Fixing Swallowing Problems:
How to Tackle (And Fix)
the Underlying Causes of
Swallowing Dysfunction
Catriona M. Steele
Ph.D., S-LP(C), CCC-SLP, BCS-S, Reg. CASLPO, ASHA Fellow
Catriona.steele@uhn.ca
www.SteeleSwallowingLab.ca
Starting Position
• Dysphagia is defined as a functional impairment
in either swallowing safety and/or efficiency
arising from structural differences or
abnormalities in the biomechanics of
swallowing
• Compensatory or rehabilitative techniques can
be used to alter bolus flow, swallowing
biomechanics and/or swallowing function
ACSLPA Conference: November, 2014
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Outline
Starting Position
Starting position statements
How to appraise evidence?
Mechanisms of impaired swallowing safety
Mechanisms of impaired swallowing efficiency
Evidence and case examples for specific
techniques:
• Compensatory and rehabilitative techniques can
have beneficial, neutral or maladaptive
consequences
• PREFERRED treatments are those that:
– Tongue-pressure training
– Chin down
- Effortful Swallow
– Mendelsohn Maneuver - Shaker exercise
– Are effective in addressing the specific underlying
causes of dysfunction (pathophysiology)
– Do not cause maladaptation
– Are efficient (can be implemented easily)
– Do not interfere with social normalcy during eating
Starting Position
• Swallowing is a complex biomechanical
process involving the coordinated behaviour
of >25 pairs of muscles in the upper
aerodigestive tract
• Swallowing behaviour can vary within and
across healthy individuals, and can be adapted
to meet different task demands
• The primary functional concerns in dysphagia
are swallowing SAFETY and EFFICIENCY
Our job as clinicians
includes:
• sifting the available
evidence, and
• being the
guide/interpreter of
evidence for our
patients and their
families.
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Systematic Reviews
and Meta-Analyses
http://www.cebma.org/wp-content/uploads/Levels-of-evidence.png
speechBITE Inclusion Criteria
• Paper MUST be published as a full-length paper in a
peer-reviewed scientific journal
• MUST evaluate at least one intervention
• MUST include empirical data applied to people
representative of those who might be seen in S-LP
practice
• Treatment MUST either be currently a part of S-LP
practice or could become part of S-LP practice
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Includes randomized or non-randomized controlled trials
(evaluated using PEDro-P Scale) and single case experimental
designs (evaluated using the RoBiN-T scale)
PEDro-P Scale Questions (www.psycbite.com)
1.
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Eligibility criteria were specified (not counted in score)
Subjects were randomly allocated to interventions
Allocation was concealed
Intervention groups were similar at baseline
There was blinding of all subjects
There was blinding of all therapists
There was blinding of all assessors who measured outcome
Measures of at least one outcome were obtained from > 85% of the
subjects originally enrolled and allocated
9. All subjects with data received the treatment or control condition as
allocated, or were analyzed as “intention to treat”
10. Results of between-group statistical comparisons are reported for at least
one key outcome variable
11. Both point measures and measures of variability are reported for at least
one key outcome variable
15-item Risk of Bias
in N-of-1 Trials (RoBiNT) Scale
http://www.speechbite.com/
Tate et al. (2013): Revision of a method quality
rating scale for single-case experimental designs
and n-of-1 trials: The 15-item Risk of Bias in Nof-1 Trials(RoBiNT) Scale, Neuropsychological
Rehabilitation: An International Journal
http://dx.doi.org/10.1080/09602011.2013.8243
83
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What can clinicians do to contribute
quality treatment stories to the literature?
• Treat each patient as a possible research case
– Consider whether ABA or BAB designs might be appropriate
• Standardize your assessment
– Consider asking someone else to blind-rate measures using
strict definitions
• Standardize your treatment protocol
• Measure a control variable that should not change as a function
of your treatment
• Choose logical, sensitive outcome measures
• Try to blind yourself when determining results
WHY DOES
ASPIRATION
HAPPEN?
How to narrow the treatment
options to limit aspiration?
