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2011 Annual Membership Meeting SPEECH & SWALLOWING   Anne G. Lefton, M.A. / CCC-SLP Nancy

2011 Annual Membership Meeting

SPEECH & SWALLOWING

 

Anne G. Lefton, M.A. / CCC-SLP Nancy Sedat & Associates

3 Phases of Swallowing

CCC-SLP Nancy Sedat & Associates 3 Phases of Swallowing Oral Pharyngeal Esophageal Normal Swallow Sequence In
CCC-SLP Nancy Sedat & Associates 3 Phases of Swallowing Oral Pharyngeal Esophageal Normal Swallow Sequence In

Oral

Pharyngeal

Esophageal

Associates 3 Phases of Swallowing Oral Pharyngeal Esophageal Normal Swallow Sequence In the mouth: lips, teeth
Normal Swallow Sequence In the mouth: lips, teeth and tongue help prepare bolus (food mass)
Normal Swallow Sequence
In the mouth:
lips, teeth and tongue help
prepare bolus (food mass)
for further stages of
swallowing.
Lips
Teeth
Tongue
Bolus

Swallowing

Transference of material from:

 

Mouth

Esophagus

Throat Stomach

Throat

Stomach

Normal Swallow Sequence
Normal Swallow Sequence
Normal Swallow Sequence Access between the nasal cavity and mouth closes as bolus moves into
Normal Swallow Sequence
Access between the nasal
cavity and mouth closes
as bolus moves into
pharynx (throat).
Nasal Cavity
Pharynx
Bolus
Normal Swallow Sequence Bolus is propelled esophagus As esophagus entrance opens: Epiglottis helps guard against
Normal Swallow Sequence
Bolus is propelled
esophagus
As esophagus entrance
opens: Epiglottis helps
guard against access to
the lungs.
Epiglottis
To the Lungs
Esophagus Entrance
Swallowing Disorders
Swallowing Disorders
Swallowing Disorders / Dysphagia Pharyngeal Stage Pooling or Stasis Aspiration Illustrations by Elliot Sheltman
Swallowing Disorders / Dysphagia
Pharyngeal Stage
Pooling or Stasis
Aspiration
Illustrations by Elliot Sheltman from Follow the Swallow by Jo Puntil-Sheltman
Normal Swallow Sequence The airway reopens and the esophagus entrance closes as muscle contractions move
Normal Swallow Sequence
The airway reopens and
the esophagus entrance
closes as muscle
contractions move bolus
toward stomach.
To the Stomach

Swallowing Disorders / Dysphagia

stomach. To the Stomach Swallowing Disorders / Dysphagia Oral Stage Difficulty controlling, forming, or transporting
stomach. To the Stomach Swallowing Disorders / Dysphagia Oral Stage Difficulty controlling, forming, or transporting

Oral Stage

Difficulty controlling, forming, or transporting a cohesive bolus

Evaluation of Swallowing Function

a cohesive bolus Evaluation of Swallowing Function Non-instrumental clinical evaluation Instrumental
a cohesive bolus Evaluation of Swallowing Function Non-instrumental clinical evaluation Instrumental

Non-instrumental clinical evaluation Instrumental assessment

Modified Barium Swallowing Study (MBSS)

aka: Videofluoroscopic Swallowing Examination

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Complications from Dysphagia

Pneumonia

Risk increases as dysphagia worsens

Choking Longer Meal Times Malnutrition Dehydration Weight Loss Quality of Life

Loss of social interaction associated w/ eating

What to Do? Immediate remedies: 1. If coughing/choking, never inhibit cough 2. Heimlich Maneuver 3.
What to Do?
Immediate remedies:
1. If coughing/choking, never inhibit cough
2. Heimlich Maneuver
3. Stack breathing
4. Portable suction
5. CoughAssist device
[www.respironics.com]
CoughAssist™
Mechanical In-Exsufflator

Reducing Risk of Aspiration [cont.]

Changes in food & liquid consistencies

Avoid problem textures and consistencies Gel/powder liquid thickener

Diet Hierarchy

Steak consistency diet Pot roast consistency diet Meat loaf consistency diet Pudding consistency diet Cream consistency diet (tube feedings)

Treatment
Treatment

Reducing Risk of Aspiration

diet (tube feedings) Treatment Reducing Risk of Aspiration Swallowing techniques Repeat swallows Alternate solids
diet (tube feedings) Treatment Reducing Risk of Aspiration Swallowing techniques Repeat swallows Alternate solids

Swallowing techniques

Repeat swallows Alternate solids and liquids

One sip at a time

Sip ‘n’ tip straws Smaller bites Slowed rate Supervision and cueing Smaller, more frequent meals per day

Reducing Risk of Aspiration [cont.]

