require maintenance program to keep gains or slow deterioration?

Front 112

What is the continuous goal of managing swallowing disorders?

Back 112

To reestablish oral feeding while maintaining adequate nutrition, hydration, and safe swallowing

Front 113

Treatment planning involves ___________ or ______________ activities to improve oropharyngeal swallow.

Back 113

Progressive exercise / sensory stimulation

Front 114

The decision to provide therapy is largely based on what two things?

Back 114

1) Potential for improvement/recovery of swallow 2) Prolonged maintenance of oral intake because of therapy

Front 115

What 8 patient characteristics are considered when determining if and what type of therapy to provide?

Back 115

1) Diagnosis 2) Prognosis 3) Reactions to compensatory strategies 4) Severity of patient's dysphagia 5) Ability to follow directions 6) Respiratory function 7) Availability of caregiver support 8) Patient motivation and interest

Front 116

When considering the patient's medical diagnosis in the decision to provide treatment, what are you trying to decide?

Back 116

1) If the patient is likely to recover swallowing in a few weeks (e.g., a healthy patient with first stroke) - then maybe only compensatory strategies are needed. 2) Patients who will NOT be recovering shortly may need compensatory strategies and therapy 3) Patients with neuromotor disease - ROM exercises or effortful swallow may not be appropriate because they will fatigue the patient.

Front 117

Prognosis for swallowing disorder: which patients are likely to have recovery of full/partial oral intake?

Back 117

Those with sudden onset neurologic damage - stroke, TBI, spinal cord injury, structural damage (due to surgery, radiation, etc.)

Front 118

Prognosis for swallowing disorder: for which patients may therapy be inappropriate?

Back 118

Those with degenerative diseases (PD, MND, MG, MS, Alzheimers) because at some point it will no longer be effective. May be appropriate earlier in the course of the disease depending on the goals.

Front 119

What about the patient's reaction to compensatory strategies may make therapy inappropriate?

Back 119

If the compensatory strategy fully eliminates aspiration/residue and swallowing is safe to maintain oral nutrition/hydration. ESPECIALLY if spontaneous recovery is likely.

Front 120

If compensatory strategies are enough to make swallowing safe, and you do not recommend therapy, what do you do with that patient?

Back 120

Instruct the patient to use those compensatory strategies and then re-evaluate after 3-4 weeks

Front 121

If the severity of the swallowing disorder is enough that compensatory strategies do NOT eliminate aspiration in MBS, what do you do?

Back 121

Use INDIRECT THERAPY - improve oral and pharyngeal ROM and coordination.

Front 122

How does the patient's ability to follow directions affect your treatment decisions?

Back 122

1) Patient needs to follow several steps - ESPECIALLY for voluntary maneuvers. 2) Compensatory strategies are easier to do and also under the control of caregivers to some extent.

Front 123

How long is the airway closed for liquids? Sequential cup-drinking?

Back 123

0.3-0.6 seconds / 3-5 seconds

Front 124

How does the patient's respiratory status affect treatment decisions?

Back 124

1) If the patient cannot tolerate brief airway closure - you may need to postpone therapy 2) Some therapy procedures require longer closure so are more taxing to the respiratory system 3) Some prolong airway closure as side-effect

Front 125

Which therapy procedures require longer airway closure during the swallow?

Back 125

Supraglottic swallow, super supraglottic swallow

Front 126

Which therapy procedures prolong airway closure as a side effect?

Back 126

Effortful swallow, Mendelsohn Maneuver

Front 127

Why is caregiver support considered when making treatment decisions?

Back 127

It is required to ensure regular practice. Especially important in patients with memory deficits. Also, remember that some compensatory strategies are under caregiver control.

Front 128

Logemann, Sisson, & Wheeler (1980) found that patients will exclude a food from their diet unless…

Back 128

OTT and PTT combined take less than 10 seconds

Front 129

When there is no aspiration/residue but oral and pharyngeal transit are slow, what is the problem?

Back 129

Patients will exclude foods from their diet if it is too much work. At this point getting adequate nutrition becomes the concern.

Front 130

If the patient's OTT + PTT are more than 10 seconds for EVERY consistency of food (but no aspiration), what is usually a solution?

Back 130

The patient can continue to eat orally, but will need non-oral feeding to supplement it and ensure adequate nutrition and hydration.

Front 131

Usually, it is not a good idea to keep a nasogastric tube in longer than…

Back 131

3-4 weeks

Front 132

Patients who are aware of their aspiration are found to eliminate foods when…

Back 132

They are aspirating 10% or more of the total bolus

Front 133

Patients who are unaware of their aspiration WILL or WILL NOT eliminate foods from their diet

Back 133

Often they will NOT - this means they are at serious risk for developing aspiration pneumonia

Front 134

In terms of aspiration, when do you recommend that a patient not be fed orally?

Back 134

When the patient is aspirating 10% or more of EVERY consistency DESPITE therapy attempts.

Front 135

What are factors in the selection of non-oral feeding type?

Back 135

(Not our decision, but encourage use of smaller, more flexible tubes), patient's GI history, cost of feedings and insurance coverage, patient's behavior, patient's preference, patient's medical diagnosis

Front 136

When are compensatory strategies first introduced?

Back 136

During the eval - usually in MBS

Front 137

Compensatory treatment procedures are those that ____________________ and ____________________ but do not necessarily ________________.

Back 137

control the flow of food / eliminate the patient's symptoms such as aspiration / change the physiology of the pharyngeal swallow

Front 138

What are some pros of compensatory strategies?

Back 138

They involve less muscle effort/work for the patient. They do not cause as much fatigue. They are relatively simple to use.

Front 139

What are the four types of compensatory strategies?

Back 139

1) Postural changes 2) Sensory heightening 3) Modifying volume and speed of presentation 4) Introducing oral prosthetics

Front 140

In general, what are the effects of postural techniques?

Back 140

1) Alter the dimensions of the pharynx 2) Change the flow of food 3) Do so without increasing work/effort

Front 141

What do you need to do before selecting a posture?

Back 141

Correctly diagnose the anatomic and physiologic characteristics of your patient's swallow and then select the posture based on that.

Front 142

Postural techniques are effective in eliminating aspiration in _______ of dysphagic patients (including _____________________)

Back 142

75-80% (infants and those with cognitive impairments)

Front 143

In MBS, how do you select/implement a posture?

