Dysphagia Assessment and Treatment. What's New

Iowa Speech-Language and Hearing Association
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ISHA FALL CONVENTION

Same Manner
---------------------
Different Place
Dysphagia Assessment and

Treatment: Whats New?
Julie A.G. Stierwalt, Ph.D.
Florida State University
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Dysphagia Assessment and Treatment: Whats New?
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Anatomy and Physiology of the Normal Swallowing Mechanism

Oral Cavity
Tongue
Hard Palate
Anterior and Lateral Sulci
lingual, buccal
Dentition
Anterior faucial pillars
Oral Cavity
Pharyngeal Structures
Velum
Tongue base
Pharyngeal walls
constrictors
superior
middle
inferior
Epiglottis
Valleculae
Laryngeal additus
Pyriform sinuses
Upper esophageal sphincter (UES)
Laryngeal Structures
Hyoid bone
Laryngeal vestibule
Ventricular folds
True vocal folds
Conus elasticus
Cricoid cartilage
Esophageal Structures
Esophagus
Three portions
Cervical
Thoracic
Abdominal
Lower esophageal sphincter (LES)
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Swallowing Physiology
Lips and Cheeks
Mechanical facilitation
Draw material into the oral cavity
labial seal
utensils
cups
straws
Contain material in the oral cavity during bolus manipulation
anteriorly
laterally
Clinical implications
Teeth
Mechanical facilitation of deglutition
Also necessary to draw material into the oral cavity
tearing food
utensils
Chewing/Mastication
breaking down the bolus
molars
Clinical implications
immediate loss
accommodation/compensation
Tongue
Sensory component
taste
Mechanical facilitation
Intrinsic muscles
Superior Longitudinal Muscle
shortens the tongue
draws the tip up
draws lateral edges up
Inferior Longitudinal Muscle
shortens the tongue
draws the tip down
Transverse Muscle
narrows / elongates the tongue
Vertical Muscle
flattens the tongue
Extrinsic Muscles
Genioglossus
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posterior fibers
pull the tongue anteriorly
anterior fibers
retraction of the tongue
whole muscle
draws the tongue downward making the tongue like a trough
Styloglossus
draws the tongue up and back
antagonist to the genioglossus
Palatoglossus
forms the anterior faucial pillars
lowers the soft palate
elevates the posterior tongue
Hyoglossus
retract and depress the tongue
may elevate the hyoid
Hard Palate
Bony plate
forms a stable foundation for the tongue to propel the bolus posteriorly
Soft Palate/Velum
Elevates during the swallow to seal the entrance to the nasal passages
prevents nasal regurgitation
facilitates pressure changes necessary for efficient bolus travel
Pressure Gradients
Boyles law
If a gas is kept at a constant temperature, pressure and volume are
inversely proportional and have a constant product.
Application to swallowing
Closed tube
Volume of the tube increases
With the opening of UES
Pressure decreases
Negative pressure
Pharyngeal constrictors
Superior Constrictor
Middle Constrictor
Inferior Constrictor
Cricopharyngeus
Pyriform sinuses
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formed by the muscle course and attachment to the thyroid cartilage
tonic contraction
prevents air in the esophagus
prevents reflux of bolus / esophageal contents
relax during the swallow
neurologic control
biomechanic nature of the laryngeal structure
elevation and anterior movement of the hyoid/laryngeal mechanism
Epiglottis
Leaf shaped cartilage located at the base of the tongue
Connected to laryngeal framework via muscle attachments, the hyoepiglottic
and thyroepiglottic ligaments
elevation and forward excursion of the hyoid during the swallow facilitates
the inversion of the epiglottis.
Aryepiglottic folds
lateral aspects of the epiglottis
form the laryngeal additus
laryngeal vestibule
Valleculae
wedge shaped spaces
left and right
located between the base of the tongue and the epiglottis
along with the pyriform sinuses are known as the pharyngeal recesses
potential location for the pocketing of material
Larynx
Primary biological function is protection of the airway
Three protective valves
laryngeal additus
ventricular folds
true vocal folds
Connected to the hyoid bone via muscle and ligament
Esophagus
Muscular, pliant tube
23-25 cm in length
sphincters located at either end
UES, PE segment
LES
two layers of muscle
