Martin-Harris et al., 2007 JSLHR Study

The (Martin-Harris et al., 2007 study showed progressively deeper progression of the 5mL liquid bolus with progressively older subjects. At the onset of maximal hyoid motion (the onset of the pharyngeal response and the starting point for measuring stage transition or pharyngeal delay time), the mean age at which the head of the bolus tended to be at the level of the intersection of the mandibular ramus with the tongue base was about 48 years (looking at their figures-not the raw data), at the vallecular pit it was age about 60, hypopharynx = ~70, and pyriform sinuses was about 72 or 3. However (and a huge however), the ranges for each age group were very wide (meaning that the range of age at which bolus head was at the various sites at swallow onset included individuals between about 40 and 70 years). Interestingly in the second swallow, all of the "pyriform sinus" swallows occurred in patients 80 and older, if I am reading this correctly.

This study also plotted pharyngeal delay time and the plot shows confirmation of a definite lengthening in pharyngeal response onset with progressive aging.

This study is published in JSLHR (50 (3): 585) which is available to all ASHA members online (Martin-Harris et al., 2007)

James L. Coyle
University of Pittsburgh

and response from Bonnie Martin-Harris, PhD:

Dear Jim,
Thank you for citing our work and for your complete summary. I do want to point out the following that we believe was one of the most interesting
findings:

"There was, however, one 91-year-old who demonstrated this "timely and safe" position relative to the onset of the swallow. More than 25% of our sample exhibited a bolus head location in the vallecular pits at the onset of hyoid motion. The youngest of these was 26 years old, and the oldest was 89 years old. Thirteen of our participants demonstrated a bolus head location in the hypopharynx superior to the pyriform sinuses at the onset of the pharyngeal swallow. This position was represented by the young (the youngest individual in our sample was
26 years of age) and the old (the oldest individual in our sample was 97 years of age)."

There is some normal variation across ages. Clinicians must understand this variation and can only recognize the threat of related swallowing difficulties via careful evaluation of all functional components of the oropharyngeal swallowing mechanism.

Great to see this dynamic discussion.
Bonnie


Bonnie Martin-Harris, Ph.D., CCC-SLP, BRS-S Director, MUSC Evelyn Trammell Institute for Voice and Swallowing Associate Professor, Otolaryngology-Head and Neck Surgery Medical University of South Carolina
135 Rutledge Avenue
PO Box 250550
Charleston, SC 29425
Phone: (843) 792-7162
Fax: (843) 792-0546

Normal Variation in Pharyngeal Swallow Times in Elderly

Dr. Robbins' work has shown that the duration of stage transition is longer in the elderly. Translated, the bolus head (with liquids) is past the ramus of the mandible for a second or two in some cases, in healthy elderly subjects (Robbins, Hamilton, Lof, & Kempster, 1992). As you know the "top" of the valleculae lie at the plane of the mandibular ramus.

That would be Hiiemae and Palmer (1999), and Saitoh, et al., 2006. These investigators found that with solids and soft solids as well as chewed foods, the bolus head tended to lie anywhere from the valleculae to the pyriform sinuses for up to many seconds, even in non-old subjects. For this reason the measure traditionally used to indicate "pharyngeal delay" (i.e. the duration of stage transition) is no longer valid for solids (Hiiemae & Palmer, 1999; Saitoh et al., 2007).


James L. Coyle

University of Pittsburgh
References

Hiiemae, K. M. & Palmer, J. B. (1999). Food transport and bolus formation during complete feeding sequences on foods of different initial consistency. Dysphagia, 14, 31-42.
Robbins, J., Hamilton, J. W., Lof, G. L., & Kempster, G. B. (1992). Oropharyngeal swallowing in normal adults of different ages. Gastroenterology, 103, 823-829.
Saitoh, E., Shibata, S., Matsuo, K., Baba, M., Fujii, W., & Palmer, J. B. (2007). Chewing and food consistency: effects on bolus transport and swallow initiation. Dysphagia, 22, 100-107.

Normal Variability in Adult Swallows: Pharyngeal Swallow Initiation

Delayed Initiation of the Pharyngeal Swallow: Normal Variability in Adult Swallows. Journal of Speech, Language, and Hearing Research Vol.50 585-594 June 2007.

by Dr. Bonnie Martin Harris et al.

Barium Standardization for MBS

Catriona M. Steele
Ph.D., M.H.Sc., S-LP(C), CCC-SLP, Reg. CASLPO writes:

Hi everyone!
I wanted to contribute to the discussion on barium standardization.

First let me start by saying that I believe the preferred option here is to use the Varibar products. These products have undergone rigorous testing.

However, if you are in a facility where Varibar is not yet available (which is true for all of us in Canada), then the next best approach is to standardize your barium recipes. I believe that we should be attempting to match the DENSITY of the Varibar products (acknowledging, of course that those products have the advantage of including various suspension agents and emulsifiers that are not part of the procedure I am going to describe below).

To make barium products of a specific DENSITY, you need a good digital scale as well as containers that specify volume (in ML). Density is always reported as a WEIGHT to VOLUME ratio. That means that for a specific VOLUME of liquid, you need to add a particular WEIGHT (in grams) of barium.

The particular amount of barium that you will add depends on the original barium product (is it a powder or already in liquid form?) and what density it is already determined to have. Liquid Polibar, for example, has a 100% weight to volume ratio in the bottle. Liquid Polibar Plus is slightly more dense (105% weight to volume). EZ-HD is intended to yield a 250% weight to volume suspension when you add the specified amount of water marked on the bottle.

So, in the absence of Varibar here in Canada, this is how I suggest that people attempt to standardize their home-made barium recipes (let me reiterate that I believe purchasing Varibar is the preferred option).

a) How to make ~1 cup (250 ml) of 40% w/v liquid barium suspension with Liquid Polibar(100% w/v base):

- Place an empty container on a digital balance and set the weight to 0 g.
- Pour in 100 g of Liquid Polibar.
- Add water until the volume reaches 250 ml.
- Shake well and leave to stand in a refrigerator.

b) How to make ~1 cup (250 ml) of 40% w/v liquid barium suspension with Liquid Polibar Plus (105% w/v base):

- Place an empty container on a digital balance and set the weight to 0 g.
- Pour in 95 g of Liquid Polibar Plus.
- Add water until the volume reaches 250 ml.
- Shake well and leave to stand in a refrigerator.

c) How to make 40% w/v barium products (any consistency) with E-Z-HD powder:

- Calculate the volume of liquid that you want to prepare (e.g. 250 ml)
- Determine the value of 40% of this volume (e.g., 250 X 0.4 = 100). Divide this value by 2.5 (e.g., 100/2.5 = 40).
- Using a digital balance, weigh out this value in grams of EZ-HD powder on a scale.
- Add this amount of powder to your liquid (e.g. 40 g of EZ-HD plus 250 ml of liquid).
- Shake or stir well with a whisk and store in a refrigerator.