Back 143

1) Diagnose anatomic/physiologic disorder 2) Use the technique with the same type of swallow in which aspiration occurred

Front 144

Are postural techniques meant to be permanent?

Back 144

1) They are usually used temporarily until the patient's swallow recovers or until direct therapy procedures take effect. 2) Some patients will need to use them permanently

Front 145

Describe the effects of the chin down posture

Back 145

Patient touches the chin to the neck - tongue base and epiglottis rest closer to posterior pharyngeal wall. Airway entrace is narrowed. Valleculae is widened.

Front 146

Chin Down posture is useful for which types of clients?

Back 146

1) Delayed pharyngeal swallow 2) Reduced tongue base retraction 3) Reduced airway entrance closure

Front 147

Chin Up posture is useful for which types of clients?

Back 147

1) Reduced tongue control

Front 148

What are the effects of the Head Rotation?

Back 148

The head is rotated to the damaged side - this closes off that side of the larynx and food goes down the normal side. Also, in the case of unilateral VF paralysis, the damaged side is pushed toward midline which helps with adduction.

Front 149

The Head Rotation is useful for which types of clients?

Back 149

1) Unilateral pharyngeal wall impairment 2) Unilateral VF weakness

Front 150

What provides the BEST airway protection (postures)?

Back 150

Combination of Chin Down + Head Rotation

Front 151

Head Tilt is useful for which types of patients?

Back 151

Those with unilateral oral and pharyngeal impairment (on the same side)

Front 152

What are the effects of the lying down posture?

Back 152

It may eliminate aspiration after the swallow because gravity will pull residue to the side of the pharynx instead of it falling into the airway. PATIENT NEEDS TO COUGH BEFORE SITTING UP.

Front 153

The lying down posture is useful for which types of clients?

Back 153

1) Bilateral pharyngeal wall disorder 2) Reduced laryngeal elevation

Front 154

What do you need to check with a patient before implementing the lying down posture?

Back 154

1) Straw drinking - necessary for this posture 2) If residue continues to build up on pharyngeal wall with successive swallows, the patient is NOT a good candidate. 3) Patient with GERD - may need to elevate body 15-30 degrees. THis will prevent reflux while still eliminating aspiration.

Front 155

____________ is the best exercise for swallowing

Back 155

Swallowing

Front 156

If a patient is successfully using a posture and returns for a reeval after 3-4 weeks, what do you do in MBS?

Back 156

Try the patient swallowing without the posture first - then if the patient aspirates go back to the posture to see what is happening.

Front 157

In general, patients will no longer need to use a posture after _________ but some will need it permanently

Back 157

1-2 months

Front 158

When a patient is going to use a posture without any therapy, what do you need to remind them??

Back 158

That if swallowing becomes easier with the posture, they should NOT change back to normal swallowing without consulting with you

Front 159

Techniques to improve oral sensory awareness are generally used for what disorders?

Back 159

1) Swallow apraxia 2) Tactile agnosia for food 3) Delayed onset of oral swallow 4) Reduced oral sensation 5) Delayed triggering of pharyngeal swallow

Front 160

Techniques to improve oral sensory awareness are both _________ and ____________ in nature

Back 160

Compensatory / therapeutic

Front 161

Why are oral sensory techniques considered compensatory? Why are they considered therapeutic?

Back 161

1) Because they are largely under the control of the caregiver 2) Because they change the physiology of the swallow (change timing for reduced oral onset and pharyngeal delay)

Front 162

All oral sensory techniques involve _________________________ and serve to _________________________.

Back 162

Providing a preliminary sensory stimuli BEFORE initiating swallow attempt / alert the CNS and lower the threshold of the swallowing centers.

Front 163

What are 6 oral sensory heightening techniques?

Back 163

1) Increasing downward pressure w/ spoon on tongue when presenting food 2) Presenting sour bolus (50% lemon, 50% barium) 3) Presenting cold bolus 4) Presenting bolus requiring chewing 5) Presenting larger volume volus (3 ml +) 6) Thermal-tactile stimulation

Front 164

For swallowing apraxia, what sensory techniques are useful?

Back 164

Downward pressure with spoon, increased volume, taste, temp; thermal-tactile stim. Some patients may be facilitated for oral onset and OTT.

Front 165

What sensory techniques are especially useful for triggering the pharyngeal swallow?

Back 165

Thermal-tactile stim; suck-swallow

Front 166

Describe Thermal-Tactile Stimulation

Back 166

1) Vertically rub the anterior faucial arch (on each side) 4-5 times using a COLD size 00 laryngeal mirror. 2) Then follow with the swallow 3) Heightens oral awareness and alters the CNS to help trigger the pharyngeal swallow 4) Reduces delay for several swallows following the stimulation.

Front 167

Describe the Suck-Swallow

Back 167

1) Exaggerated vertical tongue-jaw sucking movements with lips closed. 2) Draws saliva to the back of the mouth - helpful for patients with poor saliva control 3) Helps trigger the pharyngeal swallow

Front 168

In what ways do we measure the effectiveness of oral-sensory enhancement techniques?

Back 168

1) Duration of time between command and swallow 2) OTT 3) PTT 4) Can measure by palpating (rough) but easier to measure in videofluoroscopy (easier than videoendoscopy because in that case you can't see the oral stage, so hard to determine swallow vs. premature spillage)

Front 169

A patient with a weakened pharyngeal swallow may take ________ swallows per bolus. What do you need to watch for?

Back 169

2-3 / taking too much food too quickly may result in severe collection of food in the pharynx and aspiration. These patients should take smaller boluses and allow plenty of time between swallows.

Front 170

Generally, limiting diet to certain consistencies should be the _____________ because…

Back 170

The last compensatory strategy attempted / this can be very difficult for the patient

Front 171

When other things are not feasible, you may need to restrict your patient's diet to certain consitencies. What are some types of patients in which this may be the case?

Back 171

1) Patient with movement disorders who can't control their posture 2) Patients who cannot follow directions to use swallowing maneuvers. 3) Patients for whom oral sensory procedures are not appropriate.

Front 172

Thin liquids are the most appropriate for which (5) disorders?

Back 172

1) Oral tongue dysfunction 2) Reduced tongue base retraction 3) Reduced pharyngeal wall contraction 4) Reduced pharyngeal elevation 5) Reduced cricopharyngeal opening

Front 173

Thickened liquids are most appropriate for which (2) disorders?

