Oral Hygiene Information

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http://www.perio.org/consumer/request.htm

Masako and Effortful Swallow Maneuvers

Catriona M. Steele writes:

The Masako maneuver is described as a technique to enhance closure of the pharyngeal lumen at the level of the tongue base, however it works by eliciting greater movement of the posterior pharyngeal wall. To my knowledge, no one has yet shown that the tongue base moves more with the maneuver, and, indeed, the intention of the maneuver is to anchor the tongue further forward in the mouth to mimic a tongue base resection (the original maneuver was something observed as a spontaneous
compensation in patients with oral cancer). Additionally, as described
in the original articles by Masako Fujiu and Dr. Logemann, the Masako maneuver is recommended only as an exercise (with saliva swallows) and not advised with a bolus (because the tongue is anchored, the maneuver was reported to increase vallecular residue with a bolus). Fujiu M & Logemann JA. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5(1):23-30, 1996.

...you might find some articles on the effortful swallow quite interesting with respect to addressing tongue base issues and vallecular residue. There are series of articles coming out of Dr. Maggie-Lee Huckabee's lab that suggest that the effortful swallow can address weakness in the region of the tongue base, and that by instructing the patient to emphasize a tongue-palate "press" at the beginning of an effortful swallow you get a greater increase in the resulting pharyngeal pressures.

- Huckabee ML, Hiss SG, Barclay M, Jit S: The relationship between submental semg measurement and pharyngeal pressures during normal and effortful swallowing. Arch Phys Med Rehabil 86(11):2144-2149, 2005
- Hiss SG, Huckabee ML: Timing of pharyngeal and upper esophageal sphincter pressures as a function of normal and effortful swallowing in young healthy adults. Dysphagia 20:149-156, 2005
- Huckabee, M.L. & Steele, C.M. (2006). An Analysis of Lingual Contribution to Submental sEMG Measures and Pharyngeal Biomechanics during Effortful Swallow. Archives of Physical Medicine and Rehabilitation, 87, 1067-1072.
- Steele, C.M. & Huckabee, M.L. (2007). The influence of oro-lingual pressure on the timing of pharyngeal pressure events. Dysphagia, 22(1), 30-36.

...it is really important to remember that excessively increased pharyngeal pressures may not be something you want to contribute to in a patient with a Zenker's. I don't have my fingers on specific references in this regard, but I would recommend an article by Jane Garcia and colleagues, that shows how effortful swallow can sometimes have an undesirable outcome:

Garcia, J. M., Hakel, M., & Lazarus, C. (2004). Unexpected consequence of effortful swallowing: Case study report. Journal of Medical Speech-Language Pathology, 12(2), 59-66.

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, Special Interest Division 13 (Swallowing and Swallowing Disorders), American Speech-Language Hearing Association

E-Stimulation for Swallow Function: Reference List

E-Stimulation for Swallow Function: Reference List

Burnett, T. A., Mann, E. A., Cornell, S. A., & Ludlow, C. L. (2003). Laryngeal elevation achieved by neuromuscular stimulation at rest. Journal of Applied Physiology., 94, 128-134.

Burnett, T. A., Mann, E. A., Stoklosa, J. B., & Ludlow, C. L. (2005). Self-triggered functional electrical stimulation during swallowing. Journal of Neurophysiology, 94, 4011-4018.

Carnaby-Mann, G. D. & Crary, M. A. (2007). Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Archives of Otolaryngology Head & Neck Surgery, 133, 564-571.

Coyle, J. L. (2002). Critical appraisal of a treatment publication: electrical stimulation for the treatment of dysphagia. Perspectives on Swallowing and Swallowing Disorders, 11, 12-15.

Crary, M. A., Carnaby-Mann, G. D., & Faunce, A. (2007). Electrical stimulation therapy for dysphagia: descriptive results of two surveys. Dysphagia.22(3):165-73.

Freed, M. L., Freed, L., Chatburn, R. L., & Christian, M. (2001). Electrical stimulation for swallowing disorders caused by stroke. Respiratory Care, 46, 466-474.