Catriona M. Steele
Ph.D., M.H.Sc., S-LP(C), CCC-SLP, Reg. CASLPO

* Research Scientist, Toronto Rehabilitation Institute
* Corporate Practice Leader for Speech-Language Pathology and Audiology, Toronto Rehabilitation Institute
* CIHR New Investigator in Aging
* Assistant Professor, Department of Speech-Language Pathology, University of Toronto
* Coordinator-Elect, Special Interest Division 13 (Swallowing and Swallowing Disorders), American Speech-Language Hearing Association

Mailing Address:
550 University Avenue, #12030,
Toronto, ON, M5G 2A2
Telephone: 416-597-3422 X 7603
Fax: 416-597-7131
E-mail: steele.catriona@torontorehab.on.ca

Risks for Dehydration and/or Pneumonia

In the coming year the data from the Protocol 201 study, some of which was presented at the 2006 ASHA meeting, will be published. This study randomized aspirating Parkinson’s and dementia patients to either thin liquid using a chin-down posture, or thickened liquids (nectar or honey) for either three months follow up, or primary clinical end point (outcome of interest) of pneumonia, but hydration and nutritional parameters were also followed.



At the time of the ASHA meeting in 06, one interesting result presented was that patients in this study randomized to the “honey” thickened liquids intervention for managing aspiration of thin liquids, compared to the “nectar” thick and chin-down posture interventions, had significantly longer hospitalizations for pneumonia, than the pneumonia hospitalization durations for the other two interventions. I hope that the authors will clarify this with some data in their manuscripts and discuss this, as this “gel” discussion relates to the exact nature of the 201 finding: does aspirated thick liquid produce worse adverse outcomes than aspirated thin liquid.



The gel discussion aside, another important consideration is whether the patient drinks sufficient liquids once they are prescribed in their thick form. If we shift the risk from a potential respiratory adverse outcome (pneumonia) to a metabolic adverse outcome (inadequate hydration), there may be no net gain.

James L. Coyle

University of Pittsburgh

Fluent vs. Non-Fluent Aphasia

Listen for and document the longest running statement,note the use of content words, especially nouns. Document the presence of complete phrases within utterances that may not be meaningful overall as opposed to truncated utterances that sound like telegrams (telegraphic speech) and carry a great deal of information.

"He is flying a tike" as opposed to "kite fly"
"The boy is (neologism) the co" as opposed to "boy in boat...water"

Both types of verbal output can "sound" dysfluent, but only the second examples are considered "dysfluency" in Aphasia.

Non-fluency often carries a lot of meaning in grammatically incomplete utterances and so is called "telegraphic speech."
Fluency often is "empty speech" in grammatically correct utterances.

ASHA Convention 2007 Highlight

I wanted to draw your attention to Jim Coyle's presentation...-- "Ventilation, Respiration, & Pulmonary Diseases: Dysphagia-Related or Not?". It is session 1225 on Thursday from 8a-9a in room 257AB.