Back 173

1) Oral tongue dysfunction 2) Delayed pharyngeal swallow

Front 174

Purees and thick foods are most appropriate for which (3) disorders?

Back 174

1) Delayed pharyngeal swallow 2) Reduced laryngeal closure at entrance 3) Reduced laryngeal closure throughout

Front 175

When a patient loses 25% or more of tongue tissue (ie. Cancer patients) what may be necessary?

Back 175

Intraoral Prosthetics

Front 176

What types of patients may require intraoral prosthetics?

Back 176

1) Patients who have lost 25% or more of their tongue tissue 2) Tongue movement problems 3) Those with velopharyngeal deficits

Front 177

What are the three types of intraoral prosthesis?

Back 177

1) Palatal Lift 2) Palatal Obturator 3) Palatal Augmentation

Front 178

What does a Palatal lift do?

Back 178

Lifts the soft palate to a closed position in patients with velar paralysis

Front 179

What does a Palatal Obturator do?

Back 179

Can be used in those with a resection of the soft palate due to cancer

Front 180

What does a Palatal Augmentation do?

Back 180

AKA - Reshaping Prosthesis Used for those with significant tongue resections or bilateral tongue paralysis. It recontours hard palate to interact with remaining tongue so patient can propel bolus more efficiently.

Front 181

Who makes the intraoral prosthesis?

Back 181

The Maxillofacial Prosthodontist (The swallowing therapy consults)

Front 182

Placement of intraoral prosthesis should be within ___________ in order to…

Back 182

4-6 weeks post-operatively / avoid formation of maladaptive behaviors.

Front 183

Therapy procedures are designed to ________________ while compensatory strategies are designed to _________________.

Back 183

Change swallow physiology / simply eliminate symptoms

Front 184

Three goals of therapy procedures are…

Back 184

1) To improve ROM for oral/pharyngeal structures 2) Improve sensory input 3) Take voluntary control over the timing / coordination of selected motions.

Front 185

What is the difference between direct and indirect therapy?

Back 185

Direct therpay involves introducing food into the mouth and reinforcing behaviors during actual swallows. Indirect therapy involves working on exercises to improve neuromotor controls that are prerequisites to normal swallowing - NO FOOD GIVEN.

Front 186

When deciding whether to use direct or indirect therapy procedures, on what do you base your decision?

Back 186

The decision is based on aspiration information from MBS

Front 187

When would you provide INDIRECT therapy?

Back 187

When patients aspirate on all volumes/viscosities and are unsafe with oral intake

Front 188

Can swallow maneuvers be practiced during indirect therapy?

Back 188

Yes - they can be practiced using just saliva

Front 189

What does direct therapy involve?

Back 189

1) Presenting food or liquid to swallow while following specified instructions 2) Always give written instructions 3) Discuss the rationale for procedures and allow several dry practices before presenting food. 4) Give the patient small amounts - assure the patient it is not enough to bloch the airway. 5) ENCOURAGE THE PATIENT TO COUGH AS NEEDED!

Front 190

Major oral control and oral/pharyngeal ROM exercises include…

Back 190

1) ROM - to improve extent of movement for lips, jaw, oral tongue, tongue base, larynx, VF 2) Bolus control and chewing exercises 3) Oral-motor control exercises

Front 191

What are the most frequent problems for which oral motor exercises are used?

Back 191

1) Lateralization of the tongue during chewing 2) Elevation of the tongue to the hard palate 3) Cupping of the tongue to collect bolus 4) Anterior-posterior movement of the midline of the tongue

Front 192

What is the purpose of tongue ROM exercises?

Back 192

To increase elevation and lateralization of the tongue to improve oral transit

Front 193

Describe tongue ROM exercises

Back 193

1) Open mouth as wide as possible - do the following positions and hold for 1 second each. 2) Elevate tongue as high as possible in the front 3) Elevate tongue back as high as possible 4) Stretch tongue to clean out L/R lateral sulcus 5) Protrude and retract tongue as far as possible Do each 5-10 times each session (lasting about 4-5 minutes) - do this 5-10 times per day.

Front 194

Tongue ROM exercises are shown to improve __________________ - especially in ________ patients.

Back 194

Speech understandability and oropharyngeal swallow / Oral cancer

Front 195

Describe tongue resistance exercises

Back 195

1) Push tongue against tongue blade 2) Do this to the front and to each side, holding for 1 second each

Front 196

Bolus Control Exercises include ___________, ______________, and ______________

Back 196

1) Exercises to improve gross manipulation of material 2) Exercises to hold cohesive bolus 3) Bolus propulsion exercises

Front 197

Describe exercises to improve gross manipulation of material?

Back 197

1) Using rolled gauze, licorice whip, etc. 2) Grasp gauze between tongue and palate - roll side to side or slide front to back. 3) Progress to moving it in a circular fashion - middle of the mouth onto the teeth back to the middle and then back to the teeth again (on the same side) 4) This simulates chewing.

Front 198

Once the patient can grossly manipulate a gauze roll, how can you increase the difficulty?

Back 198

1) When patient can move the gauze three directions in one second, move to smaller items (ie. Lifesaver on a string) 2) Then thin cloth tape soaked in cranberry or orange juice - introduces small amount to swallow 3) Chewing gum - which the clinician cannot control

Front 199

Describe exercises to hold a cohesive bolus - when do you start these?

Back 199

1) You start them after the patient can manipulate material grossly 2) Begin with 1/3 teaspoon of paste - place it in the middle of the patient's mouth. The patient practices moving it around without letting it spread out. 3) Then you expectorate it- look for any residue 4) Increase difficulty by varying bolus size and then move to liquid

Front 200

Describe bolus propulsion exercises

Back 200

1) Use 4" gauze roll - soaked in juice 2) Patient is asked to push up and back against the gauze - this squeezes liquid out of the gauze and back while you hold the it so the gauze won't be swallowed. 3) Also includes a small amount of liquid to swallow

Front 201

For bolus propulsion exercises - if your patient has reduced tongue elevation what can you do?

Back 201

1) Start with a thicker gauze roll 2) Then reduce it as the patient gets more skilled

Front 202

The four general types of ROM exercises for pharyngeal structures are…

Back 202

1) Airway entrance exercises 2) Vocal fold adduction exercises 3) Tongue base exercises 4) Laryngeal elevation exercises

Front 203

When would you begin using airway entrance exercises?