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inner, circular
outer, longitudinal
upper third is striated
middle third
striated and smooth
lower third is smooth
Interrelation of Dysphagia, Respiratory Compromise, and PC Malnutrition
Triad of symptoms
Respiratory compromise
Dysphagia
Protein-calorie malnutrition
Anyone of these symptoms can contribute to the triad
The physiology of aging contributes to the probability that anyone of these
symptoms could occur
Disease Related
Conditions that impact the ability of the lungs to function
Reduced vital capacity
Intrinsic lung disease
Affecting lung health
Differs from mechanical forces that might also be related to disease
Deformities
Muscular diseases
Ventilation-perfusion mismatch
Reduced blood oxygenation
COPD
10-40%
Fifth leading cause of death in the U.S.
Chronic bronchitis
Emphysema
Asthmatic bronchitis
Cystic fibrosis
Smoking
Most common primary cause of COPD and lung cancer
Other Conditions Contributing to Respiratory Compromise
Neurological conditions
Polio, spinal muscular atrophies, motor neuron disease
Neuropathies
Multiple Sclerosis
Friedrichs Ataxia
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Myopathies
Muscular dystrophies
Sleep disorders
Kyphoscoliosis
Lung resection
S/S of Impaired Perfusion
Fatigue
HA in a.m.
Poor sleeping
Frequent arousal
Nightmares
Difficulty with cognition
Reduced attention/concentration, memory, general intellectual function.
Muscle aches
Irritability/anxiety
Aspiratory Pneumonia
Lung infection
Caused by aspiration of foreign matter
Food
Liquid
Secretions
Often identified by fluid in the lower lobe of the right lung
Larger bronchi
Orientation of the bronchi into the lung
Aspiration Pneumonia Risk
Dependent upon a number of factors
Respiratory status
Schedule of aspiration
Chronic vs. occasional
Volume of material aspirated
Nature of the material aspirated
Additional factors
Dependency for feeding/oral cares
Dental health
Xerostomia
Presence of enteral feeding
Complicated/numerous medical diagnoses
Pharmacology (poly)
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Smoking
Presence of tracheostomy a/o ventilator dependence
Frazier Water Protocol
Rationale
Patient noncompliance with thin liquid restrictions
Safety of water
60% of the human body
Neutral pH
All pts. screened with water
free water is encouraged
Risks and costs of IVs reduced
Discharged pts drink water
Protocol
Any NPO or dysphagic pt. may have water
Pts. who are impulsive or exhibit excessive coughing are restricted to water
under supervision.
For patients on oral diets, water is permitted between meals (unrestricted prior
and more than 30 minutes after)
This is the screening process
Identification system
Identifies them as on the Frazier protocol
Water is freely offered
Meds are not administered with water (delivered in a bolus)
Family education on the rationale and the guidelines of the protocol
Complaints of thirst have decreased.
Patients and families offer better compliance
Less financial burden thickening agents
Less hassle with thickening liquids
Discovery of aquaporin channels in the lungs has supported use of free water
Mechanism of water absorption directly into the blood stream
Issues Related to Assessment
Swallowing/Dysphagia Considerations
Diagnosis
Pulmonary Status
Cognitive Status
Communication Status
Physical limitations
Self feeding?
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Dependent upon feeding?
Referral
Appropriateness
Clinical judgment/intuition
Ethical considerations
May decide to decline to test
In the best interests of the patient
Physician may not have information regarding the potential risk:benefit
Medical Chart Review
Medical history
Dysphagia symptoms
Respiratory conditions/disease
Weight loss
Disease process
Current event
Symptoms
CN evaluation
Surgeries
Respiratory Status
Medications
Chest X-rays
Pleural effusion:
Fluid that accumulates in the pleural space
Trauma or disease
Hemothorax blood
Empyema pus
Pneumothorax air
Inflammation
Infection
Cancer
Infiltrates
Fluid accumulating in the lungs
Atelactesis
Collapsed lung
Compression
Obstruction
May be partial or total
Prolonged bed rest
Heavy sedation
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Obesity
Compression from pleural effusion
Foreign object
Tumors
Difficulty breathing
Chest pain
Cough
Medical Staff Interview