Positioning

Head and neck support Chin tuck

Supplements

Scandishake

Behavioral changes

Reduce distractions Eat more calories early in the day or when there is less fatigue

Reducing Risk of Aspiration [cont.] Pill management Alternative Methods of Nutrition Take with applesauce, yogurt,
Reducing Risk of Aspiration [cont.]
Pill management
Alternative Methods of Nutrition
Take with applesauce, yogurt, pudding, ice cream, or
any other slippery medium
Long-necked bottles
Carbonated beverages
Cool Whip!
Crush with pharmacist’s consent
 

Feeding Tubes

 

G-tube goes into stomach through an opening in skin

  Feeding Tubes   G-tube goes into stomach through an opening in skin
  Feeding Tubes   G-tube goes into stomach through an opening in skin

Feeding Tubes [cont.]

stomach through an opening in skin Feeding Tubes [cont.] Decisions to have or not have: Used
stomach through an opening in skin Feeding Tubes [cont.] Decisions to have or not have: Used

Decisions to have or not have:

Used to maintain nutrition/hydration; consider before eating becomes exhaustive Risks increase as respiratory function declines Will not eliminate the risk of choking on saliva

Feeding Tubes [cont.]

the risk of choking on saliva Feeding Tubes [cont.] What it does: Provides nutrition via an
the risk of choking on saliva Feeding Tubes [cont.] What it does: Provides nutrition via an

What it does:

Provides nutrition via an alternate route Allows one to receive required nutrition and hydration when no diet texture can be swallowed safely or when oral feeding is not meeting nutritional / hydration needs Allows for the combination of oral eating for pleasure and tube feeding for fluids and calories

Ataxia and Speech
Ataxia and Speech

Speech

Speech “Normal” sounding speech requires perfect coordination of the following systems: Articulatory system (e.g.,
Speech “Normal” sounding speech requires perfect coordination of the following systems: Articulatory system (e.g.,

“Normal” sounding speech requires perfect coordination of the following systems:

Articulatory system (e.g., lips, tongue, etc.) Resonatory system (e.g., velum/soft palate) Phonatory system (e.g., vocal cords) Respiratory system (e.g., lungs)

Ataxic Dysarthria Disorder of sensorimotor control for speech production that results from damage to cerebellum
Ataxic Dysarthria Disorder of sensorimotor control for speech production that results from damage to cerebellum

Ataxic Dysarthria

Ataxic Dysarthria Disorder of sensorimotor control for speech production that results from damage to cerebellum or

Disorder of sensorimotor control for speech production that results from damage to cerebellum or to its input and output pathways Sometimes likened to “drunken speech

Effects of Ataxia on Speech

to “ drunken speech ” Effects of Ataxia on Speech Articulation: disruption of the timing, force,
to “ drunken speech ” Effects of Ataxia on Speech Articulation: disruption of the timing, force,

Articulation: disruption of the timing, force, range, and direction of movements.

Imprecise consonant articulation Distorted vowels

Breakdown is most evident during longer strings of speech

“Its Greek to Me”

during longer strings of speech “Its Greek to Me” Ataxia comes from: Greek word for “lack
during longer strings of speech “Its Greek to Me” Ataxia comes from: Greek word for “lack

Ataxia comes from:

Greek word for “lack of order”

Ataxia comes from: Greek word for “lack of order” Effects of Ataxia on Speech Effects of
Effects of Ataxia on Speech
Effects of Ataxia on Speech
Effects of Ataxia on Speech [cont.] Resonance: Hypernasality Hyponasality May occur due to timing errors
Effects of Ataxia on Speech [cont.]
Resonance:
Hypernasality
Hyponasality
May occur due to timing errors between the muscles of the
velum and the other muscles of articulation.
Soft Palate / Velum

Effects of Ataxia on Speech [cont.]