Back 203

If the patient cannot get airway closure using postures or voluntary maneuvers

Front 204

Describe ROM exercises for the airway entrance

Back 204

1) Hold breath, bear down for 1 sec. and let go 2) Do this 5-10x /day for 5 minutes each

Front 205

You should not use traditional ROM exercises for patients with ____________ so instead you should use…

Back 205

1) High blood pressure - bearing down may make BP spike 2) Use repeated glottal attacks instead

Front 206

Describe vocal adduction exercises

Back 206

Set One: Bear down against chair while producing clear voice. Repeat 5x. Then do hard glottal attack on /a/ 5x. Repeat 3 times 5-10 times per day. Can use voice therapy to monitor improvement in laryngeal function. Set Two: Lifting or pushing with simultaneous voicing. Sit on a chair while pulling up while prolonging vowel. Then make repeated glottal attacks harder by making patient prolong it. Then practice the pseudo supraglottic swallow - take a breath, hold it, cough strongly.

Front 207

Generally, you will see the effects of vocal adduction exercises in __________ but some patients will need ________ to attain adequate airway protection (give an example)

Back 207

2-3 weeks / 6-8 months / Ex: patient with supraglottic laryngectomy or extensive laryngeal damage

Front 208

Describe the three tongue base exercises

Back 208

1) Retract the tongue as far as possible - hold 1 sec. 2) Pretend to gargle as hard as possible 3) False yawn 4) Effortful swallow also improves retraction

Front 209

How do you decide WHICH tongue base exercise is the best for your patient?

Back 209

1) Try all three in MBS 2) Select the one that gives the best retraction.

Front 210

Describe the laryngeal elevation exercises

Back 210

1) The Falsetto Exercise - the patient is asked to slide up the scale as far as possible. Hold that pitch for a few seconds. 2) Shaker exercises - lay on ground and lift your head to look at your toes. Hold this - strengthens the suprahyoid muscles.

Front 211

Are sensory procedures compensatory or therapeutic in nature?

Back 211

1) Compensatory - may need to be used as part of a maintenance program (Alzheimer's, MND, etc.) 2) Therapeutic - designed to regularly improve onset or oral swallow and triggering PS. (Stoke, TBI, head and neck cancer - recovery is expected)

Front 212

You only use Thermal Tactile Stim for delayed pharyngeal swallow if…

Back 212

You see the delay on TWO CONSECUTIVE swallows on MBS - some patients just need a warm up.

Front 213

If you are trying to do Thermal Tactile Stim on a patient with a bite reflex, what do you need to do?

Back 213

Coat the mirror with Teflon so that it won't break

Front 214

Thermal Tactile Stim has been shown radiographically to improve the swallow of _____% of patients with delayed triggering of pharyngeal swallow when the swallow…

Back 214

95% / immediately followed the stimulation

Front 215

What are the long term effects of using Thermal Tactile Stim on patients with delayed triggering of pharyngeal swallow?

Back 215

We don't know yet

Front 216

If you are palpating a swallow, it is considered abnormal if the oral transit + pharyngeal delay takes more than ____ seconds.

Back 216

2

Front 217

You may need to do Thermal Tactile Stim for several weeks to a month before you see improvement, one the pharyngeal swallow begins to trigger, what can you do…

Back 217

1) Increase the amount of material in small steps 2) Change to thicker material 3) Remember that the patient may need to continue non-oral feeding for some time while therapy progresses.

Front 218

Swallow manuevers involve placing _____________________

Back 218

Some aspect of the pharyngeal swallow under voluntary control

Front 219

What are three problems for which you might use a supraglottic swallow?

Back 219

1) Premature spillage 2) Reduced or late vocal fold closure 3) Delayed pharyngeal swallow

Front 220

What is the goal of the supraglottic swallow?

Back 220

Close the vocal folds to protect the trachea from aspiration

Front 221

What are the instructions for the supraglottic swallow?

Back 221

1) Take a deep breath and hold your breath 2) Keep holding your breath and lightly cover your trach (if applicable) 3) Keep holding you breath while you swallow 4) IMMEDIATELY after you swallow, cough

Front 222

What is one problem you may have while you try to teach the supraglottic swallow - how can you troubleshoot this?

Back 222

1) The patient may hold their breath by stopping chest movement - you will see the airway is still open during the MBS 2) Modify instructions: "Inhale, exhale slightly, then stop the exhalation and hold your breath" OR "Inhale, prolong /a/, then stop and hold your breath"

Front 223

What is the extended supraglottic swallow? When would you use it?

Back 223

1) AKA the "Dump and Swallow" technique - the patient holds breath, takes a large volume, and tosses head back, swallowing a few times to clear it. 2) Need to first make sure airway protection is adequate and also if the PS triggers on time. 3) Do this with patients with severely reduced tongue mobility, severely reduced tongue bulk, severe problems with oral transit - HELPS ENSURE ADEQUATE NUTRITION

Front 224

What are some problems for which you would use a super supraglottic swallow?

Back 224

1) Reduced closure of airway (entrance, too) 2) Patinets with supraglottic laryngectomies

Front 225

What is the goal of the super supraglottic swallow?

Back 225

To close the airway entrance voluntarily by tilting the arytenoid cartilage anteriorly to the base of the epiglottis before and during the swallow (The normal way of closing the airway but this technique gets it done earlier)

Front 226

What are the instructions for the super supraglottic swallow?

Back 226

1) Inhale & hold your breath tightly, BEARING DOWN 2) Keep holding breath bearing down as you swallow 3) Cough when you are finished

Front 227

Why is the super supraglottic swallow useful for patients with supraglottic laryngectomies?

Back 227

Because in these patients the epiglottis is removed so the airway entrance = the tongue base + the arytenoid cartilage. The patient needs to push hard so that the arytenoids contact the base of tongue

Front 228

The effortful swallow is particularly useful for patients with…

Back 228

Reduced tongue base retraction

Front 229

What is the goal of the effortful swallow?

Back 229

To increase posterior motion of the tongue base during the pharyngeal swallow (as well as improving bolus clearance from the valleculae)

Front 230

What are the instructions for the effortful swallow?

Back 230

As you swallow, squeeze hard with all your muscles

Front 231

The Mendelsohn Maneuver is particularly useful for what two problems?

Back 231

1) Reduced laryngeal movement 2) Discoordinated swallow

Front 232

What is the goal of the Mendelsohn Maneuver?