Impression of swallowing abilities
Impression of speech abilities
Impression of cognitive abilities
Oral secretion management
Instrumental Techniques
FEESST
Fiberoptic Endoscopic Evaluation of the Swallow with Sensory Testing
(FEESST)
FEESST procedures
Fiberscope is inserted transnasally
Moved until it is situated above the level of the valleculae
Various bolus consistencies and volumes are administered
Events prior to and subsequent to the swallow are observed
Colored bolus
Benefits
No radiation is experienced
Can do extensive testing
Treatment strategies can be studied
Feedback
Portability
Drawbacks of FEESST
Drawbacks
Oral phase cannot be viewed
Obscures events during the swallow
Cost of equipment
Cost of training
Pt. cooperation / tolerance for nasal-endoscopy
movement disorders contraindicated
Fluoroscopic Evaluation
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Fluoroscopy
dynamic x-ray
Cinefluoroscopy
film
frame by frame analysis
Videofluoroscopy
videotape
immediate playback capabilities
audio recording capability
Purpose for Videofluoroscopy
Assess overall swallow function
oral preparation and transit
pharyngeal phase
esophageal phase
Modified Barium Swallow
Determine the presence/risk of aspiration
why is the pt. aspirating
alleviation of symptoms
consistency
postural
Procedure
Systematic administration of consistencies
Extras
Therapeutic techniques
chin press/tuck
head turns
Mendelsohn Maneuver
liquid modification
solid- liquid manipulation
clear pharyngeal stasis
supraglottic swallow
Clinical Evaluation
The one type of assessment technique available to every clinician
Systematic administration of consistencies
Method for following the bolus
Observations
Oral phase
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Timing
Strength
Pharyngeal phase
Timing
Strength
Supplements to the Clinical Evaluation

Pulse Oximetry
Suggestions of decrease in O2 indicating aspiration
Tongue strength
Iowa Oral Performance Instrument (IOPI)
Subjective measures
Listening to lung sounds and the sounds of swallowing via a stethoscope

Triad of symptoms
Respiratory compromise
Dysphagia
Protein-calorie malnutrition
Anyone of these symptoms can contribute to the triad
The physiology of aging contributes to the probability that anyone of these
symptoms could occur
Respiration surrounding the swallow

Normal respiratory sequence
Inspiration
velum lowers so that breathing can continue during mastication
Exhalation begins
Apnea during the swallow
Exhalation is completed
Cervical Auscultation
Cervical auscultation is a relatively new low-tech technique to facilitate
accurate bed-side evaluation of the swallow.
Cervical auscultation is a technique for monitoring the sounds of the swallow
stethoscope
microphone
accelerometer
CA procedures
Listening/recording device is placed over the thyroid lamina
Listen to air-exchange, respiration before swallow
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turbulence in the flow of air
evidence of material in the vestibule
can material be cleared
Listen during the swallow
Normal sequence
inhalation
apnea
two clumps-clicks
exhalation
Abnormal sounds
Changes in respiratory rate
No clearing exhalation
Delayed clearing exhalation
A muffling/melding of the distinct clumps of sound
No apnea
Prolonged apnea
Prolonged swallow sounds
Turbulence in the air-exchange
stridor bubbling squeaks
wheeze gurgling crackling
Acoustics of the Swallow