Effects of Ataxia on Speech [cont.] Phonation: the sound of the voice Harsh vocal quality due
Effects of Ataxia on Speech [cont.] Phonation: the sound of the voice Harsh vocal quality due

Phonation: the sound of the voice

Harsh vocal quality

due to decreased muscle tone

Vocal tremor

Most Common Speech Changes Imprecise consonants Excess and equal stress Articulatory breakdown Distorte d vowels
Most Common Speech Changes Imprecise consonants Excess and equal stress Articulatory breakdown Distorte d vowels

Most Common Speech Changes

Most Common Speech Changes Imprecise consonants Excess and equal stress Articulatory breakdown Distorte d vowels

Imprecise consonants Excess and equal stress Articulatory breakdown Distorted vowels Harsh vocal quality Mono pitch/Mono loudness Slowed speech rate

What to do about it…

loudness Slowed speech rate What to do about it… 1. Evaluation by a Speech-Language Pathologist 2.
loudness Slowed speech rate What to do about it… 1. Evaluation by a Speech-Language Pathologist 2.

1. Evaluation by a Speech-Language Pathologist 2. Treatment

Exercises will target the affected system(s)

Improve breath support and coordination of breathing and speaking Rate control techniques (e.g., finger/hand tapping to set the pace of appropriate syllable production) Increase articulatory accuracy: over-articulate Develop stress and intonation skills to regulate pitch and loudness

Effects of Ataxia on Speech [cont.]

pitch and loudness Effects of Ataxia on Speech [cont.] Respiration: Uncoordinated movements of the respiratory
pitch and loudness Effects of Ataxia on Speech [cont.] Respiration: Uncoordinated movements of the respiratory

Respiration:

Uncoordinated movements of the respiratory muscles

Exaggerated movements

Excessive loudness

Paradoxical movements (different muscle groups work against each other)

Talking too quickly Decreased vocal volume Trying to talk on residual air

Treatment
Treatment

Compensatory Strategies

to talk on residual air Treatment Compensatory Strategies For the Speaker Energy conservation Minimize
to talk on residual air Treatment Compensatory Strategies For the Speaker Energy conservation Minimize

For the Speaker

Energy conservation Minimize environmental noise/distractions Establish context of message Alter your rate of speech…SLOW it down. Exaggerate articulation of final consonants in words Use gestures/point to props Boil down the message

decrease “filler” words Keep important/key words

Compensatory Strategies

Compensatory Strategies For the Communication Partner… Ascertain patients preferred strategy when not intelligible
Compensatory Strategies For the Communication Partner… Ascertain patients preferred strategy when not intelligible

For the Communication Partner…

Ascertain patients preferred strategy when not intelligible Decrease the need for repitition fatigue and frustration Ask yes/no questions Know the topic Maintain eye contact Give undivided attention Don’t interrupt or finish sentences Let the speaker know the parts of the message you did not understand so s/he will not have to repeat the entire message. Patience

Take Home Message With regard to speech or swallowing, th ere is always a way
Take Home Message With regard to speech or swallowing, th ere is always a way

Take Home Message

Take Home Message With regard to speech or swallowing, th ere is always a way t

With regard to speech or swallowing, there is always a way to keep you functioning at the highest level possible.

References

Freed, D. (2000). Motor speech disorders diagnosis and treatment. San Diego, CA: Singular Thomson Learning, 2000.

Puntil-Sheltman, J. (1997). Follow the swallow. Seal Beach, CA: Sheltman Publishing, 37-40.

Rangamani, G.N., J. (2006). Managing speech and swallowing problems: A guidebook for people with ataxia. National Ataxia Foundation, 1-60.

Yorkston, K.M., Beukelman, D.R., & Bell, K. (1988). Clinical management of dysarthric speakers. San Diego, CA: College-Hill Press.

Augmentative/Alternative Communication (AAC)

Press. Augmentative/Alternative Communication (AAC) Low tech Communication board Alphabet board Phrase board
Press. Augmentative/Alternative Communication (AAC) Low tech Communication board Alphabet board Phrase board

Low tech

Communication board

Alphabet board Phrase board

High tech

Speech generating devices

An SLP can help explore your options

Other

Voice amplification

Chattervox OR SoniVox

your options Other Voice amplification Chattervox OR SoniVox 2011 Annual Membership Meeting THANK YOU!   Anne
your options Other Voice amplification Chattervox OR SoniVox 2011 Annual Membership Meeting THANK YOU!   Anne
2011 Annual Membership Meeting THANK YOU!   Anne G. Lefton, M.A. / CCC-SLP Nancy Sedat

2011 Annual Membership Meeting

THANK YOU!

 

Anne G. Lefton, M.A. / CCC-SLP Nancy Sedat & Associates