Financial —
The speakers will receive no speaker fee
or compensation for travel-related expenses for the
presentation of the course. There are no products or
materials being sold in relationship to this
presentation.
Nonfinancial —
Donna Edwards is a member of the Specialty Board
on Swallowing and Swallowing Disorders (BRS-S),
Chair of the Mentor Committee and Secretary for
the BRS-S Board, ASHA Special Interest Group (SIG)
13 Perspectives Editor, ASHA 2012 and 2013
Swallowing and Swallowing Disorders Topic
Committee. OSLHA Director of Legislative
Advocacy.
Patricia Fisher is a member of the International
Association of Orofacial Myology (IAOM) and the
ASHA Special Interest Group (SIG) 13. She is the
Private Practice Representative for OSLHA. Patty has
served as adjunct faculty at Miami University and for
the College of St
St. Rose in New York
York. In 2010
2010, Patty
completed specialty certification in Orofacial
Myology.
CLIENT/PATIENT/
CAREGIVER
PERSPECTIVES
CLINICAL
EXPERTISE/
EXPERT
OPINION
EXTERNAL
SCIENTIFIC
EVIDENCE
€
Because EBP iis client/patient/family
B
li t/ ti t/f
il centered,
t
d a clinician's
li i i ' ttask
k iis
to:
™
Interpret
p
best current evidence from systematic
y
research in
relation to an individual client/patient based on that individual’s:
™
™
™
™
Preferences
Environment
Culture
Values regarding health and well-being
™
Provide optimal clinical service to that client/patient on an
individual basis
™
Incorporate dynamic integration of ever-evolving clinical
expertise and external evidence in day-to-day practice
ASHA
¾Always have physician
approval prior to adding new
foods to the diet or making
diet changes
¾Always encourage families
to check with the physician to
discuss allergies
allergies, diet
restrictions, age to introduce
certain foods/liquids or to
transition from source of
nutrition/hydration such as
bottle drinking
¾Refer to Registered Dietitian
for growth concerns and/or
questions on
nutrition/hydration
t iti /h d ti
recommendations
Complex and coordinated acts
• Involves at least 26 pairs of muscles and 5 cranial
nerve systems,
systems including trigeminal,
trigeminal facial,
facial
glossopharyngeal, vagus, hypoglossal, and the
cervical and thoracic spinal cord segments involved
in chest wall movements for coordination of
respiration with feeding
• Involves volitional and reflexive controls in central
neural patterning
• Chewing patterns benefit from sensory feedback to
make adjustments to ensure safe swallow
• Variation in bolus type (liquid or solid):
• Hardness
• volume,
volume viscosity,
viscosity texture,
texture moisture content,
content and
other sensory characteristics of the bolus (taste)
serve to modulate the timing and patterning of
motor components which constitute the overall
feed sequence.
sequence
•
(Barlow 2009)
associated with eating and feeding: Pierre-Robin
syndrome with micrognathia, cleft palate and posterior tongue
placement
placement, macroglossia
macroglossia, tracheotomy
tracheotomy, esophageal strictures
strictures, stenosis or
ankyloglossia.
The function of cranial nerves V (jaw), VII (face and lips), IX and X (pharynx and larynx)
and XII (tongue). Cranial nerves for speech can be quickly assessed by observing
symmetry of movement
movement, strength
strength, range of motion
motion, and coordination while doing
the following:
Cranial Nerve V
€
›
Cranial Nerve VII
€
Observe the client smiling, eating, laughing and puckering-and-smiling. Test resistance of the four
quadrants of the lips
lips, with either your finger or a tongue depressor
depressor, while the child or young person
keeps his or her lips closed tightly.
¾
€
Cranial Nerve X
›
€
Observe jaw opening/closing and side-to-side movements of the jaw. Palpate the
masseter and have the child bite down
down, feeling for (appropriate) bulging as the muscle
contracts. Chewing.
Gag response
Cranial Nerve XII
›
Check tongue protrusion, retraction, lateral movement, and elevation. Check strength by
pushing against the tongue with a tongue depressor.
Look for symmetry and interaction;
› Nasolabial folds
› Perioral area
› Nares
› Periorbital area
› Forehead
Synergies:
€ Collections of muscles and joints that
interact to work as a unit for
movement gradation
€ For example, an oral motor function
is the synergy based on lip and jaw
muscles that can be useful in eating,
drinking
d
g and
a d formation
o a o of
o the
e bilabial
b ab a
sounds of speech
Figure 2. Diagrammatic sagittal sections of the oropharyngeal complex.
Hiiemae K M , and Palmer J B CROBM 2003;14:413-429
Figure 1. The functional linkages among jaw, hyoid, and tongue movements in
feeding and speech.
