SWALLOWING REVISION NOTES.pdf

Adult Swallowing Adult Speech Pead Feeding Dysphagia Adult speech Signs and symptoms of dysphagia/feeding difficulty Assessment Dysarthria What factors need to be considered in your feeding assessment? Signs and symptoms Speech assessment How would you conduct this? Characteristics and r...

Adult Swallowing Adult Speech Pead Feeding Dysphagia Adult speech Signs and symptoms of dysphagia/feeding difficulty Assessment Dysarthria What factors need to be considered in your feeding assessment? Signs and symptoms Speech assessment How would you conduct this? Characteristics and reasons for oral phase dysphagia Characteristics and types of dysarthria – how would you determine this? What are some management strategies that could support safe and effective intake for • Infants • Toddlers/children Characteristics and reasons for pharyngeal phase dysphagia Understand the assessment of adult speech - How would you conduct this? How do they link to the clinical presentation? Consider the prioritisation for intervention Describe how changes to specific swallow events result in dysphagia across these phases Management Consequences of dysphagia What are treatment options? What are the key safety and efficiency factors to determine an appropriate diet? How would you conduct treatment tasks with a client? What other recommendations are needed for the client in their immediate eating environment for client safety? What other considerations are needed to optimise communication for the client? clinical rationale and evidence for swallow management Swallow Management Options for Compensation Options for Rehabilitation clinical decision frameworks Dysphagia ● ● A difficulty or disorder with swallowing It can be a combination of any of the swallow stages: ● Oral stage ● Pharyngeal stage ● Oesophageal stage ● If it occurs over both oral and pharyngeal stages – terminology = oropharyngeal dysphagia ● Odynophagia = pain on swallowing ● Sensation of bolus = feeling like there’s a ball of food in your throat Classifying Dysphagia ● Unable to swallow at all = Aphagia o ‘a’ = total loss/lack of o ‘phagia’ = swallowing ● Disordered swallowing = Dysphagia o ‘dis’ = disordered ● Dysphagia might be categorised as; Mild, moderate, severe dysphagia o What is the difference between these qualitative labels? Elements of dysphagia can be categorised into 2 major buckets: safety of swallow, and efficiency of swallow ● Safety = ability for airway to remain protected in the swallowing process o Within or across the swallowing phases ● Efficiency = ability to effectively swallow within and across the swallowing process o E.g., recently lost all teeth, difficulty chewing, affects the time it would take to chew up a bolus Primary outcomes are safety and efficiency of swallow. Measured by ● reduced or no aspiration ● oropharyngeal swallow efficiency ● No adverse events (chest infections, aspiration pneumonia and profound weight loss) Secondary Outcomes ● Return to function ● Quality of Life ● Psychological well being – depression, anxiety and stress, patient satisfaction Assessment ● ● ● ● Swallow screening Benefits ○ Safety: to determine the presence of aspiration ○ Safety: to identify clinical risk prior to further medical morbidity ○ Further assessment: to determine need for further clinical/instrumental assessment ○ Oral intake: to commence oral intake/return to baseline diet Yale swallow protocol ASSIST - NSW Health Patient reported screening tools (sydney swallow questionnaire) VFSS: Oral phase The VFSS will include visualisation of the oral stage SP will liaise with Radiographer about field of view – balance of exposure/image quality ● Lip seal/closure ● Tongue movement (elevation/retraction) ● Tongue to palate seal ● Bolus preparation/mastication ● Bolus transport/posterior lingual propulsion ● Alignment jaw/teeth (AP view) ● Symmetry of bolus residue (AP view) ○ AP view is very close to the face front on, they are so close to the person that they sometimes cannot even take a sip of water with the machine in front of them. VFSS: Pharyngeal phase ● Initiation of swallow reflex ● Soft palate elevation/retraction ● Laryngeal elevation ● Anterior hyoid excursion ● Base of tongue retraction ● Epiglottic inversionLaryngeal vestibule closure ● Pharyngeal contraction ● Pharyngeal oesophageal opening ● Symmetry of bolus flow (A-P view) ● Symmetry of pharyngeal residue (A-P view) ● Vocal fold movement (A-P view) VFSS: Oesophageal phase ● Oesophageal clearance* ● VFSS can involve an oesophageal sweep ● Screening for oesophageal phase – not a comprehensive Ax of this phase ● Ax of oesophageal phase is conducted via barium swallow Benefits of FEES ● Dynamic assessment of swallow ● Conducted at bedside/POC ● Duration of assessment ● Repeatability ● Sensory assessment ● Visualisation of residue Indications for FEES ● Evaluation of secretion management and response ● Voice involvement ● Further information required around swallow safety ● Use as biofeedback tool FEES: Oral phase ● Oral phase is not visible via camera ● Observation by SP only FEES: Pharyngeal phase ● Anatomical structures (any deviation) ● ● ● ● ● Dynamic movement Vocal fold abduction and adduction Secretions - at rest and post swallow Response to secretions Pharyngeal clearance Signs and Symptoms ● Dysphagia can be within one or across many stages of dysphagia ● Dysphagia onset and prognosis can vary o Acute = Signs/symptoms have developed immediately or in short time duration o Degenerative change = swallow function gradually changes (worsens) over time. ▪ E.g., progressive motor-neuron diseases o Chronic = Occurring over a prolonged period, little or minimal recovery over time. o +Congenital = ▪ E.g., cerebral palsy ● Sign = Observable clinical characteristic (objective), can be observed by anyone o E.g., pain ● Symptom = subjective, often reported by a client/patient o E.g., coughing while eating or drinking How we talk about reduced airway safety… ● Penetration = passage of food, liquids or saliva into the larynx but not beyond the true vocal folds ● Aspiration = passage of food, liquids or saliva into the larynx beyond the true vocal folds Penetration and Aspiration can be audible or silent... ● Audible = triggering of audible response such as throat clearing, coughing ● Silent penetration = food/fluid (saliva) that stays ABOVE or on true vocal folds that does not trigger a cough response ● Silent aspiration = food/fluid that goes beyond the true vocal folds that does not trigger a cough response Characteristics of oral phase Oral stage characteristics can include elements related to changes in sensory/motor structure and function Examples: ● Anterior spillage/drooling ● Reduced mastication ● Reduced anterior to posterior propulsion/transfer ● Oral residue ● Poor oral control ● Pain during oral preparation Characteristics of the pharyngeal phase Pharyngeal stage characteristics can include elements related to changes in: sensory/motor structure and function ● Delayed swallow onset ● Reduced or incomplete hyolaryngeal excursion ● Incomplete laryngeal vestibule closure ● Decreased pharyngeal contraction ● ● ● ● ● ● ● Pharyngeal residue Food sticking in pharynx Throat clearing and/or coughing during/after oral intake Laryngeal penetration Aspiration Decreased oxygen saturation (SpO2 = saturation of peripheral oxygen) Increased respiratory rate (RR) – tachy(fast)pnoea Describe how changes to specific swallow events result in dysphagia across these phases ● Changes to specific swallow events can result in dysphagia across the oral, pharyngeal, and oesophageal phases. These changes can include: 1. Oral Phase: - Reduced lip closure: This can lead to food or liquid spilling out of the mouth during swallowing. - Reduced mastication: Difficulty chewing food properly can result in larger food particles that are more difficult to swallow. - Reduced tongue movement: Insufficient tongue movement can result in difficulty forming a cohesive bolus for swallowing. - Delayed swallow onset: A delay in initiating the swallowing reflex can lead to food or liquid entering the pharynx prematurely. 