Rancho Los Amigos Scale of Cognitive Functioning in TBI : Revised

Rancho Los Amigos Cognitive Scale Revised

Levels of Cognitive Functioning Level I - No Response: Total Assistance Complete absence of observable change in behavior when presented visual, auditory, tactile, proprioceptive, vestibular or painful stimuli. Level II - Generalized Response: Total Assistance Demonstrates generalized reflex response to painful stimuli. Responds to repeated auditory stimuli with increased or decreased activity. Responds to external stimuli with physiological changes generalized, gross body movement and/or not purposeful vocalization. Responses noted above may be same regardless of type and location of stimulation. Responses may be significantly delayed. Level III - Localized Response: Total Assistance Demonstrates withdrawal or vocalization to painful stimuli. Turns toward or away from auditory stimuli. Blinks when strong light crosses visual field. Follows moving object passed within visual field. Responds to discomfort by pulling tubes or restraints. Responds inconsistently to simple commands. Responses directly related to type of stimulus. May respond to some persons (especially family and friends) but not to others. Level IV - Confused/Agitated: Maximal Assistance Alert and in heightened state of activity. Purposeful attempts to remove restraints or tubes or crawl out of bed. May perform motor activities such as sitting, reaching and walking but without any apparent purpose or upon another's request. Very brief and usually non-purposeful moments of sustained alternatives and divided attention. Absent short-term memory. May cry out or scream out of proportion to stimulus even after its removal. May exhibit aggressive or flight behavior. Mood may swing from euphoric to hostile with no apparent relationship to environmental events. Unable to cooperate with treatment efforts. Verbalizations are frequently incoherent and/or inappropriate to activity or environment. Level V - Confused, Inappropriate Non-Agitated: Maximal Assistance Alert, not agitated but may wander randomly or with a vague intention of going home. May become agitated in response to external stimulation, and/or lack of environmental structure. Not oriented to person, place or time. Frequent brief periods, non-purposeful sustained attention. Severely impaired recent memory, with confusion of past and present in reaction to ongoing activity. Absent goal directed, problem solving, self-monitoring behavior. Often demonstrates inappropriate use of objects without external direction. May be able to perform previously learned tasks when structured and cues provided. Unable to learn new information. Able to respond appropriately to simple commands fairly consistently with external structures and cues. Responses to simple commands without external structure are random and non-purposeful in relation to command. Able to converse on a social, automatic level for brief periods of time when provided external structure and cues. Verbalizations about present events become inappropriate and confabulatory when external structure and cues are not provided. Level VI - Confused, Appropriate: Moderate Assistance Inconsistently oriented to person, time and place. Able to attend to highly familiar tasks in non-distracting environment for 30 minutes with moderate redirection. Remote memory has more depth and detail than recent memory. Vague recognition of some staff. Able to use assistive memory aide with maximum assistance. Emerging awareness of appropriate response to self, family and basic needs. Moderate assist to problem solve barriers to task completion. Supervised for old learning (e.g. self care). Shows carry over for relearned familiar tasks (e.g. self care). Maximum assistance for new learning with little or nor carry over. Unaware of impairments, disabilities and safety risks. Consistently follows simple directions. Verbal expressions are appropriate in highly familiar and structured situations. Level VII - Automatic, Appropriate: Minimal Assistance for Daily Living Skills Consistently oriented to person and place, within highly familiar environments. Moderate assistance for orientation to time. Able to attend to highly familiar tasks in a non-distraction environment for at least 30 minutes with minimal assist to complete tasks. Minimal supervision for new learning. Demonstrates carry over of new learning. Initiates and carries out steps to complete familiar personal and household routine but has shallow recall of what he/she has been doing. Able to monitor accuracy and completeness of each step in routine personal and household ADLs and modify plan with minimal assistance. Superficial awareness of his/her condition but unaware of specific impairments and disabilities and the limits they place on his/her ability to safely, accurately and completely carry out his/her household, community, work and leisure ADLs. Minimal supervision for safety in routine home and community activities. Unrealistic planning for the future. Unable to think about consequences of a decision or action. Overestimates abilities. Unaware of others' needs and feelings. Oppositional/uncooperative. Unable to recognize inappropriate social interaction behavior. Level VIII - Purposeful, Appropriate: Stand-By Assistance Consistently oriented to person, place and time. Independently attends to and completes familiar tasks for 1 hour in distracting environments. Able to recall and integrate past and recent events. Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with stand-by assistance. Initiates and carries out steps to complete familiar personal, household, community, work and leisure routines with stand-by assistance and can modify the plan when needed with minimal assistance. Requires no assistance once new tasks/activities are learned. Aware of and acknowledges impairments and disabilities when they interfere with task completion but requires stand-by assistance to take appropriate corrective action. Thinks about consequences of a decision or action with minimal assistance. Overestimates or underestimates abilities. Acknowledges others' needs and feelings and responds appropriately with minimal assistance. Depressed. Irritable. Low frustration tolerance/easily angered. Argumentative. Self-centered. Uncharacteristically dependent/independent. Able to recognize and acknowledge inappropriate social interaction behavior while it is occurring and takes corrective action with minimal assistance. Level IX - Purposeful, Appropriate: Stand-By Assistance on Request Independently shifts back and forth between tasks and completes them accurately for at least two consecutive hours. Uses assistive memory devices to recall daily schedule, "to do" lists and record critical information for later use with assistance when requested. Initiates and carries out steps to complete familiar personal, household, work and leisure tasks independently and unfamiliar personal, household, work and leisure tasks with assistance when requested. Aware of and acknowledges impairments and disabilities when they interfere with task completion and takes appropriate corrective action but requires stand-by assist to anticipate a problem before it occurs and take action to avoid it. Able to think about consequences of decisions or actions with assistance when requested. Accurately estimates abilities but requires stand-by assistance to adjust to task demands. Acknowledges others' needs and feelings and responds appropriately with stand-by assistance. Depression may continue. May be easily irritable. May have low frustration tolerance. Able to self monitor appropriateness of social interaction with stand-by assistance. Level X - Purposeful, Appropriate: Modified Independent Able to handle multiple tasks simultaneously in all environments but may require periodic breaks. Able to independently procure, create and maintain own assistive memory devices. Independently initiates and carries out steps to complete familiar and unfamiliar personal, household, community, work and leisure tasks but may require more than usual amount of time and/or compensatory strategies to complete them. Anticipates impact of impairments and disabilities on ability to complete daily living tasks and takes action to avoid problems before they occur but may require more than usual amount of time and/or compensatory strategies. Able to independently think about consequences of decisions or actions but may require more than usual amount of time and/or compensatory strategies to select the appropriate decision or action. Accurately estimates abilities and independently adjusts to task demands. Able to recognize the needs and feelings of others and automatically respond in appropriate manner. Periodic periods of depression may occur. Irritability and low frustration tolerance when sick, fatigued and/or under emotional stress. Social interaction behavior is consistently appropriate. Original Rancho Los Amigos Cognitive Scale co-authored by Chris Hagen, Ph.D., Danese Malkmus, M.A., Patricia Durham, M.A., Rancho Los Amigos Hospital, 1972. Revised 11/15/74 by Danese Malkmus, M.A., and Kathryn Stenderup, O.T.R.

Cognitive and Emotional/Behavioral Difficulties After Traumatic Brain Injury

Cognitive Difficulties after TBI

The cognitive difficulties experienced by people after traumatic brain injury (TBI), often have more impact on their recovery and outcome than their physical limitations. Most people with traumatic brain injury, even those that are severe in degree, are ambulating after their trauma. Within a year, 90% of them are getting around independently and able to care for themselves. It is however, the cognitive difficulties and behavioral problems that have the most significant impact in terms of one independence.

TBI has a generalized effect, that is the entire brain is affected to some extent. This is different from what occurs with a stroke, where a specific hemisphere or section of the brain is affected. An individual may have aphasia because they have a left hemisphere stroke or significant neglect because they have a right hemisphere stroke. With head injury there are not, for the most part, patterns of significant deficits in some areas with intact abilities in other areas. Every ability, in a lot of cases, is affected.

It helps to think of cognitive abilities as a hierarchy, beginning with very basic skills and then moving on to more complex ones.

• Arousal or alertness is first in the hierarchy. This is the foundation for everything else. An individual first must be aroused in order to do anything cognitively or behaviorally.
  
• Sensory and motor skills are next. One must be able to sense the world in order to operate in it and manage one's life. Sensing means having the use of one's senses, including vision, hearing, and touch. While few head injuries cause blindness, they can cause double vision or perceptual problems, making it difficult to interpret visual material. With regard to hearing, an individual very rarely becomes deaf as a result of a head injury. However, there may be problems in discerning discreet sounds or in processing auditory material fast enough to be able to keep up. Motor ability involves manipulating one's environment with one's hands, particularly performing basic skills.
  