• Measure tongue strength
• Measure time bolus is in pharynx prior to
laryngeal vestibule closure
• Examine resting respiratory rate and postswallow airflow direction
• If measuring hyoid movement, use anatomically
normalized measures
• Probe treatments that address these issues
Treatments to consider
• TONGUE
– Tongue pressure resistance training; Effortful swallow
• LARYNGEAL VESTIBULE CLOSURE
– Chin down; Texture modifications
• RESPIRATORY-SWALLOW CO-ORDINATION
– 3-second oral hold; Supraglottic swallow; EMST
• HYO-LARYNGEAL EXCURSION
– Effortful swallow; Mendelsohn maneuver; Shaker
WHY DOES RESIDUE HAPPEN?
http://rd.springer.com/article/10.1007%2Fs00455-014-9516-y
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Old age
Risk is not constant from
swallow to swallow
Risk is not constant across
different bolus consistencies
Reduced tongue strength
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Respiratory rate > 25 bpm
Non exp-ap-exp pattern
? Hyoid excursion (needs to be
confirmed using anatomically
normalized measures)
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? Time to laryngeal vestibule
closure/bolus dwell time
• Low tongue driving force (diffuse; valleculae)
• Reduced pharyngeal shortening (diffuse; pyriforms)
• Reduced pharyngeal constriction (diffuse)
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To date, tongue-pressure resistance training has not yielded
significant improvement of residue
Some reports suggest effortful swallow may be effective
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Issues in residue rating…
• WHERE do you measure?
• WHEN do you measure?
– After first swallow?
– Allow one clean-up swallow?
– At the END of the sequence, regardless of how many
swallows?
• How do you grade amount? (issue: validity of 2D representation)
– Estimate % of bolus?
– % of available space?
• Pooling vs. residue (before vs. after UES opening)
• Barium density (high vs. low, expected coating?)
“Eisenhuber Scale”
(15-ml high-density 250% w/v barium; scored after first swallow)
0 – no residue
1 – “mild” i.e., 0-25% full (versus height of the space)
2 – “moderate”, i.e., 25-50% full
3 – “severe”, i.e., > 50% full
Eisenhuber, et al. (2002). AJR American Journal of Roentgenology,
178(2), 393-398.
The Normalized Residue Ratio Scale
(NRRS)
(Pearson, Molfenter, Smith & Steele, 2012)
NRRS =
(A1/A2) x [(A1/N2)*10]
Acknowledged issues with the NRRS
• Vulnerable to variation based on frame selection
• Unclear yet what values have clinical relevance
– > 0.06 for NRRSv on thin liquid barium associated
with risk of aspiration on a clearance swallow
(Molfenter & Steele, 2013)
• New data suggest there is a significant relationship
between degree of pharyngeal constriction and
resulting NRRS scores (both valleculae and pyriform)
Case Study
• 56-year old man
• 4 months post right medullary ischemic stroke
• On regular solid foods and thin liquids (no
mixed consistencies)
• Needs multiple swallows to clear
• Throat clears frequently throughout the day
and night.
Analysis
• What is the main functional impairment of
concern?
• Which treatments do you think are indicated
for this patient?
Instructions available at SteeleSwallowingLab.ca
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What we decided to do:
• 24 sessions of tongue-pressure resistance
training emphasizing improved strength
• 60 tongue-palate presses per session (half
anterior; half posterior)
• Random targets between 25% and 95% of
baseline maximum effort measures
• Biofeedback from Iowa Oral Performance
Instrument
Iowa Oral Performance
Instrument (IOPI)
www.iopimedical.com
• Records pressure when tongue
compresses air-filled bulb against
the palate
• Pressure displayed on screen in
kiloPascals
• 1 kiloPascal = 7.5 mm Hg
p < 0.01*
p < 0.01*
p < 0.01*
p < 0.01*
Anterior: 46% increase vs. baseline;
Posterior: 81% increase vs. baseline.
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Tongue Pressure Resistance Training?
• It is worth knowing if your
patient has reduced tongue
strength (MIP < 40 kPa)
• Tongue strength CAN improve
with 6-8 weeks of exercise
(ideally with biofeedback)
• Aspiration may improve
(particularly if related to poor
liquid bolus control?)
• Residues may, or may not,
improve
Case Study
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54-year old male
3-months post acquired brain injury
Left hemiparesis, ataxia
Mixed spastic-ataxic dysarthria
Eating pureed diet with thickened liquids
Uses chin down posture for water intake
Wants to resume a more normal diet texture
Analysis
• What is the main functional impairment of
concern?
• Which treatments do you think are indicated
for this patient?
What is the intended effect of the
chin down posture?
Logemann textbook states:
• ‘‘the Chin down posture pushes the anterior pharyngeal
wall posteriorly,’’
• ‘‘the air way entrance is narrowed,’’
• ‘‘the tongue base and epiglottis are pushed closer to the
posterior pharyngeal wall,’’ and
• ‘‘in many patients the vallecular space is also widened’’
Chin-down posture:
• Rasley, A., Logemann, J. A., Kahrilas, P. J., Rademaker, A. W.,
Pauloski, B. R., & Dodds, W. J. (1993). Prevention of barium
aspiration during videofluoroscopic swallowing studies: Value
of change in posture. American Journal of
Roentgenology,160(5),1005-9.