Back 232

TO increase the extent and duration of laryngeal elevation and thereby increase the duration and width of cricopharyngeal opening. Also improves the overall coordination of the swallow.

Front 233

What are the instructions for the Mendelsohn Maneuver?

Back 233

1) Swallow (saliva only) and pay attn. to your neck 2) Tell me if you can feel something (voice box, adam's apple, etc) lifting and falling as you swallow 3) Now, this time when you swallow, when you feel something lift, don't let it drop. Hold it up with your muscles for several seconds. (Alternative - everything squeezes together - HOLD THE SQUEEZE)

Front 234

What are some key points about the voluntary maneuvers?

Back 234

1) They require the ability to follow directions 2) Require increased musculatory effort - not appropriate for patients who fatigue easily 3) Each maneuver has a specific rational with different disorders.

Front 235

What are the two major tasks in the oral preparatory phase?

Back 235

1) Manipulate food in the mouth while maintaining lip closure (check nasal breathing) 2) Control the bolus to avoid premature spillage

Front 236

Describe ROM exercises for the lips

Back 236

1) Stretch to /i/ and hold 1 sec. 2) Pucker as tight as possible and hold 1 sec. 3) Bring lips together and hold 1 sec. 4) If the patient cannot close lips, use a stack of tongue blades or other item and then reduce it. 5) Increase the amount of time patient maintains lip closure. (Up to about 10 minutes/day)

Front 237

Describe strengthening exercises against resistance

Back 237

1) Use a tongue blade and have the patient hold it with their lips. They need to hold tight as the clinician tries to extract it. 2) Hold the lips closed while someone tries to manually part them

Front 238

List therapy/compensatory options for patients with reduced tongue motion (laterally) during mastication

Back 238

1) Therapy - ROM exercises to manage bolus 2) Compensation - Position food on the side with better motility. OR…tilt head to the intact side. Patient may also be asked to mash food vertically up against hard palate in the meantime.

Front 239

List therapy/compensatory options for patients with Reduced buccal tension or buccal scarring

Back 239

1) Therapy - facial ROM exercises. Rounding lips for "oh", stretch to /i/, rapidly alternate. Smile broadly and then tighten lips across cheeks. Pull lips as far as possible to one side and then hold 1 sec. 2) Compensation - Patient can put pressure on that cheek to seal lateral sulcus. Place food on unaffected side and tilt that way.

Front 240

List therapy/compensatory options for patients with reduced range of lateral mandibular motion

Back 240

1) Therapy - ROM exercises for jaw 2) Compensation - teach patient to mash food vertically to expand diet options. Also, "Guide-plane" prosthesis.

Front 241

ROM exercises for the jaw are MOST important for which types of patients?

Back 241

1) Post-operative oral cancer patients 2) Patients undergoing radiotherapy - potential scarring/fibrosis of muscles of mastication

Front 242

What are some potential effects of radiotherapy?

Back 242

1) Fibrosis of muscles of mastication 2) Narrowed mouth opening 3) Restriction of mandibular movement

Front 243

List therapy/compensatory options for patients with reduced range of tongue movement vertically

Back 243

1) Therapy - Vertical ROM exercises, strengthening 2) Compensation - If the tongue-palate contact is still incomplete after several months, you may consider a Reshaping Prosthesis

Front 244

What does a palatal reshaping prosthesis do?

Back 244

1) Lowers the palatal vault to complement tongue function - it will contain more material where the tongue is more restricted.

Front 245

A Mandibular Tongue Prosthesis may be used to…

Back 245

Improve oral manipulation of food and speed of oral transit

Front 246

List therapy/compensatory options for patients with reduced tongue movement to form bolus

Back 246

1) Therapy - exercises to control bolus 2) Compensation - tilt head forward to present spillage into pharynx or sulci. (Patient will lift head with the start of the swallow)

Front 247

List therapy/compensatory options for patients with reduced ability to hold the bolus in normal position

Back 247

1) Therapy - Patient given thick bolus and asked to hold against anterior to middle palate. This requires the tongue tip and lateral margins of the tongue contact the alveolar ridge. As patient gets better, you can make the bolus thinner.

Front 248

List therapy/compensatory options for patients with tongue thrust

Back 248

1) Therapy - Heighten patient's awareness of tongue thrust pattern. Ask patient to conciously position tongue on alveolar ridge and begin swallow with upward, backward push. 2) Compensation - position food more posteriorly on the tongue to avoid the pattern. Tilt head or body back (if food is pushed from mouth)

Front 249

The ____________ is an instrument that can help the patient gage the amount of pressure applied between tongue and hard palate

Back 249

IOPI (Iowa Oral Pressure Instrument)

Front 250

List therapy/compensatory options for patients with Swallowing Apraxia

Back 250

1) Therapy - SENSORY HEIGHTENING - thermal-tactile stim, changing bolus characteristics

Front 251

Can a scarred tongue be improved with exercises?

Back 251

NO! It must be released surgically (refer to head and neck surgeon). COMPENSATION - teach the patient to position food posterior to the scarring. Also, tilt head back to assist with oral transit.

Front 252

List therapy/compensatory options for patients with delayed or absent pharyngeal swallow

Back 252

1) Therapy - Thermal-Tactile stimulation!! Suck-swallow technique. Changing bolus characteristics. 2) Compensation - Chin tuck posture. Teach patient to pace swallows to avoid accumulation of too much material in pharyngeal recesses.

Front 253

List therapy/compensatory options for patients with Reduced tongue elevation

Back 253

1) Therapy - ROM exercises!! 2) Compensation - position food posteriorly in the tongue (may use straw). Tilt head backward (as long as pharyngeal swallow and laryngeal control are okay)

Front 254

Often, in a patient with reduced tongue elevation, you will also see…

Back 254

Reduced anterior-posterior tongue movement

Front 255

What do you do with a patient who has disorganized tongue movement patterns (ie. Parkinson's disease)?

Back 255

1) Alert the patient to the pattern 2) Instruct the patient to hold the bolus consciously against the hard palate with the tongue 3) And initiate the swallow with a single, strong, backward movement (This will be helpful as long as patient can remain aware of their swallow)

Front 256

1) If can irritate the tracheal wall and cause tracheal stenosis 2) Can prevent re-learning to swallow because it restricts laryngeal elevation, reduces laryngeal sensitivity, places pressure on the front wall of the esophagus.