2. Pharyngeal Phase: - Incomplete laryngeal vestibule closure: Failure to close the laryngeal vestibule can result in penetration or aspiration of food or liquid into the airway. - Reduced pharyngeal contraction: Weakness in the pharyngeal muscles can result in reduced pressure and clearance of the bolus from the pharynx. - Pharyngeal residue: Residue left behind in the pharynx after swallowing can increase the risk of aspiration and respiratory complications. 3. Oesophageal Phase: - Oesophageal dysmotility: Impaired motility of the oesophagus can result in difficulties with bolus transport and clearance, leading to symptoms such as regurgitation or oesophageal obstruction. Oesophageal strictures or obstructions: Narrowing or blockages in the oesophagus can impede the passage of food or liquid, resulting in dysphagia. Overall, changes to specific swallow events can disrupt the normal swallowing process, leading to dysphagia and associated difficulties in swallowing safely and efficiently Consequences of dysphagia Medical 1. Body system/structure 2. Participation 3. Activities 4. Economical – cost to individual and to healthcare system ● ● ● ● ● ● Social ● ● ● ● ● ● Risk of choking* – complete blockage of the airway, asphyxiation Malnutrition Weight loss – more delayed Dehydration Aspiration pneumonia – or other new infections Increased morbidity Activities and participation Quality of life (QOL) Friendships Relationships Mood Mental health Aspiration pneumonia ● Aspiration can lead to aspiration pneumonia ● Aspiration pneumonia = aspiration of swallowed materials from the pharynx that results in a lung infection (Groher & Crary) ● More prevalent in Nursing home residents – specific population ● Dysphagia is a risk factor however it’s multifactorial - Langmore et al. 1998 [seminal paper] ● Dysphagia risks other than aspiration… o Dependence on feeding * (19.98 OR = close to 20x more likely to aspirate if someone else is feeding you vs you feed yourself) o Number of decayed teeth o Tube feeding o More than one medical diagnosis o Number of medications o Smoking What are the key safety and efficiency factors to determine an appropriate diet? ● ● Swallowing slightly changes with older age but does not affect swallow safety Documenting safety/efficiency of swallow: ● Physio – patient gets thirsty, what sort of viscosity of fluid are they allowed to have? o Imperative that o Discomfort at best, harmed at worst Intervention ● Compensation ● Rehabilitation ● Management ● Education/Training ○ It is multifactorial and involves the patient, support network, MDT ○ Focus is centred around swallow safety and efficiency EMST: ○ The overall goal of this is to improve the safety and efficiency of the swallow, and reduced risk of aspiration with oral intake. ■ Increases cough strength, respiration rate and suprahyoid. VFSS Considerations ● Considerations for radiation safety – use of ionising radiation ● ALARA principle – as low as radiologically achievable ● Use of distancing, lead screens, lead aprons/jackets/collars/goggles ● Personal dosimeter meters ● Joint discussion with radiology for optimal frames and exposure ● Optimum viewing for VFSS = 30 frames per second (fps) ● Cohen et al. compared 30 vs 15 fps, increased accuracy with swallow diagnosis re: aspiration events ● Sound for recording (important for playback) ● Infection control Diet Modification Swallowing manœuvres and exercices ● Can involve whole or part body ● Considered compensatory (i.e. short term, not improving or changing underlying swallowing function) ● Require cognitive or consistent external support to utilise ● Underlying theory = altering body physiology to re-direct bolus flow Postural adjustments - compensation ● Lying down/side lying: Take bolus, lay on side, swallow (stronger side down) ● Chin tuck/Neck flexion: Swallow food or fluid with chin tucked down towards chest. ● Neck extension/chin up: Take bolus of food/fluid, hold breath, chin up, swallow. ● Head turn/rotation: Swallow food or fluid bolus with head turned to the affected side, e.g. if residue L>R, head turn to the left is indicated What other recommendations are needed for the client in their immediate eating environment for client safety? Seating and positioning What is a safe eating position? ● Appropriate positioning of the person's head, neck and body can make the difference between safe and unsafe swallowing. An ideal safe eating position (see illustration below) means: ○ seated, as upright as possible ○ '90-90-90, meaning the hips, knees and ankles are each positioned at 90 degrees ○ head is not turned to either side, not tilted up and not excessively tilted down. Mealtime Management Plans ● Dated and signed, reviewed at least annually or if any change in the person’s presentation. (always have their name and date of birth) (who did the plan and when it was done) ● Person’s identifying details (photo) communication methods (if they are unable to communicate who they are) ● Need for assistance, instructions for the assistant (timing, pace, reminders) ● Description of the person’s current diet and fluids (prescribed / recommended) ● Seating and positioning ● Mealtime equipment ● Foods ● Fluids ● Medication ● Saliva management ● Risk reduction ● Cross reference to any other relevant Plans (eg tube care, gastrostomy feed) 1. Modify mealtimes to reduce the risk of choking ● 1.1 Modify food textures. ● 1.2 Avoid problem foods. ● 1.3 Address problematic mealtime behaviours. ● 1.4 Improve posture during meals. ● 1.5 Document mealtime management. ● 1.6 Modify the mealtime environment. ● 1.7 Improve mealtime assistance, supports, or supervision 2. Promote aggressive dental / oral hygiene and maintain dentition ● Insufficiently chewed food – associated with choking death ● Edentulism associated with increased choking risk ● Oral hygiene: preventing oral residue for people with dysphagia 3. Monitor medications effects and polypharmacy ● Decrease in saliva production ● Lowered level of alertness ● Decreased oesophageal motility, delayed gastric emptying, and aggravation of gastroesophageal reflux ● Inhibition of the cough reflex, the swallow reflex, and the gag reflex 4. Provide multidisciplinary or interdisciplinary services to manage dysphagia 4.1. Adopt a multidisciplinary/interdisciplinary service model. 4.2. Implement regular screening for choking/dysphagia. 4.3. Assess swallowing and general health. 