Grill, W. M., Craggs, M. D., Foreman, R. D., Ludlow, C. L., & Buller, J. L. (2001). Emerging clinical applications of electrical stimulation: opportunities for restoration of function. Journal of Rehabilitation Research & Development., 38, 641-653.

Humbert, I. A., Poletto, C. J., Saxon, K. G., Kearney, P. R., Crujido, L., Wright-Harp, W. et al. (2006). The effect of surface electrical stimulation on hyolaryngeal movement in normal individuals at rest and during swallowing. Journal of Applied Physiology, 101, 1657-1663.

Leelamanit, V., Limsakul, C., & Geater, A. (2002). Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope., 112, 2204-2210.

Ludlow, C. L., Hang, C., Bielamowicz, S., Choyke, P., Hampshire, V., & Selbie, W. S. (1999). Three-dimensional changes in the upper airway during neuromuscular stimulation of laryngeal muscles. Artificial Organs., 23, 463-465.

Ludlow, C. L., Humbert, I., Saxon, K., Poletto, C. J., Sonies, B., & Crujido, L. (2007). Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal dysphagia. Dysphagia, 22, 1-10.

Power, M., Fraser, C., Hobson, A., Singh, S., Tyrrell, P., Nicholson, D. et al. (2006). Evaluating oral stimulation as a treatment for dysphagia after stroke. Dysphagia, 21, 49-55.

Suiter, D., Leder, S., & Ruark, J. (2006). Effects of Neuromuscular Electrical Stimulation on Submental Muscle Activity. Dysphagia, 20, 1-5.

Not Necessarily Turning A Dead Horse Into A Rug: More On Vital Stim

With all due respect, and at the risk of turning the dead horse into a rug, the meta-analysis published by Carnaby-Mann and Crary, used excessively lax inclusion criteria, rendering the results very difficult if not impossible to generalize to the clinical setting. Here is one set of examples to support this comment, and there are several others that the discussion group certainly does not want to hear.

A meta-analysis is only as good as the criteria for allowing studies to be included. They need to be rigorous.

The use of the Physiotherapy Evidence Database scale (PEDro) scale for judging evidence quality, at a cutoff score of 4 on the scale, allowed studies such as Freed, et al. (2001) (we all know which study that was and all of its problems-it is only one example from this meta-analysis’s included studies), to be included in the meta-analysis. Freed et al. (2001), as we all are aware, a) violated intention to treat with 10% of their patients disappearing from the data analysis for unexplained reasons or because they could not pay for the treatment after insurance terminated coverage(PEDro item 9), used judges that were not masked to patient assignment (PEDro item 6 and 7), selectively assigned patients to electrical stimulation “because they were referred for the study” (PEDro items 3 and 5), compared dissimilar groups of heterogeneous patients and excluded patients for unexplained reasons (PEDro item 4), and did not randomly assign patients to groups (PEDro item 2). In addition the study was conducted by the owner of the patent for the technology investigated, a serious conflict of interest not even acknowledged as an important criterion for evidence quality assessment by the PEDro. These serious flaws notwithstanding Carnaby-Mann and Crary included this, and several other studies of poor evidence quality, in their meta-analysis. The results must be considered weak and ungeneralizable to the clinical setting, at best, given the inclusion of poor quality studies.

Meta-analysis is an effort to use the best literature available to answer important questions about cause and effect. This study did not accomplish that goal. The lack of good quality studies does not justify the use of poor quality studies to make important decisions about treatment effectiveness or efficacy. It is always possible for a faction to cherry pick results from various studies to support their point of view. That is not what meta-analysis is about. This is why Vioxx was such a colossal failure.

James L. Coyle

University of Pittsburgh

Vital Stim Research: Questions and Answers

There were several interesting findings from Dr. Ludlow's study looking at the effect of applying NMES to the anterior portion of the neck, including the improvement in swallowing from sensory stim alone that Dr. Day mentioned. Another outcome that is often not mentioned is the unexpected finding that the patients who had greatest hyoid depression had the greatest improvement in swallowing. I would be interested to see future research looking into the cause behind this counter-intuitive finding. While these findings could possibly suggest a positive effect from using NMES during tx, as the authors point out, this is not a treatment study but an effect study. Therefore, conclusions should not be made, either positive or negative, about the impact these findings may have on treatment.

