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One of the many questions I often get asked is if I can provide templates of in patient or out patient Evals, SOAPS and/or progress notes for work in SNF's, Long Term Care Facilities, Rehabs and/or acute/sub acute care.  Jaw Opening Exercise This exercise has been studied for years and has finally been published. The authors described the Jaw opening exercise in the paper as active "jaw lowering. The jaw-opening exercise was carried out as follows. First, subjects opened their jaws to the maximum extent and maintained this position for 10 seconds. During the exercise, each patient was made aware that the suprahyoid muscles were strongly contracted. Your patient should feel the stretch right above the level of the vocal folds. This open-and-hold exercise was repeated 4 more times after 10 seconds of rest, which constituted 1 set. Subjects were instructed to perform 2 sets of the exercise daily." (Wada et al., 2012) Wada et al, 2012 states that the most widely used exercise for UES is thought to put strain on the sternocleidomastoid muscles rather than the targeted hyoid muscle group. The jaw Opening Exercise is able to implement a less straining exercise targeting intended muscle groups i.e., mylohyoid, digastric muscles, and the geniohyoid muscle. When these muscles are innervated, they act together to move the hyoid in an upward and forward fashion. In turn, opening the UES. Not very fancy but these exercises focus the effort solely on mandibular elevators without the need to lie down or do any other acrobatics. If you are interested in exercise as a means to strengthen muscles, some of the other citations below explain the rationale behind strengthening exercise which is very different from "oral motor exercise". ***Attached below is my version of a patient handout for this exercise. References Hara, K., Tohara, H., Wada, S., Iida, T., Ueda, K., & Ansai, T. (2014). Jaw-opening force test to screen for Dysphagia: preliminary results. Arch Phys Med Rehabil, 95(5), 867-874. doi: 10.1016/j.apmr.2013.09.005 Robbins, J. A., Gangnon, R. E., Theis, S. M., Kays, S. A., Hewitt, A. L., & Hind, J. A. (2005)The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53(9), 1483-1489. Robbins, J. A., Kays, S. A., Gangnon, R. E., Hind, J. A., Hewitt, A. L., Gentry, L. R., & Taylor, A. J. (2007). The effects of lingual exercise in stroke patients with dysphagia. Archives of Physical Medicine and Rehabilitation, 88(2), 150-158. YOU SHOULD BE ABLE TO GET IT HERE: http://www.archives-pmr.org/article/S0003-9993(06)01457-2/pdf Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw-opening exercise for insufficient opening of upper esophageal sphincter. Arch Phys Med Rehabil, 93(11), 1995-1999. doi: 10.1016/j.apmr.2012.04.025 YOU SHOULD BE ABLE TO GET IT HERE:http://www.archives-pmr.org/article/S0003-9993(12)00322-X/pdf Yoshida, M., Groher, M. E., Crary, M. A., Mann, G. C., & Akagawa, Y. (2007). Comparison of surface electromyographic (sEMG) activity of submental muscles between the head lift and tongue press exercises as a therapeutic exercise for pharyngeal dysphagia. Gerodontology, 24(2), 111-116. Other good stuff to read on exercise: Kent-Braun, J. A., Ng, A. V., Doyle, J. W., & Towse, T. F. (2002). Human skeletal muscle responses vary with age and gender during fatigue due to incremental isometric exercise. Journal of Applied Physiology, 93(5), 1813-1823. Portero, P., Bigard, A. X., Gamet, D., Flageat, J. R., & Guezennec, C. Y. (2001). Effects of resistance training in humans on neck muscle performance, and electromyogram power spectrum changes. European Journal of Applied Physiology, 84(6), 540-546. Thompson, D. J., Throckmorton, G. S., & Buschang, P. H. (2001). The effects of isometric exercise on maximum voluntary bite forces and jaw muscle strength and endurance. Journal of Oral Rehabilitation, 28(10), 909-917. Yeates, E. M., Molfenter, S. M., & Steele, C. M. (2008). Improvements in tongue strength and pressure-generation precision following a tongue-pressure training protocol in older individuals with dysphagia: three case reports. Clinical Interventions In Aging, 3(4), 735-747. SWALLOW ASSESSMENT IN THE LONG TERM ACUTE CARE HOSPITAL: MORE THAN JUST AN EVALUATION FOR ASPIRATION
Within the long term acute care hospital (LTACH) setting, the SLP has a role as specialist for helping determine aspiration risk in dysphagia patients. There is a large portion of SLP training and clinical practice which addresses assessment and treatment of aspiration risk. Clinical experience has shown that assessment of dysphagia spans beyond the evaluation of aspiration risk. Within the LTACH setting, proper assessment of malnutrition risk and dehydration risk are of paramount importance in the medically fragile LTACH patient. It is critical to provide an examination that addresses more than whether a patient is aspirating or not.