5. Implement training and risk management programs 5.1. Implement population-wide awareness-raising strategies 5.2. Educate health professionals and other staff 5.3. Educate support workers, family members, and people with choking risk 5.4. Implement risk management and choking-prevention programs clinical rationale and evidence for swallow management ● ● ● ● ● ● ● The clinical rationale and evidence for swallow management can be supported by official studies and research. Here are some key studies and references that provide evidence for swallow management: 1. Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Austin, TX: Pro-Ed. This textbook provides a comprehensive overview of the evaluation and treatment of swallowing disorders. It covers the anatomy and physiology of swallowing, assessment techniques, and evidence-based treatment strategies. 2. Robbins, J., & Gangnon, R. E. (2008). The beneficial effects of lingual exercise in stroke patients with dysphagia. Archives of Physical Medicine and Rehabilitation, 89(2), 330-335. This study explores the effects of lingual exercise in stroke patients with dysphagia. It demonstrates the benefits of lingual strengthening exercises in improving swallowing function. 3. Huckabee, M.-L., & Pelletier, C. A. (2018). Management of swallowing disorders in the acute care setting: A narrative review. Dysphagia, 33(2), 157-170. This review article focuses on the management of swallowing disorders in the acute care setting. It discusses the importance of early intervention, instrumental assessments, and the use of compensatory strategies and exercise-based therapies. 4. Steele, C. M., & Pelletier, C. A. (2014). Evidence-based practice in dysphagia management. Asha Leader, 19(12), 36-39. This article emphasises the importance of evidence-based practice in dysphagia management. It highlights the need for clinical decision-making based on scientific evidence and provides resources for accessing research literature. 5. National Institute on Deafness and Other Communication Disorders (NIDCD). (2020). Dysphagia. Retrieved from https://www.nidcd.nih.gov/health/dysphagia The NIDCD provides information on dysphagia, including its causes, symptoms, diagnosis, and treatment options. It serves as a reliable source of evidence-based information for healthcare professionals. These references and studies can provide clinicians with the necessary evidence and rationale for making informed decisions in the management of swallowing disorders. It is important to continually stay updated on the latest research in the field to ensure the delivery of high-quality care to patients. Swallow Management ● Swallow management involves the assessment and treatment of individuals with swallowing difficulties, also known as dysphagia. The goal of swallow management is to improve safety and efficiency during the swallowing process, ensuring that individuals are able to consume food and liquid without the risk of choking ● ● ● ● ● ● or aspiration. This may involve a combination of strategies, including modifying the consistency of food and liquid, implementing specific swallowing exercises, and providing education and support to individuals and their caregivers. Speech pathologists, in collaboration with other healthcare professionals such as dietitians, nurses, and physiotherapists, play a key role in the management of swallowing disorders. They assess the individual's swallowing function, provide recommendations for diet modifications, and develop personalised treatment plans to address any underlying issues. Additionally, they may provide education and training to individuals and their caregivers on proper swallowing techniques and strategies to improve safety and efficiency during meals. Overall, swallow management aims to enhance the quality of life for individuals with dysphagia by ensuring they can safely and effectively consume food and liquid. To manage swallowing difficulties, a comprehensive assessment and treatment plan should be developed. This plan should consider the individual's co-morbidities, access to care, cultural decisions, cost, location, and the training and skills of the speech pathologist. The treatment goals and plans should reflect the patient's pathway of care and prioritise the safety and well-being of the individual. Treatment options for swallowing difficulties may include surgical, medical, and behavioural interventions. Surgical interventions aim to improve airway safety or open the pharyngeal esophagus, while medical interventions often involve medications to manage symptoms or improve neural communication. Behavioural interventions, such as swallowing maneuvers and strategies, can also be effective in managing swallowing difficulties. It is important to note that the type and intensity of treatment should be tailored to the individual's needs and preferences. This may involve a multidimensional approach that considers the patient's motivations, quality of life, and stage of medical care. Throughout the treatment process, regular assessments and monitoring should be conducted to track progress and make necessary adjustments to the treatment plan. This may involve re-evaluating the individual's swallowing function, modifying dietary texture and consistency, and providing ongoing therapy and support. Overall, the goal of swallowing management is to improve safety and efficiency during the swallowing process, enhance the individual's quality of life, and minimise the risk of complications. By following evidence-based practice guidelines and collaborating with other healthcare professionals, speech pathologists can provide effective and comprehensive care for individuals with swallowing difficulties. Compensation strategies ● ● ● Compensation is more temporary to support safe and efficient swallow in the moment One you don’t you that compensation technique it can become unsafe again Chin down method - every single mouthful to decrease risk of dysphasia. But can we eliminate the need for a chin tuck ● Texture modification 82.8% respondents always/frequently used ● Thickening fluids 78% ● Posture/Position modification 72% ^^ These are all compensation strategies ^^ Swallowing manœuvres and exercices ● Can involve whole or part body ● Considered compensatory (i.e. short term, not improving or changing underlying swallowing function) ● Require cognitive or consistent external support to utilise ● Underlying theory = altering body physiology to re-direct bolus flow Postural adjustments - compensation ● Lying down/side lying: Take bolus, lay on side, swallow (stronger side down) ● Chin tuck/Neck flexion: Swallow food or fluid with chin tucked down towards chest. ● Neck extension/chin up: Take bolus of food/fluid, hold breath, chin up, swallow. ● Head turn/rotation: Swallow food or fluid bolus with head turned to the affected side, e.g. if residue L>R, head turn to the left is indicated ● Compensation strategies are techniques or methods used by individuals with dysphagia to help them safely and effectively swallow food and liquid. These strategies aim to compensate for any difficulties or impairments in the swallowing process. Here are some common compensation strategies: 1. Postural adjustments: Changing the position of the body or head during swallowing can help improve swallowing function. For example, tilting the head forward or to the side can help prevent aspiration. 2. Modification of food and liquid consistency: Altering the texture or thickness of food and liquid can make swallowing easier and safer. This may involve pureeing food, thickening liquids, or avoiding certain types of food that are difficult to swallow. 