Instead, we should make conclusions about treatment based on treatment studies. One study worth noting is Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg. June 2007; 133 (6): 564-571.

With regards to the question "where is research on chronic dysphagia (1 year post)?"asked in an earlier posting , look for Dr. Carnaby-Mann and Dr. Crary's study "Adjunctive neuromuscular electrical stimulation for treatment refractory dysphagia: A phase I case series report" which will be published in the Annals of Otology, Rhinology & Laryngology soon. The patients in this study were an average of 5 years post onset.

With regards to any research, rather than focusing on the source of funding, I believe it is more productive to critically read the entire study, look at the research methodology, and then make decisions about if the the findings are applicable to what we do in treatment. Again, we should agree to disagree on what conclusions we will each make.

The debate about using NMES in swallowing tx has been good for our profession in that it has challenged us to look at the research behind what we do as clinicians. The caliber of research that we are requesting about VitalStim (randomized controls, studies that account for the possibility of spontaneous recovery) should be sought for all our therapies.

Jen Carter, M.Ed., CCC-SLP
Clinical Specialist, VitalStim Therapy

Thermal Tactile Stimulation

Thermal stimulation or thermal-tactile application has been investigated quite a bit and has largely been dismissed as it has been shown to produce only momentary and non-durable reductions in stage transition duration (pharyngeal delay time) (Hamdy et al., 2003; Miyaoka et al., 2006; Rosenbek et al., 1998; Rosenbek, Robbins, Fishback, & Levine, 1991; Rosenbek, Roecker, Wood, & Robbins, 1996). It is receiving more thought recently due to current questions about the role of sensory input on neuromuscular plasticity in adults with neurological diseases and stroke.

James L. Coyle
University of Pittsburgh

References



Hamdy, S., Jilani, S., Price, V., Parker, C., Hall, N., & Power, M. (2003). Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury. Neurogastroenterology & Motility, 15, 69-77.

Miyaoka, Y., Haishima, K., Takagi, M., Haishima, H., Asari, J., & Yamada, Y. (2006). Influences of thermal and gustatory characteristics on sensory and motor aspects of swallowing. Dysphagia, 21, 1-11.

Rosenbek, J. C., Robbins, J. A., Fishback, B., & Levine, R. L. (1991). Effects of thermal application on dysphagia after stroke. Journal of Speech and Hearing Research, 34, 1257-1268.

Rosenbek, J. C., Robbins, J. A., Willford, W. O., Kirk, G., Schiltz, A., Sowell, T. W. et al. (1998). Comparing treatment intensities of tactile-thermal application. Dysphagia., 13, 1-9.

Rosenbek, J. C., Roecker, E. B., Wood, J. L., & Robbins, J. A. (1996). Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia, 11, 225-233.

Training Yes and No Responses

With some aphasias, yes and no responses may be unreliable. The person may nod negatively while verbalizing 'yes' or 'yeah' or 'okay.'

To train differentiation of the affirmative from the negative, show 4 pictured objects (e.g. hammer, saw, screwdriver, scissors) and tell the person "I am going to ask you a set of questions all of which you will answer with a "yes" and a head nod." Demonstrate this. Then point to 1 (i.e. hammer) of the 4 pictured objects, asking, "Is this a hammer?" The patient should say "yes." If so, verbally indicate that this is right. If not, then demonstrate the appropriate response. Continue.

After "yes" is established, switch to "no." Give the same instruction. "I am going to ask you a set of questions all of which you will answer with a "no" and a head nod." Demonstrate this. Then, take the same 4 pictures, point to the hammer as before, but now ask, "Is this a screwdriver?" If the person answers "no" praise and verbally indicate that is correct. If the person says "yes" then demonstrate the proper response. Continue.

Track percentage correct and establish 100% differentiation between yes and no responses with this sort of questioning.

Move to personal information or immediate situation yes no questions once you have an established differentiation.

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.

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...