• Attention and concentration are at the next level. These skills involve selecting what is important in the environment, as well as shifting one's attention to what is important. It may be easy to pick out what is important, but one must also be able to maintain attention and focus. Then as changes occur, one must be able to shift attention. All of these components of attention can be disrupted by a brain injury.
  
• Language skills or the ability to communicate with the world follow in the hierarchy. It's very rare that someone with a TBI loses all language abilities such that they cannot comprehend or express themselves. Language skill problems after TBI are more subtle. An individual may be able to express himself in a basic way, but be unable to explain complex things in a logical fashion. One of the more subtle problems that may exist involves word-finding skills. The individual cannot quickly access words from memory. When talking, they tend to talk around the topic. It is difficult for them to "hit the nail on the head". It can be very frustrating finding that correct word.
  
• Spatial and constructional abilities are at the next level and involve spatial activities, such as drawing or building things and judging distances. This requires visual perception as well as being able to take a mental image and apply it in the environment through motor output. A complex series of events has to take place for this to occur.
  
• Memory abilities come next. Individuals with traumatic brain injury, even severe injury, often have relatively good recall of events that occurred prior to their trauma. There may be gaps for a week or a month before the injury, but this usually fills in over time. All of that information is already in the memory banks. The head injury does not take that away. It may interfere somewhat with the ability to retrieve some information but it does not erase the existing memory.

The problem faced by people with TBI is with encoding and retrieving new information. Memory for new information is usually the most severe deficit experienced by people with traumatic brain injury. There are several reasons why memory for new information is difficult for people with TBI.

A major factor is the neurochemical cascade that takes place as a result of the TBI that effects the hippocampal areas of the brain, which are essential to memory encoding. In addition, disrupted executive skills may have a significant impact on memory functioning. As a result the individual may not be able to attend to information, organize information for encoding, or appropriately scan memory to retrieve information.

Think of the brain as a very organized filing cabinet. Each drawer is labeled and all the files are arranged and labeled. To locate information you open the correct drawer and locate the right file. With a head injury, it is like the filing cabinet has been turned upside down and all of the files are in the wrong place and so it is hard to organize things again.

• Reasoning skills or the ability to solve problems are at the next level in the hierarchy. First one has to know that there is a problem. Individuals with head injury often do not recognize the need for a solution or they tend to be inflexible. They may come up with one strategy but if that does not work, they cannot think of an alternative. They will stick with that same strategy even though it's not working. The basic "if - then" reasoning that most people use, does not occur for these individuals.
  
  
• Intellectual abilities follow. Here we see a combination of many different skills that combine reasoning, memory, spatial skills, etc.
  
  
• Academic abilities are at the final level, combining many different skills. For someone who has been through a reasonable educational program, it's rare to lose academic abilities following a TBI. Injured people can usually still read, write, and do math because those are ingrained skills; they're already in the memory banks to the point that the skills are almost automatic. The problem academically is that the individual is not able to add to these skills after the injury because of the memory and reasoning difficulties.

Behavioral/Emotional Difficulties

Behavioral and emotional difficulties cannot be separated from the cognitive difficulties that accompany TBI. Ninety-nine times out of 100 when there is a behavioral problem it is tied to a cognitive problem.

• Restlessness and agitation are common problems, particularly early in recovery. At that point of recovery, people with TBI have significant problems with attention. Restlessness is a normal reaction for a person who cannot pay attention or is easily distracted. The same thing applies with reasoning. When an individual cannot reason effectively enough to accomplish a goal, they tend to be restless and thus more agitated.
  
• Emotional lability and irritability exhibited by the individual with the head injury are frequently described by family. To understand what is happening, think about it in terms of executive (reasoning) skills as a gating mechanism. These gates keep behavior in control. A lot of what the frontal lobes of the brain do is inhibit actions that are not consistent with our goals. They keep you from doing things that you should not do. For example 3 year old children, whose frontal lobes are not fully activated, do whatever comes to mind, sometimes to their detriment.
  

  When you have a significant brain injury that involves the frontal areas, the gating mechanism can be knocked askew such that the person cannot inhibit behavior as well as prior to the injury. The individual is not reasoning effectively and cannot figure out what to do in a situation to solve a problem. To get the attention needed or to generate a response they may get angry or exhibit other inappropriate behavior. The gates that kept behavior in control are knocked askew and things come out that used to be kept in.

• Confabulation is another behavior problem. A patient may tell staff they were at the Talladega races last weekend when actually they have been in the hospital for the past 2 months. The person is not lying; instead their memory is playing tricks on them. They are not able to organize their memory and therefore cannot retrieve information accurately. This person may have been to Talladega, but in the distant past. Their organizational process, called "time-tagging", of their memories is often disrupted and hence their inaccurate recall.
  
• Diminished insight on the part of people with TBI is a frequent complaint among caregivers. Self-awareness is a very unique skill of adults. As adults we are able to step outside of ourselves and look at our performance and abilities. This involves being able to process information at a very high level, requiring attention, memory and reasoning abilities. Often a person with severe head injury does not have a very good understanding of their deficits or the impact of those deficits on daily life. They will deny cognitive difficulties that are obvious to others or feel they can engage in activities, such as driving, even while acknowledging significant problems.
  
• Impulsivity/socially inappropriate behavior results from both diminished reasoning and lack of inhibition. Both have a lot to do with frontal area functioning and the gating mechanism that has already been described. Many families describe the person with the head injury as saying hurtful things and that they are insensitive and blunt. They say things that come into mind without due consideration of the situation. It can be a subtle problem or it can sometimes be severe. The injured person is not able to reason that "If I say this, then something undesirable is going to happen." The appropriate inhibition is not there.
  
• Poor initiative can be confused with depression. Frontal area injury can affect the ability to plan and to organize. This results in a person not initiating activity. They will sit quietly and contentedly. If directed to do something, they will do it. But they will not go any further than that. The if/then reasoning skills are not present. In addition, attention problems may prevent the individual with TBI from focusing on something long enough to be able to carry through with a plan.
  
• Lack of emotional response is demonstrated by a lack of initiative and a flattened affect. The individual does not smile or show any emotional response to things going on in the environment. An example is an adult with TBI who was told by his mother that he cannot drive anymore. His reaction was to put his keys on the dresser and walk out without exhibiting any reaction or emotional response. Most adults would react differently. The emotional response is just not there.
  