3. Altering the swallowing technique: Adjusting the way food or liquid is swallowed can help improve swallowing function. This may involve taking smaller bites or sips, chewing food thoroughly, or using specific tongue or throat movements during swallowing. 4. Swallowing exercises: Engaging in specific exercises that target the muscles involved in swallowing can help strengthen these muscles and improve swallowing function. These exercises may be recommended and guided by a speech pathologist. 5. Environmental modifications: Making changes to the environment during meals can help individuals with dysphagia. This may include providing a quiet and distraction-free eating environment, using specialised utensils or adaptive equipment, or using specific feeding techniques. 6. Modify food textures: Thickening liquids or modifying the texture of solid foods can make swallowing easier and reduce the risk of aspiration. 7. Altering posture: Changing the position of the head, neck, and body during meals can help improve swallowing function and reduce the risk of choking or aspiration. 8. Swallowing techniques: Using specific swallowing techniques, such as chin tuck or double swallow, can help facilitate safer and more efficient swallowing. 9. Eating smaller, more frequent meals: Eating smaller meals more frequently throughout the day can help reduce the amount of food and liquid that needs to be swallowed at once, making it easier to manage. 10. Using assistive devices: Specialised utensils, cups, or straws may be used to assist with eating and drinking, making it easier to control the flow of food and liquid. Compensation strategies for dysphagia can include techniques such as chin tuck, head turn, and supraglottic swallow. These strategies aim to modify the swallowing process to improve safety and efficiency. ● Rehabilitation strategies ● ● Rehabilitation – changing and improving the underlying physiology to enable permanent change to function (this may include recovery). Most common form of intervention Rehabilitation ○ Not as much of a cognitive load for the client and long-term building with support people around ● Mendelsohn – This manoeuvre is recommended for Victor as both a compensatory strategy and rehabilitative exercise to enhance his hyolaryngeal excursion, improve bolus transfer efficiency, and increase tongue base pressure (Vose et al., 2014). It offers both short- and long-term benefits; enhancing swallow coordination, reducing residue, and lowering aspiration risk (Groher et al., 2021). Lingual resistance exercise - Resistance-based tongue strength training has proven valuable in rehabilitating stroke patients with dysphagia (Johnson et al., 2014; Park et al., 2015; Robbins et al., 2007). Park et al. (2015) found that consistent 80% isometric intensity training using the Iowa Oral Performance Instrument (IOPI), involving 5 sets of 10 repetitions per day, 5 days a week for 6 weeks, significantly improved anterior and posterior tongue strength in post-stroke dysphagic patients. Robbins et al., (2007) conducted an 8-week lingual resistance program with IOPI in chronic acute stroke patients, resulting in increased lingual strength, improved swallowing function, and enhanced dysphagia-specific quality of life. This rehabilitative exercise aims to boost Victor's lingual strength and oral motor control, enhancing his lingual sweep, bolus transfer efficiency, and reducing premature posterior bolus escape before swallowing onset. Shaker exercise – This exercise is used to train the swallowing muscles through isometric and isokinetic contraction (Shaker et al., 2002). A 2007 study of stroke patients found that those who rehabilitated using the Shaker method alongside conventional dysphagia therapy, demonstrated significant improvement on both the Penetration Aspiration Scale and the Functional Oral Intake Scale (Vose et al., 2014). Victor presents with reduced hyolaryngeal excursion and deep silent laryngeal penetration, so this exercise, which specifically activates the suprahyoid muscles and upper oesophageal sphincter (Vose et al., 2014), will help to strengthen his swallowing muscles and decrease his risk of aspiration. Clinical Decision Frameworks ● ● ● ● ● ● ● ● Clinical decision frameworks guide healthcare professionals in managing and treating dysphagia. Prognosis of dysphagia considers factors such as severity, underlying cause, and potential for improvement. Medical diagnosis informs the appropriate treatment approach. Person-centered factors, including patient's goals and preferences, play a crucial role in decision-making. Clinical decision frameworks ensure treatment is tailored to patient's specific circumstances. Ethical decision-making framework involves identifying the problem, assessing options, considering legal and ethical implications, and making a decision based on values and beliefs. The ICF framework provides a comprehensive understanding of health and disability domains for dysphagia management. Evidence-based practice guidelines offer recommendations based on research evidence and expert consensus. Factors and Frameworks in Clinical Decision-Making for Dysphagia Management ● Clinical decision frameworks guide speech pathologists in making informed decisions about dysphagia prognosis, medical diagnosis, and person-centered factors. ● The Evidence-Based Practice (EBP) framework integrates the best available evidence, clinician's expertise, and patient's values and preferences. ● The Multidimensional E3 & E4 EBP framework relies on clinical knowledge and experience when research evidence is limited. ● Person-centered factors consider the patient's goals, values, preferences, physical abilities, and cognitive abilities. ● Dysphagia prognosis considers expected outcomes and influences treatment goals and approach. ● Medical diagnosis provides crucial information about dysphagia. ● By considering all factors and using frameworks, speech pathologists can provide effective and personalized care for dysphagia management. Dysphagia Management Factors ● Dysphagia management is influenced by various factors, including underlying conditions or diseases causing dysphagia. ● Different medical diagnoses require different treatment approaches for dysphagia management. ● Person-centered factors, such as values, preferences, and goals of care, should be considered in dysphagia management decisions. ● A clinical decision framework helps guide the process of making clinical decisions for dysphagia management. ● The framework includes gathering information, assessing options, considering risks and benefits, and involving the patient in decision-making. ● Dysphagia prognosis, medical diagnosis, and person-centered factors are important considerations within the clinical decision framework. ● By employing this approach, clinicians can tailor dysphagia management to individual patient needs and promote patient-centered care Adult Speech Dysarthria ● ● ● Dysarthria is a motor speech disorder characterised by abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for breathing, phonation, resonation, articulation, or prosody of speech production. It is caused by neurological impairments that affect the planning, programming, control, or execution of speech. There are several types of dysarthria, including flaccid, spastic, ataxic, hypokinetic, hyperkinetic, unilateral upper motor