Within the LTACH, there is a greater length of average patient stay than typical acute care and the patients still require medically intensive care. Many of these patients are tracheostomy and ventilator dependent and have wounds and pressure ulcers. It is a complex patient population to manage. The staff relies on the recommendations from the SLP to help guide patient treatment regarding oral intake and non-oral intake. These medically fragile patients require a team approach concept to ensure resolution of their deficits. The feeding recommendations from the SLP can impact the patient’s nutrition and hydration status, as well as their aspiration risk.
According to the ASHA speech language pathology medical review guidelines from swallowing, treatment is provided to help prevent nutrition and hydration problems. This involves, according to these guidelines, patient assessment of the ability to eat safely and to sustain nutrition and hydration. The SLP should consider that thepresence of malnutrition can be an aspiration risk predictor.Research has been conducted to determine the characteristics of patients that are at risk to aspirate. One trait that has been correlated frequently with aspiration risk is neurological disease. In addition to neurological disease, the presence of malnutrition has now been found to be a trait in patients that are at risk to aspirate. Bouchard et al (2009) reported that among patients with aspiration pneumonia assessed, 80% of these patients with aspiration pneumonia were also malnourished as determined by a dietitian. The presence of malnutrition may be a risk predictor for developing pneumonia in elderly patients.
In the LTACH, patients in a weakened and malnourished state can become prone to having reduced resistance for battling infection rendering then immunosuppressed. The patients typically present with a common appearance in these scenarios. The patient’s develop oral bacteria and generally maintain an open mouth posture at rest with a visible reduced frequency of spontaneous saliva swallows. As these malnourished patients become weaker, there is often an impact to awareness and wakefulness. Then these patients develop retained airway secretions, as the ability to mobilize secretions becomes more impaired with further decline in cough ability and airway clearance. There may be audible rhonchi in these situations. Extra focus in the LTACH must be given to maintaining good oral hygiene and the monitoring of patient’s temperature, lung, dietary, and weight status.
ASHA addresses the SLP’s role in the nutritional management of the dysphagia patient. The Roles of Speech-Language Pathologists in Swallowing and Feeding Disorders: Technical Report indicates several SLP responsibilities in reference to not only aspiration risk, but also regarding nutritional issues. The ASHA report requires the SLP to consider the patient’s endurance and meal length as conditions that should be involved in the SLP decision-making process for feeding recommendations. ASHA’s report also describes SLP’s role in recommending non-oral intake support in relation to the patient maintaining optimal nutrition and hydration. ASHA indicates in this report that the SLP is part of the decision making team for nutrition should help determine whether non-oral intake support is temporary or more long term. There are several measures taken in the LTACH to monitor and maintain nutrition levels in dysphagia patients.
One of the methods used by the LTACH staff to track oral intake patterns is through the use of a calorie count. This is a method to document the portion of meals consumed for the patients at risk for malnutrition, with dysphagia. Calorie counts are monitored by physicians, nursing, SLP, and the dietitian. Calorie count sheets are generally filled in at the time of the meal by the nurse, nursing assistant, therapist, or family members assisting in the patient’s meal. The calorie count is not the only determining factor used for measuring oral intake levels. These calorie counts tend to be more subjective and are not always entirely accurate measures. Based on clinical experience, these calorie counts can be applied as one tool in a battery of exams when assessing the malnourished patient. It is important to have SLP involvement in the calorie count, as there may be need for dietary consistency modification and training for safe feeding measures and aspiration precautions. Another measure used in the LTACH setting are appetite stimulants.
