2011 Annual Membership Meeting

SPEECH & SWALLOWINGAnne G. Lefton, M.A. / CCC-SLPNancy Sedat & Associates

“It feels like there’s something stuck in my throat!”

Swallowing

Transference of material from:

3 Phases of Swallowing

Oral Pharyngeal Esophageal

Normal Swallow Sequence

Normal Swallow Sequence

In the mouth: lips, teeth and tongue

help prepare bolus (food mass) for further stages of swallowing.

LipsTeeth

TongueBolus

Normal Swallow Sequence

Access between the nasal cavity and mouth closes as bolus moves into pharynx (throat).

Nasal CavityPharynx

Bolus

Normal Swallow Sequence

Bolus is propelled esophagus

As esophagus entrance opens: Epiglottis helps guard against access to the lungs.Epiglottis

Vocal CordsTrachea/Airway to the

LungsEsophagus Entrance

Normal Swallow Sequence

The airway reopens and the esophagus entrance closes as muscle contractions move bolus toward stomach.

To the Stomach

Swallowing Disorders

Swallowing Disorders / Dysphagia Oral Stage

Difficulty controlling, forming, or transporting a cohesive bolus

Swallowing Disorders / Dysphagia Pharyngeal Stage

Pooling or Stasis Aspiration

Illustrations by Elliot Sheltman from Follow the Swallow by Jo Puntil-Sheltman

Evaluation of Swallowing Function Non-instrumental clinical evaluation Instrumental assessment

Modified Barium Swallowing Study (MBSS) aka: Videofluoroscopic Swallowing Examination

Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Thin Liquid Swallows

Puree Swallows

Cookie Swallows

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

Treatment

What to Do?

Immediate remedies:1. If coughing/choking, never inhibit cough2. Heimlich Maneuver3. Stack breathing4. Portable suction5. CoughAssist device

[www.respironics.com]

CoughAssist™Mechanical In-

Exsufflator

Safe Swallowing Strategies

Swallowing techniques Don’t talk with mouth full 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

Safe Swallowing Strategies [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)

Safe Swallowing Strategies [cont.] Positioning

Chin tuck Behavioral changes

Reduce distractions Eat more calories early in the day or when

there is less fatigue

Safe Swallowing Strategies [cont.] Pill management

Take with applesauce, yogurt, pudding, ice cream, or any other slippery medium Cool Whip! Long-necked bottles Carbonated beverages

Crush with pharmacist’s consent

Alternative Methods of Nutrition

Feeding Tubes

G-tube goes into stomach through an opening in skin

Feeding Tubes [cont.]

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

Speech

“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)

Random Speech Facts…

Approx. 14 different sounds produced every second when we verbalize.

Over 100 different muscles coordinate during speech.

“Its Greek to Me”

Ataxia comes from: Greek word for “lack of order”

Ataxic Dysarthria

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

Effects of Ataxia on Speech

Effects of Ataxia on Speech

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

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.] Phonation: the sound of the voice

Harsh vocal quality due to decreased muscle tone

Vocal tremor

Effects of Ataxia on Speech [cont.] 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

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

Treatment

What to do about it…

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

Compensatory Strategies

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

For the Communication Partner… Ascertain patients preferred strategy when not

intelligible Decrease the need for repetition 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

Augmentative/Alternative Communication (AAC) 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

Take Home Message

With regard to speech or swallowing, there is always a way to keep you

functioning at the highest level possible.

2011 Annual Membership Meeting

THANK YOU!Anne G. Lefton, M.A. / CCC-SLPNancy Sedat & Associates

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.