neuron, and mixed dysarthria. Each type has its own characteristic features and underlying neuropathophysiology. Treatment for dysarthria may involve speech therapy, medication, or surgical interventions, depending on the specific needs of the individual. Speech assessment ● ● ● When assessing dysarthria, speech pathologists typically evaluate various aspects of speech, including respiration, phonation, articulation, resonance, and prosody. They may use specific assessment tools such as the Dysarthria Disorders Survey (DDS) and the Functional Oral Intake Scale (FOIS) to gather information about the individual's swallowing and communication abilities. Instrumental assessments, such as Modified Barium Swallow (MBS) or Fiberoptic Endoscopic Evaluation of Swallowing (FEES), may also be used to assess swallowing function. The specific assessment methods used will depend on the individual's needs and the goals of the assessment. There are several types of assessments that can be used for dysarthria. These assessments include: 1. Anatomic-physiologic assessment: evaluating the structure and function of the muscles and structures involved in speech production, such as the tongue, lips, and vocal cords. 2. Perceptual assessment: This involves listening to the individual's speech and evaluating the quality of their articulation, resonance, voice, and prosody. 3. Instrumental assessment: This involves using specialised tools and technologies, such as electromyography (EMG) or videofluoroscopy, to objectively measure and evaluate the individual's speech production. 4. Functional assessment: This involves evaluating the individual's ability to communicate effectively in real-life situations, such as during conversation or in various speech tasks. These assessments can help determine the specific characteristics and severity of dysarthria, guide treatment planning, and measure treatment outcomes. Characteristics and types of dysarthria – how would you determine this? ● ● ● ● ● Dysarthria is a motor speech disorder that is characterised by abnormalities in the strength, speed, range, steadiness, tone, or accuracy of movements required for breathing, phonation, resonation, articulation, and prosody during speech production. There are several types of dysarthria, including flaccid dysarthria, spastic dysarthria, ataxic dysarthria, hypokinetic dysarthria, hyperkinetic dysarthria, unilateral upper motor neuron dysarthria, and mixed dysarthria. To determine the type of dysarthria, a speech pathologist assesses the individual's speech characteristics, such as weakness, imprecise articulation, hypernasality, slow rate of speech, and abnormal prosody. The speech pathologist also considers the underlying neuropathophysiology, which can be determined through instrumental assessments like a modified barium swallow study or a fiberoptic endoscopic evaluation of swallowing. These assessments provide visual information about the movement and function of the structures involved in speech production. By analysing the speech characteristics and the underlying neuropathophysiology, the speech pathologist can determine the specific type of dysarthria and ● ● develop a targeted treatment plan to address the individual's speech difficulties. There are several types of dysarthria, which is a motor speech disorder caused by damage to the muscles or nerves involved in speech production. The specific type of dysarthria can be determined by assessing the individual's speech characteristics and conducting a thorough evaluation. 1. Spastic Dysarthria: characterised by muscle weakness and increased muscle tone, leading to slow and effortful speech. It can be identified by the presence of slow and strained speech, with difficulty in controlling the rate and rhythm of speech. 2. Flaccid Dysarthria: weakness or paralysis of the muscles involved in speech production. It can be identified by the presence of breathy or hoarse voice quality, imprecise articulation, and reduced loudness. 3. Ataxic Dysarthria: Ataxic dysarthria is characterized by incoordination of the muscles used in speech production. It can be identified by the presence of irregular and uneven speech, with problems in controlling the rhythm and timing of speech movements. 4. Hypokinetic Dysarthria: Hypokinetic dysarthria is associated with Parkinson's disease and is characterized by reduced movement and muscle rigidity. It can be identified by the presence of monotonous and low-volume speech, with a tendency for words to run together. 5. Hyperkinetic Dysarthria: Hyperkinetic dysarthria is characterized by involuntary movements and muscle spasms. It can be identified by the presence of abnormal movements in the face, jaw, or tongue during speech, leading to variable speech rate and articulation. Understand the assessment of adult speech - How would you conduct this? ● ● To conduct an assessment of adult speech, the following steps can be taken: 1. Case History: Gather information about the individual's background, medical history, and any previous speech or communication difficulties. 2. Informal Observation: Observe the individual's speech patterns and behaviours in a natural setting or during conversation. Pay attention to their articulation, fluency, voice quality, and prosody. 3. Formal Assessment: Utilise standardised assessment tools to evaluate specific aspects of speech, such as articulation, phonology, voice, and fluency. These assessments may include tasks such as reading aloud, repeating specific words or phrases, and engaging in conversation. 4. Oro-Motor Assessment: Assess the strength, range of motion, and coordination of the articulatory muscles involved in speech production. This can be done through various exercises and tasks that target specific muscle groups. 5. Perceptual Judgment: Listen to the individual's speech and make subjective judgments about their overall intelligibility, clarity, and naturalness of speech. 6. Provide feedback to the individual and their caregivers or healthcare professionals based on the assessment findings. Make recommendations for further intervention or therapy if necessary. It is important to note that this is a general overview of the assessment process, and specific details may vary depending on the individual's needs and the context of the assessment. There are several assessments that can be used to evaluate phonation in individuals with dysarthria. Some commonly used assessments include: 1. The GRBAS Scale: This scale is used to assess the overall quality of voice, including measures of grade (overall severity), roughness, breathiness, asthenia (weakness), and strain. It is a perceptual assessment completed by a trained listener. 2. The Voice Handicap Index (VHI): This is a self-report questionnaire that assesses the impact of voice problems on an individual's quality of life. It includes questions about physical, functional, and emotional aspects of voice impairment. 3. Acoustic Analysis: Acoustic measures, such as fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio, can be used to assess various aspects of vocal function, including pitch, variability, and noise. 4. Aerodynamic Measures: Aerodynamic measures, such as maximum phonation time and airflow, can be used to assess vocal function and efficiency. 