The most frequent appetite stimulant used in this clinician’s facilities is Megace. This can help avert or rectify weight loss in the malnourished patient. Oxandrin is another separate medication used during the management of the malnourished patient. This medication can be used to help with weight gain in malnourished patients with pressure ulcers who have endured weight loss. Clinical experience has shown that the physicians mayprovide these types of medications to malnourished patientsduring times of reduced oral intake. These orally routed medicinal interventions are typically attempted by the physicians prior to non-oral intake measures being implemented. This includes oral nutritional supplementation.
Beneprotein is a protein powder and can be used with oral feeding patients who are malnourished in the LTACH. This powder can generally be combined with foods and liquids. This contains 6 grams of protein, has 25 calories and is 99% Whey protein. Magic cup is a frequently used nutritional supplement in the LTACH with malnourished patients that have dysphagia. This is an ice cream cup 4 oz with 290 calories and 9 grams of protein. This is a high calorie supplement that can be instrumental improving the nutritional parameters of malnourished patients. This ice cream can be consumed when frozen and does not melt to thin liquid. Instead, it becomes pudding and can be used with most dysphagia patients. BOOST pudding is a frequently used nutritional supplement in the LTACH setting. The pudding consistency is often used for dysphagia patients that cannot tolerate thin liquids. This 5 oz supplement has 240 calories and 7 grams of protein.
Data suggests that the route of nutrient administration influences the body’s response to injury (Pompeo, 2009). Patients with pressure ulcers and other complex problems are particularly prone to nutritional deficits (Salva et al., 2009). Study data indicate that the challenge to achieve an optimal nutritional status in these patients is significant (Pompeo, 2009). In the presence of a functioning gastrointestinal tract, patients who are unable to meet their nutritional needs orally may require enteral tube feeding. Access to the gastrointestinal system is via naso-gastric, naso-intestinal, percutaneous endoscopic gastrostomy or jejunostomy. Percutaneous Endoscopic Gastrostomy (PEG) is the preferred method when long-term feeding is needed (Fergunson et al 2000).
Naso-gastric tube is passed through the nose, through the pharynx, through the esophagus and into the stomach.These are not meant to be used for long term needs.Percutaneous endoscopic gastrostomy (PEG) is a surgically placed feeding tube in the stomach which can be used forlong term needs if necessary. Percutaneous endoscopic jejunostomy is similar to PEG placement except the tube is placed directly into the middle portion of the small intestine (jejunum). The nasojejunal tube is passed the same route as the naso-gastric but enters the jejunum. The nasoduodenal tube is also passed the same route as ng tube but enters the duodenum, the first part of the small intestine. These all use enteral feeding for nutrition via the gastro-intestinal tract.
TPN is total parenteral nutrition. This is used in the patients who are not having oral intake and cannot have tube feeding for other medical reasons. This is done through a central venus catheter which delivers liquid nutritional support through a central vein. TPN can be used for long term use if needed. It is combination of proteins, vitamins, and other nutritional requirements. PPN is partial parenteral nutrition. This is used for more short term needs, with some patients who can take some oral nutrition but not enough for sufficient intake.