– 165 patients who aspirated during liquid barium swallows
of 1, 3, 5, 10 ml or cup drinking
– 1 of 5 possible postures attempted on next swallow (chin
tuck, head extension, head rotation, head tilt, lying down)
– Aspiration eliminated on next swallow for 77% of patients
and on all volumes for 41%
– Chin-down used most commonly – about 50% effective in
reducing aspiration
Chin-down posture:
– Benefit may be limited to pre-swallow aspiration;
– Chin-tuck can be DANGEROUS with post-swallow
pharyngeal residues
Shanahan, T. K., Logemann, J. A., Rademaker, A. W.,
Pauloski, B. R., & Kahrilas, P. J. (1993). Chin-down posture
effect on aspiration in dysphagic patients. Archives of
Physical Medicine & Rehabilitation, 74(7), 736-739
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Chin Down: New evidence
• New article in JSLHR by Phoebe Macrae and Ianessa Humbert
• Measured the duration of LVC with and without the chin down
posture across multiple trials in healthy adult volunteers
• Showed that the chin down posture elicited LONGER closure of
the laryngeal vestibule by ~ 20% (100 ms) but did NOT facilitate
earlier closure
Chin Down Posture?
• Worth trying in patients who
aspirate due to short or
incomplete LVC
• Effects do not generalize to
head neutral swallows
• Can be maladaptive,
particularly in patients who do
not self feed
• Effectiveness needs to be
evaluated directly (VFSS)
Case Study
• 82 year old male
• 3 months post lateral medullary stroke
• Previously no coordinated pharyngeal swallow
– Limited LVC
– Limited pharyngeal constriction
– Limited UES opening
– Significant pyriform sinus residue
– Aspiration of residue
Analysis
• What is the main functional impairment of
concern?
• Which treatments do you think are indicated
for this patient?
What we decided to do:
• 8 weeks of twice-per-week therapy using
effortful swallow
• sEMG for biofeedback
– Saliva swallows
– 5 Regular effort swallow amplitudes measured
at the beginning of each session
– 55 repetitions of 110-120% of regular effort
amplitude
Effortful Swallow
• Available data primarily only report on immediate
compensatory effect of the effortful swallow:
• Hind, J. A., Nicosia, M. A., Roecker, E. B., Carnes, M. L., &
Robbins, J. (2001). Comparison of effortful and noneffortful
swallows in healthy middle- aged and older adults. Arch
Phys Med Rehabil, 82(12), 1661-1665.
• Improved clearance (less vallecular and pyriform sinus
residue) and improved hyolaryngeal excursion with this
manoeuvre (but in healthy adults!?)
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Effortful Swallow
Huckabee, M.L. & Steele, C.M. (2006). An Analysis of Lingual
Contribution to Submental sEMG Measures and Pharyngeal
Biomechanics during Effortful Swallow. Archives of Physical
Medicine and Rehabilitation, 87, 1067-1072.
Steele, C.M. & Huckabee, M.L. (2007). The influence of orolingual pressure on the timing of pharyngeal pressure events.
Dysphagia, 22(1), 30-36.
What we decided to do:
• 8 weeks of twice-per-week therapy using
Mendelsohn Maneuver
• sEMG for biofeedback
– Emphasis on sustaining amplitude > 30% of regular
effort saliva swallows for 2-3 seconds
– 60 repetitions per session
• Pharyngeal pressure benefits (both amplitude and timing) of
effortful swallow are enhanced when pressure emphasis is
located between tongue and palate (rather than in pharynx
while de-emphasizing tongue-palate pressure)
Case Study
• 25-year old female
• Severe dysphagia due to lupus-related
vasculitis
• Previously lacking a coordinated pharyngeal
swallow
– Absent hyo-laryngeal excursion
– Limited pharyngeal constriction
– Limited UES opening
– Significant pyriform sinus residue
Analysis
• What is the main functional impairment of
concern?
• Which treatments do you think are indicated
for this patient?
Mendelsohn Manoeuvre
Mendelsohn, M. S., & McConnel, F. M. (1987).
Function in the pharyngoesophageal segment.
Laryngoscope, 97(4), 483-489.
• original paper, showing link between
laryngeal elevation and PE segment opening
• maximizing hyolaryngeal elevation augments
size of PE segment opening
• prolonging hyolaryngeal elevation increases
duration of PE segment opening
PE Segment opening
occurs when:
(A) Intrabolus pressure
+
(B) anterior traction
force
B
A
>/=
(C) Resistance at PE
Segment
C
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Questions regarding the
Mendelsohn Manoeuvre
• The manoeuvre is
difficult to teach
• Even using sEMG
biofeedback, it is
possible to create the
signal picture that we
believe represents a
“correct” MM using
different strategies
Mendelsohn Manoeuvre?