5. Videostroboscopy: This is a procedure that uses a specialized camera and light source to visualise the vocal folds during phonation. It can provide information about vocal fold movement, closure, and vibratory patterns. Resonance ● quality and balance of sound vibrations produced by the vocal tract during speech. It is an important aspect of speech intelligibility and can be affected by various factors, including anatomical differences, muscle weakness, or structural abnormalities. 1. Perceptual evaluation: The speech pathologist listens to the client's speech and assesses the quality of resonance, such as hypernasality (excessive nasal resonance) or hyponasality (reduced nasal resonance). 2. Nasometer: This instrument measures the acoustic energy in the oral and nasal cavities during speech. It can provide objective measurements of nasal airflow and help identify any resonance abnormalities. 3. Mirror examination: The speech pathologist visually examines the movement and position of the soft palate and other structures involved in resonance using a mirror or a flexible endoscope. 4. Aerodynamic assessment: This involves measuring airflow and pressure during speech production. It can help determine if there are any abnormalities in the airflow patterns that may affect resonance. Articulation, ● Oral motor assessment: Articulation assessment: The speech pathologist would evaluate the individual's ability to produce individual speech sounds in different word positions (initial, medial, and final) and in different contexts. ● This may involve using standardised assessment tools, such as the Goldman-Fristoe Test of Articulation or the Clinical Assessment of Articulation and Phonology. ● Speech sample analysis: The speech pathologist may analyse a sample of the individual's spontaneous speech to determine patterns of errors and overall intelligibility. ● Stimulability testing: This involves assessing the individual's ability to imitate correct production of speech sounds when given visual and/or verbal cues. ● Phonological processes assessment: The speech pathologist would evaluate the individual's use of phonological processes, which are patterns of sound errors that affect multiple sounds or sound classes. Based on the results of the assessment, the speech pathologist would then develop an individualised treatment plan to target specific speech sound errors and improve overall articulation skills. Respiration ● Respiratory Muscle Strength Assessment, which measures the strength of the muscles involved in respiration. This assessment can include tasks such as measuring maximum inspiratory and expiratory pressures, as well as assessing the endurance of the respiratory muscles. ● Another assessment that may be used is the Respiratory Kinematic Analysis, which involves measuring the movement of the chest wall and abdomen during breathing using specialised equipment. This assessment can provide information about the coordination and efficiency of breathing patterns. ● Additionally, observation of breathing patterns during speech production can also be informative in evaluating respiration. Management ● Dysarthria management involves a variety of approaches to address the specific speech difficulties caused by the condition. The goal of management is to improve speech intelligibility and overall communication effectiveness. One approach is direct therapy, which focuses on training the motor skills necessary for speech production. ● This may include exercises to strengthen the muscles used in speech, techniques to improve breath support and control, and strategies to improve articulation and prosody. ● Direct therapy often follows the principles of motor learning, which emphasizes practice, feedback, and gradual progression of difficulty. ● Another approach is compensatory therapy, which aims to improve intelligibility through the use of communication strategies, improving listener skills, and modifying the communication environment. This may involve training the individual with dysarthria to use alternative communication methods, such as augmentative and alternative communication (AAC) devices, gestures, or writing. In addition to therapy, medical interventions may be considered in some cases. ● This could include surgical interventions, such as pharyngeal flap or vocal fold injections, or the use of prosthetic devices, such as palatal lifts or nasal obturators. ● What are treatment options? ● ● ● ● ● ● ● ● Restorative approaches: These focus on improving speech intelligibility, prosody, and naturalness. Lee Silverman Voice Treatment (LSVT) for hypokinetic dysarthria ○ Effort closure techniques to increase adductory forces of vocal folds ○ Exercises to improve timing of phonation Compensatory approaches: These aim to compensate for deficits that cannot be retrained. Communication strategies to increase intelligibility, such as using gestures or visual aids Modifying the communication environment, such as reducing background noise or using visual cues Using augmentative and alternative communication (AAC) devices for severe speech impairments Multidisciplinary management: Collaboration with other professionals, such as occupational therapists, physical therapists, or psychologists, to address underlying issues that may impact speech production Patient-reported outcome measures (PROMs): These can be used to assess the impact of dysarthria on a patient's quality of life and guide treatment decisions. Examples include the Dysarthria Impact Profile and the Communicative Participation Item Bank. How would you conduct treatment tasks with a client? 1. Establish rapport: Build a positive and trusting relationship with the client to create a comfortable therapy environment. 2. Set goals: Collaborate with the client to establish specific and measurable goals that align with their needs and desires. 3. Assess baseline skills: Conduct a thorough assessment to determine the client's current abilities and areas of difficulty 4. Plan treatment activities: Develop a treatment plan that includes a variety of activities and exercises targeting the client's specific goals. 5. Provide clear instructions: Clearly explain each task or exercise to the client, ensuring they understand the purpose and expectations. 6. Demonstrate and model: Show the client how to perform the task or exercise correctly, providing a visual demonstration and modeling the desired behavior. 7. Provide feedback and reinforcement: Offer constructive feedback and positive reinforcement throughout the session to motivate the client and facilitate learning. 8. Practice and repetition: Encourage the client to practice the tasks or exercises repeatedly to reinforce skills and promote progress. 9. Monitor progress: Regularly assess the client's progress and adjust treatment activities as needed to ensure continued growth and improvement. 10. Document and track: Keep detailed records of the client's progress, including notes on their performance, goals achieved, and any modifications made to the treatment plan. By following these steps, you can conduct effective treatment tasks with a client and support their progress towards their goals. What other considerations are needed to optimise communication for the client? 1. Assessing the client's cognitive and linguistic abilities: It is important to determine the client's cognitive and linguistic abilities to tailor communication strategies and interventions accordingly. This may involve assessing their language comprehension, expressive language skills, and cognitive processing abilities. 