Dehydration is common in malnourished patients with pressure ulcers (Fergunson et al 2000). Dehydration reduces the amount of oxygen, nutrients and cell-building substances to the wound because of its effect on blood volume and circulation, (Campbell et al. 1997). The age-related decrease in total-body water (relative and absolute) makes elderly persons markedly susceptible to stresses in water balance (Kugler et al. 2000). Fluid is an essential nutrient for the normal functioning of cells and is especially important for older adults because of their increased risk for dehydration. A number of factors increase the risk of dehydration in the elderly. These include inadequate intake, poor appetite, compounded by chronic illnesses such as diabetes (Mayo Clinic, 2009). It is critical for the SLP to be aware of the consequences of inadequate fluid intake to assist in the prevention of pressure ulcers. DYSPHAGIA ASSESSMENT IN LONG TERM ACUTE CARE: MORE THAN JUST EVALUATING FOR ASPIRATION RISK
Many elderly patients have aspiration risk and require thickener in the liquid as an anti-aspiration measure. Many of these same patients are also unable to take the liquids independently and are completely reliant on others forfeeding assistance. Clinical experience has shown that these patients may refuse thick liquids because of taste, which can impact hydration. Some patients may also take longer to consume liquids with a need for slower feeding to avoid aspiration. This too can impact total liquid consumed.Patients who are receiving thickened liquids should begiven routine re-assessment to determine if they still require the liquid thickener. Patients may require intravenous fluids at times, should oral hydration intake by insufficient. There are times when patients will take thin liquid despite the known aspiration risk they may have. In this instance, the SLP and physician consults with the patient and the family if indicated, to explain the aspiration risk. This allows patients and their families to make informed decisions about patient care.
The SLP has a unique role in the LTACH. The SLP, along with the physicians, nurses, and nutritionists work closely together to monitor nutrition and hydration status of patients. The patients have an average length of stay of 25-30 days in the LTACH, based on national averages, which is typically longer than the acute care stay. As a member of the nutritional team for these patients, the SLP must have a fine balance between restoring and managing patient dysphagia function. Therapeutic exercise and skilled mealtime interventions are typically both required. The most frequent obstacle encountered in terms of maintaining patient nutrition and hydration is generally reduced patient endurance and subsequent fatigue with meals. This situation may require smaller, more frequent meals during the day.
SLP may need to assess the effect of nutritional supplementation consistencies on dietary intake in critically ill elderly patients. This may be happening while the patient is simultaneously being monitored for their ability to sustain a compensatory posture in order to consume sufficient quantities of the nutritional supplement. Another large part of the LTACH treatment is family education, as many of the families stay at the facility and maintain a role as primary caregiver during meals. Their role in understanding patient’s nutritional and hydration needs as well as compensatory swallowing strategies is critical.Equally important to the family education is the education of the nursing staff. SLP will rely on the nursing observations in terms of dietary consistency tolerance, nutritional pattern changes in patients, and changes in aspiration risk behaviors. Ongoing communication with the nursing staff is critical to track patient’s oral intake needs.
Given that the speech language pathologist in medical dysphagia care has frequent recommendations that can impact nutrition and hydration, it is critical that the SLP becomes aware of the potential impact of their recommendations, beyond assessing aspiration risk.
http://www.asha.org/policy/TR2001-00150/
Bouchard, J. (2009). Association between aspiration pneumonia and malnutrition in patients from active geriatric units. Canadian Journal of dietetic practice and research, 70(3), 152-154.
(Speech-language pathology medical review guidelines published by the American Speech Language Hearing Association, September 15, 2008).
Salva, A. et al. (2009). Nutritional assessment of residents in long-term care facilities (LTCFS): Recommendations of the task force on nutrition and aging. The Journal of Nutrition, Health and Aging, 13(6), 475-483.
Pompeo, M. (2009) Misconceptions about protein requirements for wound healing: Results of a prospective study. Ostomy Wound Management, 53(8). www.o-wm.com.
Fergunson, M. et al (2000). Pressure ulcer management: The importance of nutrition. Med surge Nursing, 9(4), 163-177.
Campbell, S. M. et al. (1997). Enteral Nutrition Handbook. Columbus, OH: Ross Products Division, Abbott Laborator.
Kugler, J. et al. (2000) Impact of aging on water metabolism. The American Academy of Family Physician. Retrieved October 4, 2009 from www.aafp.org.
Mayo Clinic (2009). Dehydration. Retrieved July 14, 2009, from www.MayoClinic.com
WRITTEN BY: Dr Eric Blicker MA CCC-SLP.D BCS-S
Wada, S., Tohara, H., Iida, T., Inoue, M., Sato, M., & Ueda, K. (2012). Jaw-Opening exercise for insufficient opening of upper esophageal sphincter. Archives of Physical Medicine and Rehabilitation, 93(11), 1995-1999.
