1. Preparation for Medical Practicum
Spring

2. Objectives Observe Patients during meal time
Interview Patients regarding swallowing
Oral Motor Examination
Chart Review
Begin to develop dysphagia screening skills

3. Swallowing Screening Sensation Dentition Tongue surface
Touch/pressure
Temperature
Pocketing of food
Dentition
Tongue surface
Oral thrush
Managing secretions
Feeding

4. What to bring Medical Practicum Notebook/ Clipboard
Small penlight for OME
See INFO CDS> UO Placements>Medical Practicum
Dysphagia Chart Review
Initial Eval
Oral Facial Exam-Adult
Food Textures List
Clinical Swallow Exam

5. Goal
Primary goal in dysphagia therapy is to meet nutrition and hydration needs by mouth – while minimizing the risk of aspiration or other adverse events (choking)

6. Approaches to Treatment of Dysphagia
Compensatory strategies
Compensate for lost function
Do not target change in swallowing physiology
Strategies include posture modification, diet texture modification etc.
Used during meals
Rehabilitation strategies
Intended to change selected aspects of swallow physiology
No food needed to teach maneuvers
Other

7. Compensatory Strategies
Posture modification
Modification of bolus volume
Modification of liquid and food consistencies
Modification of how food is presented to patient
Enhancing sensory input
Special eating utensils

8. Rehabilitation Strategies
Swallowing maneuvers - examples
Effortful swallow
Supraglottic/Super-supraglottic swallow
Mendelsohn maneuver
Physical Exercises - examples
Head-lift exercises
Oral-motor exercises to increase vertical, lateral ROM of lingual movements in cancer patients

9. Other considerations Oral Care Reducing distractions during meals
Assistance during feeding
Multidisciplinary approach (Dietician, Physician, Nursing, CNA, Occupational Therapy)
Patient Preferences
Quality of Life

10. Liquid Modification
Thin Liquids: Milk, juice, water, carbonated beverages, ice cream, jello, ice cubes
Nectar Thick Liquids: Should be pourable and comparable to nectars and cream based soups.
Honey Thick: Slightly thicker and less pourable, drizzle from cup or bowl
Pudding or Spoon Thick: Hold their own shape , usually eaten with a spoon.

11. Diet Texture Modification National Dysphagia Diet
NDD Level 1: Dysphagia-Pureed (homogenous, very cohesive, pudding-like, requiring very little chewing ability).
NDD Level 2: Dysphagia-Mechanical Altered (cohesive, moist, semisolid foods, requiring some chewing).
NDD Level 3: Dysphagia-Advanced (soft foods that require more chewing ability).
Regular (all foods allowed).

12. Study – thickened liquids
Diet texture modification and thickening liquids should be used as a last resort (Logeman, 1998)
Large-scale study with stroke, PD, and dementia patients - compared chin-tuck and thickened liquids (Logeman et al., 2008; Robbins & Hind, 2008)
Part I (N=742) - Eliminating aspiration
49% aspirated on all 3 interventions
Honey-thick liquid < nectar-thick liquid < chin tuck
Part II (N=515) - Preventing pneumonia
Pneumonia within 3 months occurred in 52 participants (11%)
Lower incidence of pneumonia in patients randomized to nectar-thick than those on honey-thick

13. Using thickened liquids Factors to consider (Garcia et al
Using thickened liquids Factors to consider (Garcia et al., 2005; Mills, 2008)
Absorption of water by the digestive system
Patient acceptance of thickened fluid
Mixing characteristics
Starch-based thickener – unstable, thickens over long period of time, varies across liquid types
Xanthan-gum thickener – more stable over time & across liquid types & different temperatures
Absorption of water by the digestive system

14. References
Garcia, J. ,Chambers, E., & Molander, M. (2005). Thickened liquids: Practice patterns of speech-language pathologists. American Journal of Speech-Language Pathology, 14(1), 4-13.
Logemann, J. A., Gensler, G., Robbins, J. A., Lindblad, A.S., Brandt, D. K., Hind, J. A. et al. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's disease. Journal of Speech, Language, and Hearing Research, 51,
Mills, R. H. (2008, October 14). Dysphagia Management: Using Thickened Liquids. The ASHA Leader.
Robbins, J., & Hind, J. (2008). Overview of Results From the Largest Clinical Trial for Dysphagia Treatment Efficacy. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 17(2), 59–66.
Sharpe, K., Ward, L. Cichero, J., Sopade, P., & Halley, P. (2007). Thickened fluids and water absorption in rats and humans. Dysphagia, 22,