2. Identifying any assistive communication devices or strategies: If the client has difficulty with verbal communication, it may be beneficial to explore alternative communication methods such as augmentative and alternative communication (AAC) devices or strategies. These can include communication boards, sign language, or electronic devices that generate speech. 3. Providing education and support to communication partners: It is crucial to involve and educate communication partners, such as family members, caregivers, and healthcare professionals, on how to effectively communicate with the client. This may include strategies for clear and concise communication, active listening skills, and providing appropriate cues and prompts 4. Creating a supportive communication environment: Ensuring a supportive and accessible communication environment can greatly enhance the client's ability to communicate. This may involve reducing background noise, ensuring good lighting for visual cues, and providing any necessary modifications or accommodations to facilitate effective communication. 5. Regularly assessing and reassessing communication needs: It is important to regularly assess and reassess the client's communication needs and adjust interventions and strategies accordingly. Communication abilities may change over time, and ongoing monitoring and evaluation can help optimize the client's communication experience. Overall, taking a holistic and individualized approach to communication optimization is essential, considering the specific needs and abilities of the client and providing appropriate support and resources to facilitate effective communication. Pead Feeding Signs and symptoms of dysphagia/feeding difficulty 1. Difficulty with latching or bottle feeding 2. Nipple pain or damage during feeding 3. Weak or uncoordinated suck 4. Fatigue or tiredness during feeds 5. Coughing, spluttering, or gagging while feeding 6. Frequent, large gulping swallows 7. Biting or chomping on the breast or bottle 8. Refusal to eat solids or difficulties with cup drinking 9. Gagging or choking on lumpy foods or finger foods 10. Fussy eating or food refusal 11. Coughing or aspiration on fluids or foods 12. Slow or prolonged mealtimes 13. Difficulty with chewing or managing different food textures 14. Challenging mealtime behaviors, such as tantrums or refusal to sit at the table 15. Poor weight gain or failure to thrive What factors need to be considered in your feeding assessment? 1. Medical history: Understanding any underlying medical conditions or diagnoses that may impact feeding and swallowing function. 2. Developmental history: Assessing the child's developmental milestones and any delays or challenges that may affect their feeding skills. 3. Feeding history: Gathering information about the child's feeding experiences, including their current feeding method (breastfeeding, bottle-feeding, or solids), any difficulties or challenges with feeding, and their growth and nutritional status. 4. Oral motor assessment: Evaluating the child's oral motor skills, including their muscle tone, range of motion, coordination, and strength of the muscles involved in feeding and swallowing. 5. Observing feeding skills: Observing the child during a mealtime to assess their ability to self-feed, chew, swallow, and manage different food textures and consistencies. 6. Environment and caregiver factors: Considering the child's feeding environment, including any distractions, noise levels, and the caregiver's approach to feeding. It is important to assess the caregiver's knowledge, skills, and attitudes towards feeding and their ability to provide a supportive and nurturing feeding environment. 7. Multidisciplinary approach: Collaborating with other healthcare professionals, such as dietitians, occupational therapists, and medical specialists, to ensure a comprehensive assessment and management plan for the child's feeding difficulties. How would you conduct this? 1. Case history: Gather information about the child's medical history, feeding history, developmental history, and any concerns or challenges related to feeding. 2. Interview: Speak with the child's caregivers or parents to gather information about the child's feeding history, including any difficulties or concerns they have noticed. Ask about the child's appetite, food preferences, and any previous interventions or therapies they have received. 3. Observation: Observe the child during mealtime to gather information about their feeding behaviours, oral motor skills, and mealtime routines. Look for signs of difficulty such as refusal or aversion to certain foods, difficulty chewing or swallowing, excessive drooling, and prolonged mealtime duration. 4. Oral muscle assessment: Evaluate the strength, range of motion, and coordination of the muscles involved in feeding, including the cheeks, lips, jaw, tongue, and palate. 5. Feeding observation: Observe the child during mealtime to assess their feeding skills and behaviours, including their ability to handle different textures, their chewing and swallowing patterns, and their overall mealtime behaviour. 6. Food and Fluid Intake: Assess the child's current diet and fluid intake, including the types of foods and textures they are able to tolerate. Evaluate their ability to self-feed and use utensils, as well as their overall oral intake. 7. Assessment of function: Evaluate the child's overall feeding function, including their ability to adequately intake and manage food, their efficiency and stamina during feeding, and any signs of fatigue or discomfort. 8. Further assessment if needed: Depending on the findings of the initial assessment, further assessment may be necessary, such as instrumental swallow assessments (such as a videofluoroscopic swallow study or fiberoptic endoscopic evaluation of swallowing) to get a more detailed view of the child's swallowing function.This may include recommendations for modified diets, positioning strategies, and therapy techniques to improve feeding skills. 9. Feeding plan: Develop a feeding plan based on the assessment findings, considering the child's specific needs and challenges. 10. Follow-Up and Monitoring: Regular follow-up and monitoring are essential to track the child's progress and make any necessary adjustments to the feeding plan. This may involve periodic reassessments, ongoing therapy sessions, and communication with the child's caregivers to ensure consistency in the feeding approach. By following these steps, a feeding assessment for children can provide valuable information to guide intervention and support the child's feeding development and overall well-being. What are some management strategies that could support safe and effective intake for Infants 1. Proper positioning: Ensuring that the infant is positioned in a comfortable and safe position during feeding, such as being held in a semi-upright position with their head supported. 2. Establishing a feeding routine: Creating a consistent feeding schedule can help infants establish a regular pattern and prevent them from becoming overly hungry or tired during feedings. 