The outcome of this no named new Dysphagia exercise is increasing hyoid elevation, Upper Esophageal Sphincter (UES) opening, pharynx passage time, and decreasing pharyngeal residue after swallowing at preexercise and postexercise evidenced by VFSS. As per Dr. James Coyle this exercise is also designed to increase UES opening by using strengthening the anterior muscles of the floor of the mouth (submandibular suprahyoid) muscles. It exercises these muscles by depressing the mandible. We do it with gentle resistance and use the same schedule that is published in the studies on tongue strengthening. Coyle During a swallow, the UES is open, and works closely b/c of the location of the cricopharyngeal muscle. The cricopharyngeal muscle is attached to the cricoid cartilage and is relaxed upon swallowing as it is pulled by the hyoid laryingeal structures. "The UES does not open automatically. Successful opening of the UES requires an anterior-superior traction of the hyoid and larynx and further UES relaxation and hyoid traction on the larynx precedes UES opening" Wade. Further described, when the hyoid decreases laryngeal elevation can cause dysphagia resulting from UES opening. This exercise involves jaw opening and multiple muscles therefore during ones' Oral Periphieral Exam Jaw as well as Labial muscles must be assessed for this exercise. It doesn't mean they have to have within normal limits, but it must be documented. The suprahyoid muscle group including mylohiyoid muscle, the anterior belly of the digastric muscles and the geniohyoid muscles are also involved in hyoid elevation and some in jaw opening. These muscles include the mylohyoid muscle, the anterior belly of the digastric muscles, and the geniohyoid muscle. Given the above mechanisms, the authors performed a jaw-opening/strenghening exercise among patients with UES dysfunction and assessed the effect of this exercise on swallowing function with a videofluorographic swallowing study (VFSS). Evidence has shown that there was significant improvements when you compare swallow functions pre-exercise and post-exercise. Advances were demonstrated in the extent of upward movement of the hyoid bone, the amount of UES opening, and the timing of pharyeal passage. Four (4) weeks after initiating the exercise. Some subjects evidenced decreased pharyngeal residue. No increases were noted in any subjects. The conclusion demonstrated that this jaw-opening exercise is an effective treatment for dysphagia; caused by dysfunction of hyoid elevation and UES opening. Everyone should take a look at this. Unfortunately this kind of behavior occurrs on a nearly regular basis in SNFs & LTCs. No one should have to go through or even watch this subhuman conduct.
I assure you, I haven't personally witnessed this kind of disgust or any evidence that it may have it occurred. I also know a lot A LOT of therapists who say the same thing. For the most part your loved ones are in good hands. However, there are no excuses, if you suspect one little thing is off, you talk to management. If it keeps happening, you get your loved one into another facility if you have to. Please click on the link below, read the article, and watch the video. If you find any of the information presented in the article familiar, either bring it to your management's attention (by-passing the nursing staff), or feel free to contact me & I'd be happy to assist if I can. http://m.bbc.co.uk/news/health-24958181 If there is ANYONE you want to learn anything Dysphagia related about, it's from Susan Langmore! She is highly respected and very well published in the field. I personally turn to her name first when researching articles!