• Definitely worth trying in patients
with incomplete or short LVC
• Definitely worth trying in patients
with restricted UES opening
• Consider using sEMG biofeedback
paired with vigilant clinical
observation
• Be aware that the manoeuvre can
be done incorrectly and lead to
maladaptation
• Not recommended if you cannot
monitor outcome using VFSS
Case Study
• 63-year old female
• Dysphagia secondary to ponto-medullary
stroke
• Previously severe problems with UES opening
Analysis
• What is the main functional impairment of
concern?
• Which treatments do you think are indicated
for this patient?
Shaker Exercise
Easterling, C., Grande, B., Kern, M., Sears, K., &
Shaker, R. (2005). Attaining and maintaining
isometric and isokinetic goals of the shaker
exercise. Dysphagia, 20(2), 133-138.
• An isometric-isokinetic head lifting exercise used
for treating swallowing difficulties caused by
reduced opening of the upper esophageal
sphincter (UES).
• In particular, it aims to improve the strength of the
suprahyoid muscles (mylohyoid, geniohyoid,
digastric) which contribute to opening the UES via
traction.
Shaker Exercise
• Patient lies in the supine position (without a pillow)
and performs 3 sustained head raisings for 1
minute. The head must be raised high and forward
enough to see the toes without raising their
shoulders off the bed/floor. Each lift is interrupted
by a 1-minute rest period (Shaker et al., 2002).
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Shaker Exercise
Shaker Exercise – Latest Evidence
• Following the sustained head raisings, short lifts
are repeated 30 times (Shaker et al., 2002).
• 19 participants with 3 month history of dysphagia and impaired
UES opening on videofluoroscopy
• Randomized to “traditional therapy” or Shaker exercise for 6
weeks
• 14 participants underwent pre- and post-treatment VFSS
Muscles contributing to hyoid excursion
Contraction of
suprahyoid
musculature
moves the hyoid
superiorly
(mylohyoid) and
anteriorly
(geniohyoid).
Fig 2 in Pearson et al., 2010. Evaluating the Structural Properties of
Suprahyoid Muscles and their Potential for Moving the Hyoid. Dysphagia,
Epub.
Evidence regarding the Shaker Exercise
Shaker Exercise – Net Evidence
• Decrease in post-swallow aspiration (but no accompanying
change in post-swallow pharyngeal residue, although measures
were extremely blunt, i.e. present/absent)
• Queried impact on actual range of hyoid excursion* or laryngeal
excursion (mixed results across studies, when reported in mm in
either the anterior or superior direction)
• Reported increases in UES opening diameter and accompanying
decrease in intra-bolus pressure, suggesting easier passage of
the bolus through the UES
• Functional outcomes appear to be dependent on compliance
with the exercise beyond 2 weeks
• Different muscles respond over course of treatment: SCM first
and supra/infra hyoids responding only after extended practice
VFSS
Shaker Exercise
Shaker, R., et al. (1997). Augmentation of deglutitive upper esophageal sphincter
opening in the elderly by exercise. Am J Physiology, 272(35): G1418-1522.
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Shaker, R., et al. (2002). Rehabilitation of swallowing by exercise in tube-fed
patients with pharyngeal dysphagia secondary to abnormal UES opening.
Gastroenterology, 122, 1314-1321.
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Easterling, C., Grande, B., Kern, M., Sears, K., & Shaker, R. (2005). Attaining and
maintaining isometric and isokinetic goals of the Shaker exercise. Dysphagia,
20(2), 133-138.
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White, K. T., Easterling, C., Roberts, N., Wertsch, J. & Shaker, R. (2008). Fatigue
analysis before and after Shaker exercise: Physiologic Tool for Exercise Design.
Dysphagia, 23, 385-391.
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Mepani, R., Antonik, S., Massey, B., Kern, M., Logemann, J., Pauloski, B.,
Rademaker, A., Easterling, C. & Shaker, R. (2009). Augmentation of deglutitive
thyrohyoid muscle shortening by the Shaker exercise. Dysphagia, 24, 26-31.
•
Definitely worth trying if your patient
has reduced UES opening leading to
residue and post-swallow aspiration
We need to measure change in residue
with a more informative scale (new
NRRS scale)
? Need to develop graded challenge
Can the same exercise effects be
achieved without lying down (toweltuck)?
Are there specific aspects of task
performance that might alter results
(jaw clench during?)
As a first step prior to botox or
myotomy?
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