Recent investigation
101 subjects
No history of dysphagia, oral surgeries that might interfere with swallowing
ability
Consistencies
Thin liquid
Honey thickened liquid
Puree (applesauce)
Soft (diced pears)
Findings
Duration of the swallow signal
Thin liquid (.49 sec)
Thickened liquid (.55 sec)
Puree (.53 sec)
Soft (.57 sec)
Intensity of the swallow signal
Thin liquid (60.70 dB)
Thickened liquid (60.90 dB)
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Puree (60.82 dB)
Soft (60.84 dB)
Upper and Lower Airways
Other applications for auscultation
Upper airway
mechanisms that protect the upper airway
normal sequence/structures
three valves
epiglottic inversion, sealing the laryngeal additus
ventricular fold adduction
true fold adduction
Lower airway
mechanisms that protect the lower airway
cough
ciliary action
alveolar macrophages
Lung Sounds
Apnea- total cessation of breathing
Dyspnea- difficult, labored and/or painful breathing
Cheyne Stokes- cycles of breathing that increase then decrease in rate and
depth with periods of apnea between cycles
Rales- discrete crackling sounds typically heard on inspiration when air
collides with secretions indicates fluid in lung fields
Rhonchi- coarse sounds heard throughout the respiratory cycle
exhalation
Wheezing- indicates narrowing of the bronchioles, possibly bronchospasm
Cervical Auscultation
Hands on Demonstration
Treatment
Indirect Treatment
Treating structures that are utilized in swallowing to improve function
Strengthening
Direct Treatment
Treatment that involves bolus manipulation
Postural changes
Combinations of the two
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Oral Phase
Impairments
Labial weakness
Lingual weakness
Reduced bolus manipulation/formation
Reduced bolus transit
Reduced containment
Buccal weakness
Pocketing
Pharyngeal Phase
Impairments
Delayed initiation
Velar weakness
Lingual weakness
Reduced base of tongue retraction
Pharyngeal weakness
Reduced bolus transit
Reduced laryngeal elevation
Remediation of Weakness
Strengthening exercises as a method for remediating weakness in oral motor
structures is a common practice in rehabilitation
Isometric in nature
tongue blade
spoon
measuring improvement can be difficult
subjective judgments
functional change
Controversy
There has been a great deal of controversy regarding the value of treating
measures, such as tongue strength.
Speech literature rather than dysphagia literature
Opponents
Opponents of assessing and treating such parameters have maintained that:
the gestures used in oral motor activities differ from those used in
speech/swallowing, therefore, assessment of measures of tongue function
offer little useful diagnostic or therapeutic information
only a fraction of our total performance capability is necessary for speech
and/or swallowing.
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Proponents
Proponents for assessing and remediating strength measures believe:
greater overall strength is required to move muscle quickly,
a reduction in the total performance capability may result in an inability to
maintain previous levels of performance, and
knowledge regarding what is normal performance is just one piece of the
puzzle.
Case Studies
14 yo Severe TBI thirty months post injury
21 yo TBI seven months post injury
Strengthening Protocols
Exercise
Intensity
Resistance
Task specificity
Oral Phase Protocols
Strengthening protocols
Labial weakness
Lip compression
Tongue weakness
IOPI protocols
Pharyngeal Phase - Exercise
Masako technique
Tongue base
Pharyngeal closure
Velar weakness
Continuous Positive Air Pressure
Effortful swallow
Pharyngeal constriction
Laryngeal elevation
E-Stim
Vital stimulation
Pharyngeal weakness
Motor unit recruitment patterns
Compensatory Techniques
Diet Modification
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Thickened bolus
Bolus formation
Slows transit
Requires increased pressures
Taste manipulation
Sour
Carbonation
Postural manipulations
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Pharmacologic Agents causing Xerostomia