Susan Langmore’s FEES Courses are being held in Boston, Ma. An Advanced FEES Course will be held on Saturday September 14, 2013. A two day Foundation FEES Course on October 25 & 26, 2013. As soon as I find out more information it will be posted! Some of these courses I would give my left arm to get to if I am able! So, as described:
Dr. Micheal Crary and Dr. Giselle Carnaby will be teaching MDTP Training in Raleigh, NC on October 5 Dr. Micheal Groher and Dr. Micheal Crary will be teaching sEMG Biofeedback Training in Raleigh, NC on October 6 For details on both of those courses, visit http://carolinafees.com/ceu/ Also, offered is a two-day FEES Training Course with hands-on practice on August 2 and 3 in Las Vegas! Visit http://ndohd.com/fees-training/ for more information. FDA warns infants face increased risk in developing life threatening conditions if fed Simply Thick9/23/2012
Article taken directly from the FDA website:
Go here for the direct link to the FDA website: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm256250.htm?source=govdelivery The Food and Drug Administration (FDA) wants parents, caregivers and health care professionals to be aware that infants of any age may face an increased risk of developing a life-threatening condition if fed a thickening product called SimplyThick. Since May 2011, the agency has identified 22 infants who developed necrotizing enterocolitis (NEC), a condition in which tissue in the intestines becomes inflamed and dies, after being fed SimplyThick. Seven of those infants died. Further study is needed to determine if there is an actual link between consumption of SimplyThick and the development of NEC. But, FDA wants everyone involved in the care of a baby to be aware of the potential risk before deciding whether to feed SimplyThick to infants of any age. SimplyThick is a brand of thickening agent—available to consumers and medical centers—used to help manage swallowing difficulties. It is sold in individual serving packets as well as in 64-ounce dispenser bottles, which can be purchased from distributors and local pharmacies throughout the United States. Benson M. Silverman, M.D., director of FDA's Infant Formula and Medical Foods Staff—himself a neonatologist—explains that the thickening agent is added to breast milk and infants' formula to help the premature babies swallow their food and keep it down, without spitting up. The product is also used in older children and adults with swallowing problems caused by trauma to the throat, he notes. back to top The ProblemFDA first learned of bad side effects possibly linked to SimplyThick on May 13, 2011. Silverman says he was alerted by two reports in FDA's MedWatch Safety Information and Adverse Event Reporting Program. He followed up with the physicians who filed those reports and later with a network of other neonatologists, doctors who treat newborns in need of special care. Karl Klontz, M.D., a medical officer in FDA's Center for Food Safety and Applied Nutrition, says the scope of the problem soon became apparent. At the time, the agency was aware of 15 cases of NEC, including two deaths, involving premature infants who were fed SimplyThick, reportedly as directed, mixed with mothers' breast milk or infant formula products. The mixture was fed to infants for varying amounts of time. In May 2011, FDA advised against feeding SimplyThick to infants born before 37 weeks gestation because it could cause NEC. (Gestational, or post-menstrual, age is calculated from the first day of the last menstrual period, which is about two weeks before ovulation.) After issuing that warning, FDA conducted an extensive review of reports of health problems potentially tied to SimplyThick. Its findings, published recently in The Journal of Pediatrics, included the discovery that among almost two dozen infants ultimately found to develop NEC after ingesting SimplyThick was a baby born at full term—not a premature baby. The other 21 infants, however, were born prematurely. The infants ranged from about 24 to 48 weeks post-menstrual age when they became sick. (An infant who is 24 weeks post-menstrual age is about four months premature.) Half of the infants developed NEC in the hospital, while half developed the condition at home following discharge from the hospital. Fourteen required surgery. Silverman and Klontz are among the authors of the report that concluded that further study is warranted to establish if there is a link between NEC and SimplyThick and other thickening agents. In the meantime, says Klontz, parents should contact their child's health care provider before using SimplyThick. back to top Symptoms to Watch for
You or your health care professional may report side effects related to using SimplyThick to FDA's MedWatch by:
Updated Sept. 18, 2012 For more information on Simply Thick http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm256253.htm http://www.jpeds.com/ http://www.flickr.com/photos/fdaphotos/sets/72157626641899297/ I just wanted to pay homage and make sure my followers take notice to this recently posted article on Advanceweb.com about spicing up pureed dysphagia diets. I can't say anymore about it except... click on the following link to read it and enjoy! http://speech-language-pathology-audiology.advanceweb.com/Features/Articles/Think-Outside-the-Blender.aspx
I just wrote my first guest blog in partner with CaregiverPartnership.com in what will be a series of blogs on first Dysphagia and then Language in the aging population and the caregiver. To see the first blog click here: http://blog.caregiverpartnership.com/2012/08/dysphagia-is-hard-to-swallow-get-facts.html
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Amy Reinstein, M.S., CCC - SLP
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