Back 256

Involved clinician sucking on finger and then swallowing, then patient does the same but

Front 257

List therapy/compensatory options for patients with Bilateral Reduction in Pharyngeal Contraction

Back 257

1) No direct therapy improves this at all levels 2) Masako Exercises 3) Compensation - Alternate liquids and semisolids to wash residue down. Limit diets to foods requiring less pressure. Follow each swallow with repetitive dry swallows.

Front 258

Describe the Masako Exercise

Back 258

1) Hold tip of tongue between the teeth 2) Extended 3/4 of an inch 3) This stabilizes the anterior portion of the tongue and exercises the posterior tongue - GLOSSOPHARYNGEUS

Front 259

List therapy/compensatory options for patients with Unilateral Reduction in Pharyngeal Contraction

Back 259

1) Therapy - no exercises to improve this 2) Compensation - ROTATE head to damaged side. Closes that side. (If patient has lingual issues on the same side, the patient should instead TILT to the normal side)

Front 260

List therapy/compensatory options for patients with Scarred Pharyngeal Wall

Back 260

1) No exercises 2) Compensation - Head rotation can close damaged side and redirect bolus. Can also use supraglottic swallow to try to eliminate residue that collects near the scar.

Front 261

List therapy/compensatory options for patients with Cervical Osteophyte

Back 261

1) Surgical removal may be needed 2) May need to thin out consistency 3) May also compensate by having the patient Rotate Head either way - see if it improves the swallow

Front 262

List therapy/compensatory options for patients with Pseudoepiglottis at the Base of the Tongue after Total Laryngectomy

Back 262

1) Therapy - May need to be removed surgically 2) Compensation - Thin liquids, head rotation

Front 263

Three possible causes of cricopharyngeal dysfunction are…

Back 263

1) Failure of the CP to relax (Tx - myotomy) 2) Reduced laryngeal motion up/fwd (Try Mendelsohn maneuver) 3) Poor pressure to drive bolus (improve tongue base action)

Front 264

List therapy/compensatory options for patients with Reduced Laryngeal Elevation

Back 264

1) Mendelsohn Maneuver 2) Clear throat / Supraglottic swallow 3) Super-supraglottic / Falsetto exercise

Front 265

List therapy/compensatory options for patients with Reduced Laryngeal Closure at the Vocal Folds

Back 265

1) Therapy - improve adduction using VF exercises 2) Compensation - supraglottic swallow. May use chin tuck to help protect airway (as well as head rotation to bring damaged VF closer to midline)

Front 266

Usually disorders affecting the esophageal phase of the swallow are handled with…

Back 266

Medication or surgery

Front 267

When you are going to use a combination of posture + voluntary maneuver - what do you need to do in MBS?

Back 267

Check the effectiveness of each one separately and then the combination on MBS

Front 268

What combination of posture + voluntary maneuver is useful for patients with poor airway entrance closure?

Back 268

Head Rotation + Super-Supraglottic Swallow

Front 269

What combination of posture + voluntary maneuver is useful for patients with poor tongue base motion?

Back 269

Chin Down + Effortful Swallow

Front 270

What combination of posture + voluntary maneuver is useful for patients with Poor Cricopharyngeal Opening?

Back 270

Head Rotation + Mendelsohn Maneuver

Front 271

If you use surface EMG for biofeedback what type of information can the patient pet?

Back 271

Information on amount of effort for lip closure (electrodes on lips); muscle effort during swallow (electrodes under chin); electrical activity in laryngeal elevators (on larynx during Mendelsohn maneuver)

Front 272

If you use Ultrasound for biofeedback, what type of information does the patient get?

Back 272

Information about tongue movement patterns during swallowing so that the patient can watch changes

Front 273

What are the different types of non-oral feeding?

Back 273

1) IV 2) Nasogastric tube 3) Gastrostomy (including PEG) 4) Jejunostomy (including PEJ) 5) Pharyngostomy 6) Esophagostomy

Front 274

What does IV feeding entail? How long would this be done?

Back 274

The patient is fed through sugar water in the vein. This is done no more than a few days because you don't get much nutrition.

Front 275

IN non-oral feeding, the width of the tube determines ___________________. For example, with a 1/8 inch tube…

Back 275

1) The type of food the patient can get 2) The patient will need prepared feedings - table food will clog it up. This is more expensive.

Front 276

Will you do swallowing therapy with an NG tube in place? How about a G-tube?

Back 276

1) NO - the NG tube will disrupt the swallow. 2) You can do it with a G-tube in place

Front 277

Why would you use a Jejunostomy or Nasal-jejunum tube? What is one added expense?

Back 277

It helps prevent reflux because the food is introduced in the system below the level of the stomach. It is more expensive because the patient HAS to have prepared feedings, not table food (because it does not pass through the stomach to be digested)

Front 278

What are some red flags for refux?

Back 278

1) Mild hoarseness 2) Waking up gagging / coughing 3) Gagging within a few minutes after a meal 4) If the patient has had non-oral feeding

Front 279

Are X-ray studies good for observing reflux? What is the best test?

Back 279

1) NO - you are not looking that low in MBS & even regular Barium studies miss it 60-80% of the time 2) REFLUX MONITORING - tube inserted through nose and into esophagus. This tube has acid-sensitive sensors which will be set off by reflux.

Front 280

What is a pharyngostomy? Any specific problems with this?

Back 280

1) A type of non-oral feeding in which there is a hole from the outside of the neck into the pharynx for the feeding tube. 2) Problem - it may move migrate opening up the sutures and creating a fistula from the skin into the pharynx.

Front 281

What is an esophagostomy? Any specific problems with this?

Back 281

1) A non-oral feeding type in which there is a hole lower in the neck for the tube to enter and go down into the esophagus. 2) Problem - there are major blood vessels in the neck which can get disrupted (ie. the tube may irritate/degrade the carotid)

Front 282

What is a gastrostomy? Any specific problems with this?

Back 282

1) A non-oral feeding type in which there is a hole directly into the stomach for the feeding tube 2) This requires general surgery and many older people cannot undergo anesthesia.

Front 283

What is a Jejunostomy? Any problems with this?

Back 283

1) A non-oral feeding type in which there is a hold into the digestive system just below the stomach 2) Requires prepared feedings because the food is no longer passing through the stomach.

Front 284

What are PEG and PEJ?

