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?

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