• Paranoia or blaming of others for negative events is a natural tendency when individuals do not reason effectively. This can be compounded for individuals having traumatic brain injury because they are not reasoning well enough to know the logical explanation for what is happening. They automatically assume that someone else is doing something to them and project blame automatically. If you are not able to reason through things, you assume that somebody is doing something to you. When the person is not able to remember something that they did, they blame someone else.
  
• Depression is a common problem for individuals after head injury. The issue is how much of it is organic, related to the brain injury itself, versus reactive to the situation. Fortunately, in either case, the condition is usually responsive to medication and counseling. The danger is that depression can compound the problems that already exist by decreasing activity levels and undermining the expression of skills possessed by the injured person.
  
• Anxiety occurs, in part, because of reasoning difficulties. The inability to comprehend a situation or anticipate what is going to happen leads to anxiety. Three situations in particular seem to generate anxiety among people with TBI: 1- Riding in a vehicle in heavy traffic, 2- Being in crowds and 3- Being around small children.

Source: Center for Neuro Skills

Early Cortical Atrophy in Persons Developing Alzheimers Disease: Will Boggs MD.

Cortical Mapping Shows Early Changes Associated With Alzheimer Disease
By Will Boggs, MD

NEW YORK (Reuters Health) Oct 24 - Advanced 3-dimensional cortical mapping can distinguish between mild cognitive impairment (MCI) and mild Alzheimer disease (AD), according to a report in the October issue of the Archives of Neurology.

"AD pathology marches through the brain many years before we can diagnose it - which is unsettling," Dr. Liana G. Apostolova told Reuters Health. "These avant-garde neuroimaging advances deliver a promise that pre-clinical diagnosis of AD will soon be feasible."

Dr. Apostolova from the David Geffen School of Medicine, University of California at Los Angeles, and associates used 3-D cortical mapping to analyze structural MRI data for 24 patients with amnestic MCI and 25 patients with mild AD.

Patients with mild AD showed 10% to 15% greater gray matter atrophy in most of the cortex than did patients with amnestic MCI, the authors report.

Atrophy was more than 15% greater in the bilateral entorhinal, right more than left lateral temporal, right parietal cortex, and bilateral precuneus areas.

In both groups of patients, the researchers note, there was less cortical gray matter in the right hemisphere than in the left hemisphere.

"With several promising disease-modifying candidate compounds under development, being able to discern subtle structural cortical changes between mild AD and the immediately preceding cognitive state of amnestic MCI with anatomical precision raises hopes for our ability to show structural disease-modifying effects," the investigators say.

"At this point these analysis methods are largely a research tool, but we are hopeful in the near future to develop software techniques that could be useful in the clinic," Dr. Apostolova said. "Our new maps reveal the systems that change with the gradual descent to AD, and we hope to compare individual imaging findings to these maps to help understand future prognosis."

Arch Neurol 2007;64:1489-1495.

More on Polymyositis

Polymyositis

Polymyositis (PM) is found mostly in people over the age of 20 and affects more women than men. Muscle weakness usually happens over days, weeks or months. The weakness begins with muscles closest to and within the trunk of the body. Neck, hip, back and shoulder muscles are examples. Some patients also have weakness in muscles farther from the trunk, like hands and fingers. Some PM patients experience muscle pain, breathing problems, and trouble swallowing.

Researchers are finding that each case of PM is quite different from others. Sometimes, cases originally diagnosed as PM and not responding to treatment are later found to be inclusion-body myositis (IBM). Patients with certain types of PM may have one or more other autoimmune diseases.

Signs and symptoms

Signs

* Sudden or gradual weakness in the muscles
* Difficulty swallowing (dysphagia)
* Falling and difficulty getting up from a fall
* General feelings of tiredness


Symptoms

* Marked weakness in the muscles closest to the center of the body, like the forearms, thighs, hips, shoulders, neck and back
* Sometimes, weakness in the fingers and toes
* Thickening of the skin on the hands (mechanic’s hands)

Polymyositis: What Is It and How is it Related to Swallowing?

Look it up...

James L. Coyle on Kagel

Marion Kagel, in the late 80’s and 90’s, described a tactic in which thermal (cold) gustatory (taste) stimulation was used to treat dysphagia. I believe they presented some of this data at the first of second DRS meeting in Milwaukee. It spawned the use of Italian lemon ice in the management of dysphagia. I still see the stuff in the freezers of the nursing units of some of the sites in which I see patients. I don’t know if they published their results.

Logemann et al. (1995) looked at the sour bolus effects on swallowing and others have investigated the combined effects of thermal, gustatory, and tactile/mechanical stimulation on swallowing (Sciortino, Liss, Case, Gerritsen, & Katz, 2003) using different methods and reporting varying degrees of effects on different outcomes. I’m almost certain others have looked at these things too. Logemann’s group flavored barium with a sour taste (lemon juice I think) for MBS swallows with and without the sour bolus, in dysphagic patients, and analyzed the traditionally measured biomechanical swallow variables. Sciortino’s group injected water into the mouths of normals after stimulating the faucial pillars (anterior) with the various combinations of thermal, tactile/mechanical, and taste stimuli.

James L. Coyle

University of Pittsburgh

Reference List

Logemann, J. A., Pauloski, B. R., Colangelo, L., Lazarus, C., Fujiu, M., & Kahrilas, P. J. (1995). Effect of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. Journal of Speech and Hearing Research, 38, 556-563.

Sciortino, K., Liss, J. M., Case, J. L., Gerritsen, K. G., & Katz, R. C. (2003). Effects of mechanical, cold, gustatory, and combined stimulation to the human anterior faucial pillars. Dysphagia, 18, 16-26.

Bedside Swallowing Evaluation Components

Lip closure : oral receipt and containment; ability to suck (intraoral pressure)
Tongue movement: receipt of bolus, preparation of bolus, control and transport of bolus, clearance
Pharyngeal swallow response: Occurs? Appears timely, delayed
Laryngeal rise: Occurs? Appears brisk or sluggish?
Number of swallows per bolus: One or several? May indicate pharyngeal clearance
Voice quality: immediately prior to bolus presentation and after swallow; also monitor for later changes
Cough/throat clear: present or absent

Length of meal: Timely or prolonged?
Patient complaints: What? When?