Analgesics
Brand Name Generic Name
Codral, Panadeine/Forte Paracetamol/codeine
Di-gesic, Paradex, Capadex Paracetamol/dextropropoxyphene
Anti-Anxiety & anti depressant agents
Xanax, Ralozam, Kalma Alprazolam
Endep, Tryptanol Amitriptyline
Buspar Buspirone
Valium, Antenex, Ducene Diazepam
Sinequan, Deptran Doxepin
Prozac Fluoxetine
Tofranil, Melipramine Imipramine
Ativan Lorazepam
Equanil Meprobamate
Allegron Nortriptyline
Serepax, Alepam, Murelax Oxazepam
Nardil Phenelzine
Zoloft sertraline
Euhypnos, Nomison, Temaze, Temtabs Temazepam
Halcion Triazolam
Anti-cholinergics
Atrobel, Forte, Atropt, Contac Cold Atropine
Tablets, Donnagel, Donnalix,
Donnatab, Lomotil. Neo-Diophen
Merbentyl, Infacol-C Colic Syrup Dicyclomine
Pro-Banthine Propantheline
Anti-histamines/ decongestants
Hismanal Astemizole
Benadryl, Benatuss, Benyphed, Delixir, Diphenhydramine
Ergodryl, Paedamin Elixir
Dimetapp Brompheniramine
Action, Day & Night Cold & Flu Caps, Chlorpheniramine
Demazin, Head Clear, Lemsip Flu,
Orthoxicol 3 Sinus Relief, Panadol
Allergy Sinus, Piriton, Sinutab
Sinus/Allergy and Pain Relief, Tylenol
Cold & Flu, Allergy Sinus
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Atarax Hydroxyzine
Sudafed Pseudoephedrine
Teldane Terfenadine
Phenergan, Painstop Syrup,Panquil Promethazine
suspension, Phensedyl, Seda-Quell,
Tixylix Cough Linctus
Actifed, Codral Nightime, Sudafed Plus Triprolidine& pseudoephedrine
Anti-asthmatics
Ventolin-aerosol, nebuliser, rotacaps, Salbutamol
syrup, Asmol
Becotide, Becloforte, Aldecin beclomethasone
Atrovent-aerosol, nebuliser Ipratropium bromide
Intal-aerosol, forte nebuliser, spincaps Sodium cromogylcate
Antibiotics
Ciproxin Ciprofloxacin
Noroxin Norfloxacin
Alphacin, Alphamox, Augmentin, Amoxicillin
Amoxil, Cilamox, Moxacin
Anti-convulsants
Tegretol, Teril Carbamazepine
Rivotril Clonazepam
Anti-parkinson agents
Sinemet/CR, Madopar Levodopa
Cogentin Benztropine mesylate
Anti-psychotic
Largactil Chlorpromazine
Haldol, Serenace Haloperidol
Mutabon D Perphenazine
Sparine Promazine
Melleril, Aldazine Thioridazine
Stelazine Trifluoperazine
Anti-hypertensive/ anti-angina
Tenormin, Anselol, Noten Atenolol
Capoten Captopril
Catapres 150 Clonidine
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Cardizem CD/SR, Coras, Dilzem diltiazem
Renitec, Amprace Enalapril
Transiderm-Nitro, Anginine, Nitra- Glyceryl trinitrate
disc,Nitrolingual Spray, Deponit
Ismelin Guanethidine
Natrilix, Dapa-Tabs, Napamide Indapamide
Zestril, Prinivil Lisinopril
Isordil, Isogen, Sorbidin Isosorbide Dinitrate
Betaloc, Lopresor, Minax Metoprolol
Aldomet, Aldomet M, Hydopa Methyldopa
Adalat/Oros Nifedipine
Minipress, Pressin Prazosin
Inderal, Deralin Propanolol
Hytrin Terazosin
Isoptin, Cordilox, Veracaps SR, Anpec Verapamil
Anti-inflammatory
Panafcort/Panafcortelone, Sone/Solone Prednisone/Prednisolone
Anti-nauseant
Stemetil Prochlorperazine
Anti-ulcerants
Pepcidine Famotidine
Tazac Nizatidine
Losec Omeprazole
Carafate, SCF, Ulcyte Sucralfate
Anorectics
Tenuate/Dospan Diethylpropion
Bladder Disorder
Hytrin Terazosin
Ditropan Oxybutyin
Diuretics
Burinex Bumetanide
Chlotride Chlorothiazide
Lasix, Uramide, Urex Frusemide
Moduretic, Hydrene, Amizide, Hydrochlorothiazide
Dichlotride, Dyazide
___________________________________________________________ 23
_________________________________________________October 25, 2007
Aldactone, Spiractin Spironolactone
Dyazide, Hydrene Triamterene/Hydrochlorothiazide
NSAIDS (anti-inflammatory)
Voltaren Diclofenac
Brufen, ACT 3, Nurofen, Rafen Ibuprofen
Orudis Ketoprofen
Tardol Ketorolac
Feldene, Pirox Piroxicam
Hypolipidaemics
Lopid Gemfibrozil
Nicotine Dependence
Nicorette, Nicotinell, Prostep Nicotine
___________________________________________________________ 24
_________________________________________________October 25, 2007
Sage Oral Care Protocol.
Protocols
1. The oral cavity is assessed initially and daily by nursing
2. Unconscious or intubated patients are provided oral care 2-3X a day, more frequent if
necessary
3. Intubated patients are assessed to determine the need for removal of oralpharyngeal
secretions as needed as well as prior to repositioning the tube or deflation of the cuff
Procedures
1. Set up equipment.
2. Position the patients head to the side or place in semi-fowlers
3. Provide deep suction, as needed, in intubated patients to remove oropharyngeal
secretions that can migrate down the tube and settle on top of the cuff.
4. Brush teeth using suction toothbrush and small amounts of water and alcohol free
antiseptic oral rinse.
Brush for approximately one to two minutes
Exert gentle pressure while moving in short horizontal or circular strokes.
5. Gently brush the surface of the tongue
6. Use suction swab to clean the teeth and tongue if brushing causes discomfort or
bleeding
Place swab perpendicular to gum line, applying gentle mechanical action for one
to two minutes.
Turn swab in clockwise rotation to remove mucous and debris.
7. Apply mouth moisturizer if needed
8. Apply lip balm if needed
Typical solutions include hydrogen peroxide and chlorhexidine gluconate
Do not use antimicrobial products such as chlorhexidine and fluorides together. Allow 2-
3 hours between their use. (fluoride can interfere with effectiveness of chlorhexidine).
___________________________________________________________ 25
_________________________________________________October 25, 2007
Tongue Strengthening Protocol
Although the following strengthening protocol incorporates the use of the IOPI,
the instrument is not necessary. It is a nice method for obtaining baseline
measures and monitoring progress, but there is enough research to support that
the protocol does result in improved function both speech and swallowing in
severely impaired individuals. The same treatment protocol could be
implemented with pushing the tongue against the hard palate, or even against a
tongue blade if they feel the need to push against something tangible.