3. Feeding techniques: Utilising appropriate feeding techniques such as paced bottle feeding or paced breastfeeding to allow the infant to take in an appropriate amount of milk or formula at a comfortable pace. 4. Texture modification: Adjusting the texture of foods or liquids to match the infant's developmental readiness. This may involve introducing pureed or mashed foods before progressing to more solid textures. 5. Oral motor exercises: Providing gentle oral motor exercises to strengthen the muscles involved in sucking, swallowing, and chewing. This can help improve coordination and control during feeding. 6. Using appropriate feeding equipment: Using bottles and nipples that are appropriate for the infant's age and developmental stage can help facilitate effective feeding. For example, using a slow-flow nipple for newborns or infants who have difficulty with a fast flow. 7. Paying attention to feeding cues: Observing and responding to the infant's hunger and fullness cues can help prevent overfeeding or underfeeding. Signs of hunger may include rooting, sucking on fists, or increased alertness. 8. Ensuring a calm and quiet environment: Providing a calm and quiet environment during feedings can help infants focus on feeding and reduce distractions and stress. 9. Offering breast milk or formula: Providing breast milk or formula that is appropriate for the infant's age and nutritional needs can support adequate nutrition during feedings. 10. Parent education and support: Providing parents with education and support on feeding techniques, signs of hunger and fullness, and appropriate portion sizes for their infant's age and development. 11. Seeking guidance from healthcare professionals: Consulting with a pediatrician or lactation consultant can provide valuable guidance and support for managing infant feeding and addressing any concerns or challenges that may arise. It is important to note that these management strategies may vary depending on the individual needs and circumstances of the infant. It is always recommended to consult with a healthcare professional for personalized advice and guidance. Toddlers/children 1. Feeding strategies recommended: This includes techniques like paced feeding, offering appropriate food textures, and using supportive seating to promote proper positioning during meals. 2. Texture modification: Adjusting the texture of food to make it easier to chew and swallow. This can include pureeing or mashing foods for toddlers and children who have difficulty with solid foods. 3. Positioning: Ensuring that the child is in a comfortable and upright position while eating. This can help facilitate proper swallowing and prevent choking. 4. Feeding utensils and equipment: Using appropriate utensils and feeding equipment, such as special spoons or cups, to assist with feeding and ensure safe intake. 5. Follow-up plan by the speech pathologist: Regular check-ins and evaluations by a speech pathologist can help monitor progress and make any necessary adjustments to the feeding plan. 6. Supervision and monitoring: Providing close supervision and monitoring during meal times to ensure the child is eating safely and effectively. 7. Referrals to instrumental swallow assessments: If there are concerns about swallowing difficulties, referrals may be made for assessments such as videofluoroscopic swallow studies (VFSS) or fiberoptic endoscopic evaluation of swallowing (FEES) to further evaluate the swallowing function. 8. Multidisciplinary team referrals: Depending on the specific needs of the child, referrals may be made to other healthcare professionals such as dietitians, occupational therapists, or lactation consultants for additional support or assessments. 9. Feeding plan adjustments: The feeding plan should be regularly reviewed and adjusted based on the child's progress and specific needs. This may include modifications to the type of food offered, feeding strategies, or mealtime routines. 10. Working with fussy eaters: For children who are selective eaters, strategies such as building appetite for food, involving them in meal preparation, and focusing on variety throughout the day can be helpful. It's important to avoid pressuring the child or labeling foods as "healthy" or "unhealthy." 11. Providing family support and education: Supporting caregivers and providing them with resources and education on feeding strategies can help create a positive feeding environment and promote healthy mealtime interactions. Remember, these strategies should be tailored to the individual needs of the child and should always be implemented under the guidance of a healthcare professional. How do they link to the clinical presentation? Consider the prioritisation for intervention ● ● ● ● ● ● Feeding difficulties in infants, children, and toddlers can present with various clinical manifestations that inform the prioritization for intervention. These clinical presentations can range from difficulties with breastfeeding or bottle feeding, to struggles with solid food introduction and fussy eating behaviors. The specific feeding challenges observed in each individual will guide the prioritization for intervention. For infants, the clinical presentation may include difficulty latching, weak or uncoordinated suck, frequent coughing or spluttering during feeding, and bottle or breastfeeding refusal. These challenges can indicate issues with oral motor skills, such as weak or uncoordinated sucking, or oral aversion. In children, feeding difficulties may manifest as refusal to eat solids, difficulties with cup drinking, gagging on lumpy or finger foods, and fussy eating behaviors. These challenges can be indicative of sensory issues, oral motor difficulties, or developmental delays. In toddlers, the clinical presentation may include struggles with chewing and swallowing solid foods, difficulty with using utensils, and challenging mealtime behaviors. These challenges can be related to oral motor skills, sensory issues, or behavioral factors. Prioritisation for intervention should be based on the specific clinical presentation and its impact on the child's overall health and development. ● ● ● ● 1. 2. 3. 4. The severity and persistence of feeding difficulties, as well as their impact on growth and nutrition, should be taken into consideration. It is important to address any underlying medical or developmental issues that may be contributing to the feeding difficulties. In some cases, a multidisciplinary approach may be necessary, involving professionals such as pediatricians, dieticians, occupational therapists, and speech pathologists. The specific interventions and strategies employed will depend on the individual's needs and may include feeding therapy, dietary modifications, and caregiver education and support. Overall, the link between feeding difficulties and the clinical presentation lies in the specific challenges observed in the child's feeding behaviors and their impact on the child's overall health and development. Prioritisation for intervention should be guided by the severity and persistence of these challenges, as well as the child's individual needs. Swallowing difficulties: Children with swallowing difficulties may have trouble coordinating their sucking, swallowing, and breathing during feeding. This can result in choking, coughing, or gagging during feedings. Oral motor dysfunction: Some children may have difficulties with the movement and coordination of their oral muscles, which can impact their ability to suck, chew, and swallow. This can lead to food aversions, difficulty