Back 284

1) Percutaneous Endoscopic Gastrostomy OR Jejunostomy. Only LOCAL anesthetic is needed because an endoscope is placed down into the structure to determine where to enter for the feeding tube. The benefit is that now more people can have this instead of an NG or NJ tube. Unfortunately, it means some patients are given this too hastily.

Front 285

What are the general problems with non-oral feeding?

Back 285

1) It is more expensive than oral feeding 2) Puts people at risk for reflux - across ALL the types

Front 286

While you may wait 2-3 days to put a patient on a feeding tube, you should not wait more than…

Back 286

4-5 days - it is our job to help ensure the patient gets adequate nutrition

Front 287

Why is non-oral feeding trickier in those under six years of age?

Back 287

1) They have an underdeveloped LES so you need to do a surgery to reinforce it (to avoid reflux). The surgery involves twisting the entrance of the stomach around the LES. (Fundoplication)

Front 288

If you patient has been recently intubated…

Back 288

1) You will generally wait at least 24 hours (but preferably 3 days) before initiating swallowing eval/therapy. The intubation will likely cause some reduced ROM.

Front 289

If your patient is tracheostomized, there will always be a ___________ in the room. You need to find out whether the trach is clean or _______ for that patient.

Back 289

Trach kit / sterile

Front 290

How do you clean out the trach?

Back 290

Remove the inner canula, rinse it out. Then use a bottle brush to clean it. Rinse again, shake it, and stick it back in (this is the clean procedure)

Front 291

When you start working somewhere, what do you need to do to figure out about handling trachs there?

Back 291

1) Ask for an inservice with the respiratory staff to show you how to clean them (if you are allowed) 2) Find out if you are allowed to suction 3) Ask about cuff procedures - Minimal leak vs. fully inflated?

Front 292

What is deep suctioning? Who does it?

Back 292

1) A procedure in which a long flexible catheter is inserted in past the bifurcation of the bronchi to suction. 2) Selected Nurses can do it

Front 293

Most ventilators work on ____________ which means…

Back 293

1) Positive pressure 2) The ventilator applies pressure to inject air into the lungs. 3) Then the air is allowed to flow passively out of the lungs. 4) Cuff must be INFLATED!!!

Front 294

What is auscultation? What are the clinical uses of it?

Back 294

1) Listening to the sounds of the swallow. 2) Data is poor and you cannot tell if the patient is aspirating or not using this technique. What you CAN tell is the coordination of breathing and swallowing - remember that the swallow should NOT interrupt the inhalation.

Front 295

For 75-80% of patients, what is the pattern of the swallow in relation to respiration? How is this controlled?

Back 295

The patient inhales, stops breathing, swallows, and then exhales / Controlled by the medulla

Front 296

How long does it take children to stabilize the pattern of swallowing in relation to respiration?

Back 296

About three months

Front 297

What are some respiratory issues that might prevent you from working on swallowing?

Back 297

1) Rapid respiration 2) If the patient is ventilator dependent

Front 298

How can you test different tastes, textures, etc. without putting the patient at risk?

Back 298

Wrap fabrics of different textures around flexible straws - dip these in different tastes in order to see what elicits the best swallow.

Front 299

Which taste seems to evoke the best swallow?

Back 299

SOUR

Front 300

Besides increasing fibrosity of tissues, patients with radiation will also often experience…

Back 300

Loss of sensitivity in places

Front 301

______ of women and _______ of men have NO gag reflex

Back 301

10% / 40%

Front 302

What is the goal of therapy (RSTSC)?

Back 302

To improve the oropharygneal swallow by changing the physiology: Range of motion, strength, timing, coordination, sensory input

Front 303

Therapy is designed to be _________ and _________

Back 303

Functional / Measurable

Front 304

Reduced Mandibular Movement: Populations, Procedures, Measurement

Back 304

1) Population: Oral Cancer (radiation, surgery) 2) Procedures: Open/Close mouth; lateral movement; circular movement; combine above with resistance 3) Measurement: Distance of opening; ability to put the bolus in the mouth

Front 305

Reduced Labial Seal: Populations, Procedures, Measurement

Back 305

1) Population: CVA, Oral cancer 2) Procedures: Protrusion/retraction; form seal around a cup (then hold the cup up that way); maintain air puffed cheeks; resistance against tongue blade. 3) Measurement: Distance, resistance, improved saliva/bolus control.

Front 306

Reduced lingual movement for mastication, bolus formation, bolus control, and oral transit: Populations, Procedures, Measurement

Back 306

1) Population: Oral cancer, CVA, TBI 2) Procedures: WORK IN ALL PLACES OF MOTION, MARGINS of STRENGTH: protrusion/retraction; lateralization; elevation (tip and back); resistance against tongue blade. 3) Measurement: distance, resistance.

Front 307

What are the procedures and measurement options for chewing and tongue control?

Back 307

These allow patients to manipulate something moving from gross to more skilled movement: 1) Procedures: manipulating item L to R / R to L in 2-3 lingual sweeps, rotary motion (midline to teeth again and again), tongue cupping bolus, A/P movement. 2) Measurement: number of lingual movements needed. (Materials = gauze, swab, licorice whip, lollipop, lifesaver on a string)

Front 308

Reduced Tongue Base Retraction: Population, Procedure, Measurement

Back 308

1. Population: CVA (subcortical), Pharyngeal cancer, SCI (cervical fusion), Respiratory failure (intubation), generalized dysfunction. 2. Procedures: pull back, yawn, gargle (use VFG to pick one), effortful swallow, Masako 3) Measurement: increased movement, reduced residue in valleculae.

Front 309

Reduced Laryngeal Elevation: Populations and three procedures

Back 309

1) Population: CVA (brainstem), SCI (cervical fusion), H/N cancer (surgery / XRT), generalized deconditioning. 2) Procedures: Falsetto voice, Mendelsohn maneuver, Shaker exercises

Front 310

Describe Falsetto Voice procedure and how you would measure progress

Back 310

1) Pitch glide up on /i/ and then hold for 2-3 seconds 2) Measurement: Palpate for laryngeal movement, improvement in pitch glide.

Front 311

Describe how you would measure progress from using the Mendelsohn maneuver?

Back 311

Increased movement, reduced pyriform sinus residue visualized in VFG

Front 312

Describe the Shaker exercise and how you would measure progress. Also, what type of clients would you NOT use this for?