Florida State University
Iowa Oral Performance Instrument
Blaise Medical, Inc.

713 Cumberland Hills Drive,
Hendersonville, Tennessee 37075, United States
Email: kevin@blaisemedical.com
Phone: 1-888-497-3579
Fax: 615-824-5825
___________________________________________________________ 26
_________________________________________________October 25, 2007
IOPI Strengthening Protocol
Select the structure that you have targeted for strengthening with the
IOPI. Set the Mode dial to PEAK. Ask the patient to press against the bulb as
hard as they can. Encouraged trials ensure maximum performance. Let them
see the IOPI display for biofeedback regarding their effort. The following is an
established protocol for strengthening. You may need to modify it to fit the
needs of your patients. Record the peak pressure displayed on the IOPI for each
trial in the set. Provide a brief rest period (approx. 1 minute) between each set.
Set 1 Set 2 Set 3 Set 4 Set 5
1._____ 1._____ 1._____ 1._____ 1._____

2._____ 2._____ 2._____ 2._____ 2._____
3._____ 3._____ 3._____ 3._____ 3._____
4._____ 4._____ 4._____ 4._____ 4._____
5._____ 5._____ 5._____ 5._____ 5._____
Set 6 Set 7 Set 8 Set 9 Set 10
1._____ 1._____ 1._____ 1._____ 1._____

2._____ 2._____ 2._____ 2._____ 2._____
3._____ 3._____ 3._____ 3._____ 3._____
4._____ 4._____ 4._____ 4._____ 4._____
5._____ 5._____ 5._____ 5._____ 5._____
*CAUTION
As with the effortful swallow, be sure to monitor generalized effort. Make every
attempt to ensure they are focusing their effort on the structure in question.
___________________________________________________________ 27
_________________________________________________October 25, 2007
EMG Protocol
The focus is on two separate areas with this treatment. One is on the actual
instruction for the exercise the purpose of which is to avoid movements that
might interfere with functional swallowing (e.g. tongue pumping, excessive
throat clearing etc.), and the other includes the feedback provided by the EMG
instrumentation.
Swallowing Instruction
Sustained postures:
1) Mouth closure from bolus administration too completion of swallowing
attempts
2) Sustain pharyngeal contraction during each swallow attempt
Following each swallow attempt, have the patient inhale gently though the nose
and hum, to act as a clearing mechanism. (listen for evidence of material
"bubbling" on the vocal folds).
Surface EMG Feedback
The purpose of the EMG is to measure the muscle activity of the previous
swallowing instructions and to quantify any change.
1) To provide information that is otherwise difficult to monitor (strength
of contraction).
2) To increase the strength of the pharyngeal component of swallowing.
I think the best way to record data is to have a data sheet with the protocol
outlined. The following is an example. You may need to add to it once you get
started. Or you may not like it and decide to develop your own.
Youll notice that I have 3 blanks to fill in the numbers that occurred when the
patient held the contraction for three seconds. Any other system that you adopt
may display the muscle activity in another format. Just change the data sheet to
reflect how you want to document the patients performance.
___________________________________________________________ 28
_________________________________________________October 25, 2007
EMG Data Sheet

Session # _____
Date: ________
Baseline Measures (baseline should be approximately one minute of rest)
Highest number _____