The Human Brain

Estimating Risk of Pneumonia

James L. Coyle of the University of Pittsburgh wrote on the Dysphagia List-Serve:

"Eisenhuber et al (2002) developed a three point scale, using the height of retention in the vallecular and pyriform sinuses, as scale values.

A score of 1 corresponded to “less than 25% of the height” of the cavity described, 2 to “25-50% height”, and 3 to “>50% height”. They adapted a rating system published earlier by Perlman et al. (1994) by taking the published height values and attributing the values in the 3 point scale to the three measures created by Perlman.

They then used videofluoroscopy to determine whether pharyngeal retention seen on fluoroscopic images was predictive of laryngeal penetration or aspiration. They did not differentiate between the two (penetration, aspiration), instead lumping them together. This makes it difficult for the reader to know with certainty which outcome (penetration, aspiration) should be expected. They also lumped vallecular and pyriform sinus retention together in the attribution of aspiration/penetration risk however 83% of their patients had retention in both.

At any rate, The score “3” for pharyngeal retention was significantly more likely (about 4 to 1 odds of higher likelihood) to be followed by laryngeal penetration or aspiration than scores of 1 or 2. One finding that is a bit easier to swallow (ha ha) was that 93% of patients with pharyngeal retention (valleculae or pyriform sinuses or both) exhibited laryngeal penetration or aspiration whereas only 33% of patients without retention exhibited penetration or aspiration.

Robbins et al. (1999) used the penetration aspiration scale to differentiate between normals, and two groups of disordered swallowers (stroke, head and neck cancer). They found that 21% of normals exhibited high laryngeal penetration (no deeper than the vestibule-PAS scores of 2 or 3). Therefore deep penetration (to vocal folds) is not normal (nor is aspiration).

Combining the two measures, one can attribute risk of laryngeal penetration or aspiration to the height of pharyngeal retention, and the risk of inhalation of swallowed material to the severity of laryngeal penetration and aspiration. Added to the other host risk factors predisposing a patient to pneumonia, the clinician can generate a reasonable likelihood of pneumonia.

We use the two scales together to attribute risk associated with the dysphagia and discuss the additional risk factors to estimate pneumonia risk."

James L. Coyle

University of Pittsburgh

Reference List

Eisenhuber, E., Schima, W., Schober, E., Pokieser, P., Stadler, A., Scharitzer, M. et al. (2002). Videofluoroscopic assessment of patients with dysphagia: pharyngeal retention is a predictive factor for aspiration. American Journal of Roentgenology, 178, 393-398.

Perlman, A. L., Booth, B. M., & Grayhack, J. P. (1994). Videofluoroscopic predictors of aspiration in patients with oropharyngeal dysphagia. Dysphagia, 9, 90-95.

Robbins, J. A., Coyle, J. L., Rosenbek, J. C., Roecker, E. B., & Wood, J. L. (1999). Differentiation of normal and abnormal airway protection during swallowing using the penetration-aspiration scale. Dysphagia, 14, 228-232.

Written Word Finding

Sometimes a person who is unable to look at an object and subsequently name it can look at the written word associated with that object, read it aloud correctly, and then verbally answer the question, "What is this?" with the name of the object.

So, you show a photograph of a cup. The person says, "glass." You show a list of written words, one of which is "c-u-p." The person is able to locate the correct word, and read it aloud. Then you show the photograph again, and ask, "What is this?" and the person correctly verbalizes "cup."

Remember T.E.E.?

If you recall trans-esophageal echocardiogram posts, then also recall that the AOS vs. phonemic paraphasia patient was undergoing that procedure the day we were working with him...

Do you think this patient might have come out of that procedure with a new swallowing problem?

Dysarthria Treatment

In order to increase the length of a response, ask: "Tell me what you like about __________(cookies, for example)" rather than "What kind of cookies do you like?"

During establishment of a new habit such as pacing, do not tell the patient "You don't need to use your board for this." Rather, give this sort of feedback: "When you use your pacing board, you slow down and you are so much easier to understand."

Use "Think slow" to assist in internalization of a slow speech rate as opposed to "slow down" which is an external cue.

Expect to need to use "lip reading" with most if not all patients with dysarthria.

AOS or Phonemic Paraphasias; Anterior vs. Posterior Lesions?

To ponder:

Errors: v/b as in tavle for table
sh/ch as in share for chair or wash for watch
d/t as in dime for time
s/sh as in sip for ship
sh/j as in Shawn for John

vowels tending toward schwa

superior awareness of errors with multiple and sometimes successful attempts
to correct

errors consistent across tasks and within same task

Is this more consistent with apraxia of speech or phonemic paraphasia?

SHAKER Exercise References

Several references for Shaker Exercise:

Easterling C, Grande B, Kern M, Sears K, Shaker R: Attaining and maintaining isometric and isokinetic goals of the "Shaker" Exercise. Dysphagia 20: 133-138, 2005

Easterling C, Kern M, Nitzsche T, Grande B, Kazandjian M, Dikeman K, Massey BT, Shaker R: Restoration of oral feeding in 27 tube fed patients by the Shaker Exercise. Dysphagia 10:66-74, 1999.


Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S, Grande B, Kazandjian M, Dikeman K: Rehabilitation of swallowing by exercise in tube fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 122:1314-1321, 2002.

Tracking Data

Suggestion: As we discussed day before yesterday, you may find it helpful to chart a patient's progress via a plot graph or chart.

Another use of this sort of graph is feedback for the patient, assuming that progress is being made.

I used to track my Goodwill Industry clients' productivity on individualized charts set at each person's work station. Made a huge difference in motivation, believe it or not.

"Normal" Laryngeal Penetration

James L. Coyle (University of Pittsburgh) wrote on the Dysphagia List-Serve:

"Robbins et al. (1999) used the PA {Penetration/Aspiration} Scale to differentiate normal from abnormal airway protection, and was written by the same group of authors of the original Penetration Aspiration Scale paper (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996).