Hiiemae K M , and Palmer J B CROBM 2003;14:413-429
Increasing breath support, coordination of respiration, symmetrical oral motor
skills, reinforcing cause/effect relationships and bonding with grandparent.
This little one is using her finger instead of her lips to keep the bolus in her
mouth. Also watch for use of fingers rather than the tongue to lateralize food
to the molar ridges.
€
Goffman and Smith studied lip and jaw movements in
adults and children. They posed:
¾
Between the ages of 6 years old and adulthood there is
continued refinement of controlled movement and
coordination
Between ages
g 2 and 6 years,
y
lip
p and jjaw spatiotemporal
p
p
coupling continued to increase.
9 6 year olds had similar movement patterns of adults but
were more variable
¾
™ spatial and temporal coupling in 6-year-olds was less than
adults
™ upper lip, lower lip, and jaw synergy for oral closure
€
These findings parallel the continuous refinement of speech
performance from mid
mid-childhood
childhood to adolescence
Attend to:
Size of the oral motor complex
Jaw excursion
Size of the spoon bowl
Chewing requirement
Width of the food
Exploring the world and having her ‘first milkshake’
…………at the mall no less!
Schwartz, Niman, Gisel) 1984
Sensory pathways influence motor production in a
multitude of ways. Two primary sensory pathways
that have an important role in speech are:
The short latency pathways quickly carries
sensory information from the periphery to central
(spinal cord or brainstem)
• Mainly associated with reflexive activity
• Important in speech production and swallowing
The long
Th
l
latency
l t
pathways
th
carries
i sensory
information from the periphery to the higher
cortical centers. More consciousness involved and
volitional movements
Sunil Kumar. R, 2006
A relationship between chewing and speech is inherent as both
incorporate many of the same muscles, therefore it is logical to ask
ourselves about similarities and differences in neural control .
In 1991 Martin completed one of the few direct comparisons of
kinematics in speech and swallow. The conclusion was that a primary
difference occurs in tongue-jaw synergy.
For swallowing: coordination of the jaw and tongue movements
were highly coordinated, with a close temporal association between
mandibular stabilization and rapid elevation of the tongue.
For speech: coordination of the jaw and tongue movements were
much more variable.
variable
Though we often hear of the differences in oral motor function
associated with feeding and speech, it is important that we also consider
the similarities.
€
As you know
know, causes of dysarthria may include
neural insult from cerebral palsy (neonatal stroke)
and traumatic brain injury.
€
In such cases, the speech musculature, including
respiratory muscles, may be weakened, paralyzed,
or poorly coordinated.
€
The dysarthrias can affect all motor speech
processes:
•
•
•
•
•
breathing
producing sounds in the larynx
Articulation
resonance
prosody
d
Slowed speech rate
Effortful speech due to reduced coordination of respiration
Approximation of articulation
Slurred speech
Reduced vocal control with fluctuating vocal intensity
€ Fluctuating pitch
€ Reduced intonation patterns
€ Reduced vocal quality
q
y
€
€
€
€
€
›
›
›
›
Examining for dysarthria:
S
Speech
h assessmentt
Feeding assessment
Structural/functional assessment
‹ Malynki was born at 41 weeks gestation
‹ Pregnancy complications included nuchal cord x1, variable
infant heart rate,
rate maternal fever and limited prenatal care
‹ Apgars were 11/15/110 with need for intubation, chest
compressions and a heart rate of less than 90 until 20 minutes of
age
‹ MRI revealed basal ganglia infarcts. Severe disturbances of
cortical function and seizure-like activity
‹ CN II-XII grossly intact though visual tracking was inconsistent
‹ He refused pacifier but tolerated oromotor stimulation. He was
unable to feed adequately orally and received a gastrostomy
with fundoplication
‹ At 2 ½ months of age Malynki began to tolerate handling
and touch for comfort,
comfort but still had difficulty tolerating car
rides.
‹ Overall weakness with extensor tone
‹ Mildly increased tone in the pelvis and fluctuating muscle
tone in the lower extremities.
‹ Now diagnosed with hypoxic ischemic encephalopathy
with concerns for CP
ƒ NPO
ƒ Father repositioned infant frequently for neutral
alignment
ƒ Malynki did not move arms, but did move one leg at
times
ƒ General hypotonia with poor head control
ƒ High palatal vault
ƒ Hypertonia
H
t i in
i th
the cheeks
h k
ƒ Forehead wrinkling on the left but not the right Cranial
Nerve VII (Facial Nerve)
ƒ Fair to good vocalizations
ƒ Accepted tactile stimulation to all extremities and the
face
ƒ Symmetrical lip rounding
ƒ He spontaneously opened his mouth to taste puree from
his top lip x2
ƒ Oral hypersensitivity: briefly tolerated stimulation to the
molar ridges, lips and tongue. More sensitive left than
right. Pulled away, squirmed and tried to turn away.