Lowest number _____
Intervention
Swallow attempt #1 (peak number followed by next two numbers)
Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______
___________________________________________________________ 29
_________________________________________________October 25, 2007

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______

Peak: ________ _______ _______
___________________________________________________________ 30
_________________________________________________October 25, 2007
Homework
Date: __________
Ten swallow attempts with sustained pharyngeal contraction (just like what we
do in therapy). Try to complete one set of ten attempts at least three times per
day. Shoot for five if you are able to.
_____ # Attempts Completed _____ Time of Day
Amount of intake for today (If you can remember, measure intake, e.g. # of
portions, amount of liquid. This can serve as a measure of progress).
*CAUTION
Monitor generalized effort. Make every attempt to ensure they are focusing their
effort on the structure in question to avoid excess strain on the cardiac/vascular
system.
___________________________________________________________ 31

Dysphagia Assessment and Treatment. What's New

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Iowa Speech-Language and Hearing Association

_________________________________________________October 25, 2007

ISHA FALL CONVENTION

Dysphagia Assessment and

Anatomy and Physiology of the Normal Swallowing Mechanism

Medical Staff Interview

Supplements to the Clinical Evaluation

Listening to lung sounds and the sounds of swallowing via a stethoscope

Respiration surrounding the swallow

Acoustics of the Swallow

Combinations of the two

Butcher, B.R., Treatment of Chronic Aspiration as a Complication of Cerebrovascular Accident.

Johnson, A. and Jacobson, B., Medical Speech-Language Pathology: A Practitioners Guide.

Langmore, S.E., Managing the Complications of Aspiration in Dysphagic Adults in Seminars in

Luschei, E. S. (1991). Development of objective standards of nonspeech oral strength and

Miller, A., Neurophysiological Basis of Swallowing. Dysphagia, 1986, 1:91-100.

Splaingard, M.L., Hutchins, B. and Sulton, L.D., Aspiration in Rehabilitation Patients:

Pharmacologic Agents causing Xerostomia

Sage Oral Care Protocol.

Typical solutions include hydrogen peroxide and chlorhexidine gluconate

Julie A.G. Stierwalt, Ph.D.

Iowa Oral Performance Instrument

Blaise Medical, Inc.

IOPI Strengthening Protocol

Set 1 Set 2 Set 3 Set 4 Set 5

1._____ 1._____ 1._____ 1._____ 1._____

Set 6 Set 7 Set 8 Set 9 Set 10

1._____ 1._____ 1._____ 1._____ 1._____

Surface EMG Feedback

EMG Data Sheet

Baseline Measures (baseline should be approximately one minute of rest)

Highest number _____

Swallow attempt #2 (peak number followed by next two numbers)

Swallow attempt #3 (peak number followed by next two numbers)

Swallow attempt #4 (peak number followed by next two numbers)

Swallow attempt #5 (peak number followed by next two numbers)

Swallow attempt #6 (peak number followed by next two numbers)

Swallow attempt #7 (peak number followed by next two numbers)

Swallow attempt #8 (peak number followed by next two numbers)

Swallow attempt #9 (peak number followed by next two numbers)

Swallow attempt #10 (peak number followed by next two numbers)

Swallow attempt #11 (peak number followed by next two numbers)

Swallow attempt #12 (peak number followed by next two numbers)

Swallow attempt #13 (peak number followed by next two numbers)

Swallow attempt #14 (peak number followed by next two numbers)

Swallow attempt #15 (peak number followed by next two numbers)

Swallow attempt #16 (peak number followed by next two numbers)

Swallow attempt #17 (peak number followed by next two numbers)

Swallow attempt #18 (peak number followed by next two numbers)

Swallow attempt #19 (peak number followed by next two numbers)

Swallow attempt #20 (peak number followed by next two numbers)

Swallow attempt #21 (peak number followed by next two numbers)

Swallow attempt #22 (peak number followed by next two numbers)

Swallow attempt #23 (peak number followed by next two numbers)

Swallow attempt #24 (peak number followed by next two numbers)

Swallow attempt #25 (peak number followed by next two numbers)

_____ # Attempts Completed _____ Time of Day

_____ # Attempts Completed _____ Time of Day

_____ # Attempts Completed _____ Time of Day

_____ # Attempts Completed _____ Time of Day

_____ # Attempts Completed _____ Time of Day

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