They found that all laryngeal penetration events in this group of 95 healthy subjects, showed penetration no more deeply than the laryngeal vestibule. All of these "penetration" events (55 events out of 284 swallows) were scored {as a} 2 (material enters the airway, remains above vocal folds, no contrast is visible in larynx after the swallow) or 3 (same anatomic "level" as 2, but with visible postprandial laryngeal residue). There were no 4 or 5 scores (material contacts the vocal folds without (4) or with(5) visible laryngeal postprandial residue). A single aspiration event was observed in the old group only (PAS score = 7, aspiration with responsive cough that did not clear tracheal residue).

Events...described as transient would probably be scored 2 and 4 on the PA scale because no residue is left behind in the larynx, whereas 3 and 5 (4 and 5-material contacts the vocal folds) indicate visible laryngeal postprandial residue. The scale was published in an effort to standardize these descriptions of swallowing airway compromise viewed with videofluoroscopic instrumentation.

Reference List

Rosenbek, J. C., Robbins, J. A., Roecker, E. B., Coyle, J. L., & Wood, J. L. (1996). A penetration-aspiration scale. Dysphagia, 11, 93-98."

My comments: Post-prandial usually refers to "after the meal," but I think J.L. Coyle is referring to post-swallow residue remaining in the laryngeal vestibule here.

Oral Stimulation

With some patients, even though they are awake and even alert, they are not responding to oral instructions such as "open your mouth," etc.

You can use a dry or moistened toothette to stimulate oral opening by stroking the lower and/or upper lips. You may be able to gently enter the mouth with the toothette along the inner cheek or along the gumlines. It may even be possible to stroke the tongue blade. As you perform these actions, watch your patient to determine tolerance, sensation, and any responses.

To further provide oral stimulation, you may also use the spoon to stroke the lips or the area of the cheek or chin around the lips. Before placing a food item in the mouth, you may want to put a little on the lower lip to see if the patient will lick it off indicating sensation is relatively intact. You have also determined that the tongue will protrude at least a little.

If the patient does not close around the spoon with presentation of liquids, pouring the liquid (very small amount) onto the tongue tip may then elicit lip closure. Be prepared to suction this liquid from the mouth if the patient does not handle well.

Applying pressure with the bowl of the spoon to the tongue blade may also assist in the cupping of the tongue for oral preparation. Letting go of the spoon also may assist the patient to close his or her mouth around the spoon -- appears to be a typical response to this technique.

Just some thoughts...

Medical Terms

What do the following terms mean?

Cephalopathy
Ascites

Adult Clinical Rotations: Student Presentation Guidelines

Adult Clinical Rotations

Student Presentation Guidelines

Description: Students will be required to present a clinical topic to the adult speech pathologists. Oral and written components are required.

Topics: Teach us something new! Maybe a disorder you had an experience with during your rotation (something we could learn more about); patient and/or family information packets; or a treatment strategy. If you decide to present a treatment strategy, please include the following information: treatment efficacy, cost efficiency, availability, reliability, etc. If you have difficulty choosing a topic, ask your supervisor for suggestions.

Written requirement: Please prepare a summarized handout for clinicians (1-2 pages) or a packet for patients/families. Include references. Do not print something directly from a website. You should organize this information on your own. If creating a Pt/family packet, provide helpful web sites, phone numbers, support groups, etc.

Oral requirement: You will be given approximately 5-7 minutes including a question-answer period. This is not a great deal of time, so plan accordingly.

Date: Presentations will be Tuesday, November 6th from 12:00-12:45pm.

Location: 11^th floor of Rutledge Towers (ENT conference room). Please bring your lunch.

Hierarchy of Cues and Verbal Feedback

In general, during a confrontational naming task, cues are as follows:

1. Extra time (about 15 seconds)
   
2. Function, location, property cues (i.e. semantic feature analysis)
   
3. Cloze condition cueing such as "You sleep in a _________."
4. Initial letter cue or
   
5. Phonemic cue

Verbal feedback should consist of:

"That's right." or "That's correct."
"That's wrong." or "That's not correct."

Additionally, verbal feedback can provide the person with information about what he or she is doing correctly, such as: "That's right. You allowed yourself extra time to think before you answered."

Or, conversely, what he or she is doing incorrectly, as in: "That's not correct. Try to wait before you answer. Give yourself extra time to find the word."

Coma Arousal

If you are inclined, consider bringing in items to use in coma arousal/stimulation. Please don't purchase anything. Just look around, see what you already have that might be appropriate...

Patient Care Team Conference

During team conference, think in terms of "bullets" of information.
Keep your statements short, precise.
Avoid emotionalism, if possible.
Stay objective.

Advice for all of us!

Monday September 24th

Update: Practicum canceled for today.

Trach Inservice Postponed

Trach inservice has been postponed...

Page me in the morning, and I will let you know what is happening...

Thank you.

Coma Stimulation Part II

Coma arousal therapy should begin as soon as possible or when the patient is medically stable. The brain must receive frequent and intense repetitions of the stimulus items to be stimulated. Administration can vary from 1-8 hours/day, depending upon each individual. Listed below are the sensory modalities to treat and suggestions for different stimulus items.

AREAS TO TREAT
Sensory Modalities	Stimulus Items
Auditory	banging items together ring bells music loud whistle familiar voices of family/friends telephone ringing knock on door call person's name general conversation with patient television/radio
Tactile	temperatures (warm/cool) touch (different fabrics such as fur, silk, feathers, corduroy) pressure (deep pressure massage) vibrator
Visual	pictures of favorite people, pets, or items bright colors moving objects, flashcards (different shapes/colors)
Olfactory	familiar fragrance citrus coffee flowers peppermint spices eucalyptus oils garlic
Taste	swabs (peppermint, lemon) squeeze lemon juice on tongue mustard salt soy sauce sugar sucker
Proprioception	range of motion exercises (roll side to side) alternating movements (arms/legs raised)

Patient Interview Comment

Coma Stimulation

What do you know about coma stimulation?

What kind of stimulation?
Is it effective?
Who does it?
What is the rationale?
For how long?

What is a persistent vegetative state?

Cues and Timing

Timing of cues is important. Of value is allowing time for the person to process the task; however, too much latency between the stimulus presentation and the person's first response can lead to even greater failure.

So, do allow approximately 15 seconds for a response. If 15 seconds goes by and you have not elicited any kind of verbal or gestural response, then give a cue or prompt.