Hypergag response (lateral tongue and mid tongue)
Continued NPO status and alternate source of
nutrition/hydration
Position upright (neutral alignment) for feeding and oral
stimulation activities
Continue oral stimulation with pacifier dips as
accustomed
Incorporate oral stimulation activities during tube feeding
to associate satiety with oropharyngeal stimulation
Keep stimulation brief and positive
Use fingertip massage to molar ridges bilaterally
Stop stimulation if Malynki’s presents with cues of
discomfort
ƒ MBS to assess oropharyngeal swallow
function and assist with determining nutritive
or non-nutritive therapy goals
ƒ Careful pulmonary monitoring
ƒ Feeding
F di
th
therapy
ƒ Referral to a Developmental Pediatrician
ƒ Continued consultations with registered
dietitian
ƒ Continued OT/PT
ƒ Parent support group contacts provided
ƒ Contact Help Me Grow (Early intervention)
Severely delayed oral transit
Bolus residue on the palate eventually transferred to the lateral sulcus before alternating between the posterior and anterior tongue before
before alternating between the posterior and anterior tongue before entering the unprotected airway with silent aspiration
Intermittent stridorous inhalation and refusal responses
Silent aspiration of puree
Non‐nutritive goals it is with a focus on:
‹ increasing tolerance to utensils, textures
l
l
‹ Improving oral motor movement and function……….
Alexander 2011; Ogura E, Matsuyama M, Goto TK, Nakamura Y, Koyano K (2012)
For Malynki these techniques were successful in:
1) promoting awareness of oromotor structures 2) facilitating symmetrical movement as level of challenge was gradually increased
Tolerate gradual introduction of tactile stimulation to tongue and molar ridges to overcome hypergag response
For him:
Z‐vibe with small tip (off then on) to molar ridges
Nuk brush to molar ridges
brush to molar ridges
Parent massage to molar ridges
Successful introduction of tooth brush
With improved oral skills demonstrated in therapy, we returned to MBS to re‐assess oropharyngeal swallow in hopes of introducing oral intake and nutritive goals.
Good acceptance of the spoon and fair to poor acceptance of the open cup with assistance. Purees, honey thick liquid, and nectar thick liquids were consumed efficiently via teaspoon or cup. Trial of thin via infant teaspoon (¼ trials with possible aspiration versus artifact) thin by open cup was timely and efficient for 1 trial.
RECOMMENDATIONS:
Continued careful pulmonary monitoring
Supported seating (bilateral, trunk)
Chin support to stabilize the jaw
Midline positioning
Oral diet of puree
He is 31 months here. Notice how his parents have quite cleverly masked his poor trunk control and persistent lack of neutral head alignment Age: 4‐10
Bright and very interactive child. Though he is moderately to severely dysarthric, he produces 3‐5 word sentences. Speech intelligibility improves dramatically with bilabial and vowel laden utterances. He enjoys school, humor, travel and skyping with his military dad. He
enjoys school, humor, travel and skyping with his military dad. He appears well nourished. Family support is consistent, positively reinforcing and facilitative of his independence in daily activities.
Trunk instability
Straw drinking without spillage
Notice his front dental gaps
Notice his problem solving
to
o move
o e the
e bo
bolus
us to
o hiss
right lateral molars.
His jaw stability continues
to improve and physical
therapy continues to
address trunk stability.
Though open mouth
chewing is immature, he
continues to improve in his
independence.
€
Malynki is going to School! He and mom are working on foods, words and plans to teach his new teacher and aide how to help him be most independent.
d id h t h l hi b
ti d
d t
What do
oes the futuree hold??
BIG BOY SCHOOL
Swallowing has four different phases that overlap and are influenced by different
variables (such as the type of substance, the amount of substance and
timing). The following phases are simplified from Medical guide models used
in Hospitals, Nursing Care facilities and Trauma Centers:
Oral Preparatory Stage, the food is chewed, mixed with saliva, and formed
into a cohesive bolus
Oral Stage, the food is moved back through the mouth with a front-to-back
squeezing action, performed primarily by the tongue
Pharyngeal Stage, which begins with the pharyngeal swallowing response:
€ Food enters the oropharynx
€ Soft palate elevates, vocal folds approximate
€ Epiglottis closes off the trachea,
trachea as the tongue moves backwards,
backwards the
pharyngeal wall moves forward
€ These actions help force the food downward to the esophagus.
Esophageal Stage,
Stage
€ Food bolus enters the esophagus
€ The bolus is moved to the stomach by peristalsis of the throat muscles.
€
€
€
Normative data for motor speech
developmental milestones
Improved
p
understanding
g of neural
innervation and synergistic muscle
patterning that evolves into a corelationship between feeding and
swallowing coordination
Impact
p
of functional limitations and
family dynamic at meal times in
various settings
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