Back 312

Part A: Lie down, elevate head for 1 minute, rest head for one minute, repeat process 3x. Part B: Repetitive head elevations X 30. 2) Measurement: Reduced pyriform sinus residue on VFG, observing duration of head lift. 3) DO NOT USE on patients with SCI or trach

Front 313

Reduced glottic closure: Populations, Procedures, Measurement

Back 313

1) Populations: Intubation trauma, VC paralysis 2) Procedures: Bearing down or lifting against hard surface with one hand; sustained phonation with hard onset, effortful breathhold, combine techniques to make it more difficult. 3) Measurement: Improvement in Voice Quality

Front 314

What are the two functions of voluntary maneuvers?

Back 314

1) To use as a compensatory strategy to make the swallow safer NOW 2) To use in therapy as an exercise to change the physiology of the swallow over time

Front 315

Two disorders for which a supraglottic swallow is helpful; Rationale; populations

Back 315

1) Reduced laryngeal closure at the vocal folds 2) Delayed pahryngeal swallow 3) RATIONALE: closes vocal cords before and during the swallow 4) Populations: VC paralysis, intubation trauma

Front 316

How can you measure the effectiveness of the supraglottic swallow in VFG? At bedside?

Back 316

1) VFG - presence/amount of aspiration on repeat 2) At bedside: Monitor for sequencing, duration of breath hold.

Front 317

What disorder is most helped by super supraglottic swallow? Rationale? Typical Populations?

Back 317

1) Reduced laryngeal closure at the airway entrance 2) Rationale: the arytenoids tilt forward, closing airway entrance before/during swallow 3) Partial laryngectomy, intubation trauma

Front 318

How can you measure the effectiveness of the super supraglottic swallow on VFG? At bedside?

Back 318

1) Presence/absence of aspiration on repeat VFG 2) At bedside: monitor for sequencing , duration of breath hold, effort of breath hold

Front 319

What disorder is most helped by effortful swallow? Rationale? Populations?

Back 319

1) Reduced tongue base retraction 2) Rationale: Effort improves movement 3) Populations: H/N cancer, SCI, CVS, generalized deconditioning

Front 320

How can you measure improvement from using effortful swallow at VFG? At bedside?

Back 320

1) VFG - movemetn seen on VFG, amount of vallecular residue seen on repeat VFG 2) Palpate for tension at bedside

Front 321

Which disorder is most helped by the Masako exercise? Populations?

Back 321

Reduced tongue base retraction / H/N cancer, SCI, CVA

Front 322

How can you measure progress from using the Masako exercise on VFG? At bedside?

Back 322

1) On VFG - Movement observed, amount of residue in the valleculae. 2) At bedside - monitor protrusion of the tongue, signs of fatigue

Front 323

Should you use food when doing the Masako exercises?

Back 323

Not if the patient is shown to have dysphagia in VFG

Front 324

Name the two disorders most helped by the Mendelsohn maneuver. Rationale? Populations?

Back 324

1) Reduced Laryngeal elevation 2) Reduced coordination of the swallow 3) Larygneal movement opens the UES so by prolonging laryngeal elevation we can increase the extent and width of UES opening. It also normalizes timing of the pharyngeal swallow. 4) Populations: SCI, H/N cancer (surgery,XRT), CVA

Front 325

How can you measure progress from using the Mendelsohn Maneuver on VFG? At bedside?

Back 325

1) On VFG - increased movement, reduced pyriform sinus residue on VFG. 2) At bedside - palpate the swallow

Front 326

Which disorder is most helped by Thermal Tactile Stim? Rationale? Populations?

Back 326

1) Delayed pharyngeal swallow 2) Rationale - technique heightens sensory awareness and alerts the cortex/brainstem that a swallow is coming. 3) CVA / TBI

Front 327

How can you measure progress of patients using TTS? How can you increase the difficulty?

Back 327

1) Improved timing of trigger seen on VFG, palpate the swallow at bedside. 2) Increase difficulty by withdrawing the frequency of TTS, increase bolus amount or viscosity)

Front 328

What disorder is most helped by Suck-Swallow? Rationale?

Back 328

1) Delayed pharyngeal swallow 2) Exaggerated movement provides sensory stimulus.

Front 329

Other sensory enhancing procedures include…(besides suck-swallow, TTS)

Back 329

1) Downward pressure with spoon 2) Changing bolus characteristics: volume, sour bolus, carbonated bolus

Front 330

Intraoral prosthetics are used as a _________ procedure

Back 330

Compensatory

Front 331

List some populations that may benefit from intraoral prosthetics

Back 331

1) Oral cancer patients loss of ROM or TISSUE itself 2) Neurologic disorders resulting in reduced lingual movement/strength.

Front 332

Intraoral prosthetics are usually initiated _______

Back 332

4-6 weeks post-surgery

Front 333

The prosthetic device used for patients who have intact anatomy but reduced velopharyngeal competency. What does it do?

Back 333

1) Palatal Lift 2) It elevates the natural tissue to close off the nasopharynx and reduce nasal regurgitation, increase pharyngeal pressure generation

Front 334

The prosthetic device used for patients who have had resections of the soft palate. What does it do?

Back 334

1) Palatal obturator 2) Designed to replace missing tissue

Front 335

The prosthetic device used for those with limited lingual ROM or tongue bulk. What does it do?

Back 335

1) Palatal Augmentation / Reshaping prosthesis 2) Lowers the palatal vault to improve lingual-palatal contact for bolus transit and speech.

Front 336

Every therapy plan needs…

Back 336

1) Long Term Goals 2) Short term goals (specific techniques, conditions) 3) Daily practice schedule (therapy and individual) 4) Explanation of rationales 5) WRITTEN INSTRUCTIONS 6) Timeline for reevalation or revision of goals

Front 337

List the five disorders for which you should use THIN LIQUIDS

Back 337

1) Oral Tongue dysfunction 2) Reduced Tongue Base retraction 3) Reduced Pharyngeal Wall Contraction 4) Reduced laryngeal elevation 5) Cricopharyngeal dysfunction

Front 338

List the two disorders for which you should use THICKENED LIQUIDS

Back 338

1) Oral Tongue Dysfunction 2) Delayed pharyngeal swallow

Front 339

List the three disorders for which you should use PUREES/THICK FOODS

Back 339

1) Delayed Pharyngeal Swallow 2) Reduced laryngeal closure @ entrance 3) Reduced laryngeal closure throughout