Allow approximately 10 to 15 seconds to check effectiveness of the cue, then give the next type of cue.

If this final cue does not work, then model the target response.

Give verbal feedback for each response you elicit.

Swallowing Dysfunction and TEE

Authors Full NameKohr, Lisa M. Dargan, Margaret. Hague, Amy. Nelson, Suzanne P. Duffy, Elise. Backer, Carl L. Mavroudis, Constantine.
InstitutionDivision of Cardiovascular-Thoracic Surgery, Department of Speech and Language Pathology, Children's Memoiral Hospital,
TitleThe incidence of dysphagia in pediatric patients after open heart procedures with transesophageal echocardiography.
SourceAnnals of Thoracic Surgery. 76(5):1450-6, 2003 Nov.

AbstractBACKGROUND: Pediatric patients who undergo open heart operations may be at risk for the development of dysphagia because of interventions such as intubation and transesophageal echocardiography. Although the occurrence of dysphagia after cardiac surgical procedures in adults is reported to be 3% to 4%, the incidence in children and adolescents has not been documented. This study was undertaken to determine the incidence of and risk factors contributing to dysphagia in pediatric patients after open heart procedures. METHODS: Fifty patients were evaluated after open heart operations with transesophageal echocardiography between March 1, 1999, and September 30, 1999. The diagnosis of dysphagia was made by a speech pathologist using a clinical swallowing evaluation. Potential predictors examined included demographic variables, anatomical diagnosis, surgical procedure, size of the transesophageal echocardiographic probe in relation to body size, length of probe insertion time, preoperative patient acuity status, duration of intubation, and time until discharge. RESULTS: Dysphagia was found in 9 (18%) of the 50 patients. Risk factors identified were age of less than 3 years (odds ratio, 20.4; 95% confidence interval, 2.7 to 157; p = 0.002), intubation prior to operation (odds ratio, 17.7; 95% confidence interval, 9.4 to 210; p = 0.004), intubation for more than 7 days (odds ratio, 74.7; 95% confidence interval, 13.8 to 405; p = 0.001), and operation for left-sided obstructive lesions (odds ratio, 1.9; 95% confidence interval, 2.2 to 8.3; p = 0.038). The size of the transesophageal echocardiographic probe in relation to the weight of the patient was found to be predictive (p = 0.0001) of dysphagia. Vocal cord paralysis was noted in 4 (8%) of the 50 patients postoperatively. Adverse events related to aspiration occurred in 2 patients (4%). At discharge, nasogastric tube feedings were required in 6 patients (12%), and thickened feedings were recommended for 3 (6%) of the 50 patients. Resolution of dysphagia ranged from 13 to 150 days. CONCLUSIONS: Eighteen percent of patients had dysphagia after an open heart operation with transesophageal echocardiography. Age of less than 3 years, preoperative patient acuity status, longer intubation times, and operation for left-sided obstructions are risk factors for dysphagia in this cohort of pediatric patients. The size of the transesophageal echocardiography probe in relation to the patient's weight was predictive of dysphagia. Physicians should consider using the new mini-multiplane transesophageal echocardiographic probes in patients weighing less than 5.5 kg. Vigilance in monitoring for the signs of preoperative and postoperative dysphagia with prompt referral to a speech therapist can substantially reduce patient morbidity, length of hospital stay, and requirement of prolonged nasogastric tube use.

AuthorsRousou JA. Tighe DA. Garb JL. Krasner H. Engelman RM. Flack JE 3rd. Deaton DW.
Authors Full NameRousou, J A. Tighe, D A. Garb, J L. Krasner, H. Engelman, R M. Flack, J E 3rd. Deaton, D W.
InstitutionDepartment of Anesthesiology, Baystate Medical Center, Springfield, Massachusetts 01107, USA.
TitleRisk of dysphagia after transesophageal echocardiography during cardiac operations.
SourceAnnals of Thoracic Surgery. 69(2):486-9; discussion 489-90, 2000 Feb.
Local MessagesMUSC Library has journal title; click Library Holdings link for issues.
AbstractBACKGROUND: Dysphagia can be a significant complication following cardiac operations. This study evaluates its incidence and relationship to intraoperative transesophageal echocardiography (TEE) for specific indications versus known factors such as stroke or prolonged intubation. METHODS: Records of 838 consecutive cardiac surgical patients were reviewed, and categorized into those who received TEE for specific indications versus those who did not (nonTEE). Dysphagia was recorded when symptoms were confirmed by barium cineradiography. Multiple logistic regression identified significant factors causing dysphagia. RESULTS: TEE was significantly related to the development of postoperative dysphagia by multiple logistic regression (p <> CONCLUSIONS: TEE may be an independent risk factor for dysphagia following cardiac operations.

AuthorsHogue CW Jr. Lappas GD. Creswell LL. Ferguson TB Jr. Sample M. Pugh D. Balfe D. Cox JL. Lappas DG.
Authors Full NameHogue, C W Jr. Lappas, G D. Creswell, L L. Ferguson, T B Jr. Sample, M. Pugh, D. Balfe, D. Cox, J L. Lappas, D G.
InstitutionDepartment of Radiology, Washington University School of Medicine, St. Louis, Mo., USA.
TitleSwallowing dysfunction after cardiac operations. Associated adverse outcomes and risk factors including intraoperative transesophageal echocardiography.
SourceJournal of Thoracic & Cardiovascular Surgery. 110(2):517-22, 1995 Aug.
Local MessagesMUSC Library has journal title; click Library Holdings link for issues.
AbstractThe frequency, importance to patient outcomes, and independent predictors of postoperative swallowing dysfunction documented by barium cineradiography were examined in 869 patients undergoing cardiac operations over a 12-month period. Swallowing dysfunction was diagnosed in 34 patients (4% incidence) and was associated with documented pulmonary aspiration in 90% of these patients, increased frequency of pneumonia (p < p =" 0.0002)," p =" 0.0001)," p =" 0.0001)." p =" 0.001)," class="bibrecord-highlight">transesophageal echocardiography (p = 0.003). Dysfunctional swallowing after cardiac operations, a serious complication significantly related to postoperative respiratory morbidity and extended length of hospitalization, is more common in older patients. An association between intraoperative use of transesophageal echocardiography and swallowing dysfunction was also observed in our patients.