Download SLP2 Copeland - Kansas Speech-Language

9/1/2016
Occupational
Therapy
Respiratory Therapy
Speech
Therapy
Physical
Therapy
Interdisciplinary Approach to
Dysphagia, Posture, and Positioning in
the Medically Complex Population
Jeanne Copeland, M.S., CCC-SLP & Alyssa Thrush, DPT, GCS, CEEAA
KSHA, September 29th, 2016
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With sincere gratitude to contributing author:
Diane Dismukes, OTR
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Disclosure Statement
 The program content focuses on the science and/or
practice associated with our healthcare profession.
 As employees of Genesis Rehab Services we are not
attempting to persuade you as learners to favor,
purchase, use or promote a particular product, piece
of equipment, device or service discussed today.
 We have no relevant financial or non-financial
relationships to disclose.
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9/1/2016
Objectives
 Identify the relationship between postural changes and
patients with medical complexities
 Learn how poor posture can exacerbate dysphagia symptoms
in the elderly population
 Understand the relationship between resting tongue/jaw
position, breathing, and posture
 Understand the roles of the physical therapist, occupational
therapist, and speech-language pathologist in the evaluation
and treatment of posture, positioning, and dysphagia
 Integrate new concepts to promote interdisciplinary
treatment of posture and positioning in the elderly population
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Case Study: Janelle (5/27/74 – 7/17/14)
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FREEZE!
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Things to Consider…
 Our treatment environments are changing
― SNF: more sub-acute, short term stay patients
― ALF: direct referrals from the hospital as opposed to a
skilled inpatient stay
― Shorter hospital stays
o Observation vs. Admission
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“Medically Complex”
 A condition in which pathological processes:
― Interfere with an individual’s ability to maintain
homeostasis
― May result in actual physiologic change
 May include the following:
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Multiple medical diagnoses
Frail elderly
Medical decline of unknown origin
Unstable medical status
Extensive hospitalization
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What Are We Expecting?
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Supplemental oxygen
Trachs/vents
IV medications
Heart monitors
Feeding tubes
Severely debilitated
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Muscle atrophy – increased risk for skin breakdown
Significant weight loss
Limited activity tolerance
“Bed bound”
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Challenges to Treatment
 PATIENT mindset
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Lack of understanding – benefits of early intervention
“Too sick”
Fear
Learned helplessness
 THERAPIST mindset
― Lack of comfort with more complex cases
― Fear of “harming” patient
o Medical instability
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Overcoming Treatment Challenges
 Understanding our role and the benefits of early
rehab interventions on functional outcomes and
ability to return to PLOF
― Minimize the systemic complications of immobility
― Minimize functional decline
 Educating patient, families and other healthcare
professionals on our role in medically complex cases
 Increasing confidence in assessment/ treatment
strategies with medically complex patients
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Let’s Discuss!
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Postural Changes and Parkinson’s Disease
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Anterocollis
Scoliosis
Striatal limb deformities
Camptocormia
Pisa syndrome
(Jankovic, 2008)
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Postural Changes and Dementia
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The Somatosensory Cortex and
Postural input
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Head, jaw, tongue, and lips
Hands and feet
Eyes
Vestibular portion of inner ear
Specialized sensory cells
(spindles) in muscles
 Sensors in articulations and
joints
 Skin, fascia, and internal
organs
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Abnormal Posture Formation
Abnormal
Posture
Influenced by:
Physiological
Changes
Pain
Intensity
Duration
Frequency
Structural
Changes
Neuromuscular
Changes
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Common Postural Disorders
Forward Head Posture
(FHP)
Abnormal
Pelvic/Trunk Posture
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Causes and Effects of FHP
Causes
Effects
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Increased Sedentary Lifestyle
Kyphosis
Trunk Instability / Weakness
Abnormal tone
Arthritis
Neck Pain
Thoracic Outlet Syndrome
TMJ Symptoms
Bruxism
Ligament Deformity
Disc Decay
Stretched Nerves
Stretched Spinal Cord
Headaches
Stretched Blood Vessels
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Respiratory Biomechanics and FHP
(Hruska, 1997, Huggare & Laine-Alava, 1997, Okuro, et.al., 2011)
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Inhibited neck flexors and
Rhomboids
Tight Pectoralis, Upper
Trapezius, and Levator
Scapulae
Neck hyperextension
Rib cage elevation
Decreased respiratory support
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There is a cascading effect on oral functions,
especially when nasal breathing is reduced or absent
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FHP and Oral Breathing
 Tongue sits low and forward
 Jaw moves low and forward to compensate for
tongue
 Head tilts up
 Increased tension in the neck muscles
 Cervical spine changes shape
 Shoulder blades compensate for changes in c-spine
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Oral Breathing, cont.
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Reasons for oral breathing
Physical Appearance and Effects
Allergies
Enlarged tonsils or adenoids
Chronic nasal congestion
Respiratory infection
Postural deviations
In children; thumb or finger
sucking habit
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Long, narrow face and mouth
Less defined cheek bones
Small lower jaws and “weak” chin
Headaches
Gingivitis and gum disease
Sore throat and cold symptoms
Bad breath and higher risk for
cavities
 Poor sleep leading to chronic
fatigue
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Treatment: Breathing
When do we want to use:
 Diaphragmatic Breathing?
 Accessory Breathing?
 Symmetry?
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Treatment: Breathing
Diaphragmatic Breathing Facilitation
(Accessory Muscle Inhibition)
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Posterior Pelvic Tilt
Neck in slight Flexion (Pillow)
Shoulder Ext, Add, and IR
Knees Bent
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Treatment: Breathing
Accessory Muscle Facilitation
 Anterior Pelvic Tilt
 NO Neck Flexion (No Pillow)
 Shoulder Flex, Abd, ER
 Legs Straight
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Treatment: Postural Interventions
We can make a difference in our patient’s posture by
assessing and treating:
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Postural Muscle Strength
ROM
Soft Tissue Extensibility
Patient/Staff Education
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Positioning: What Am I Really Looking
At?
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Head and Neck Position
Trunk Position
Position in Space
Effect of Position on Function
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Pelvic Position Affects Head and Neck
Posture
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FHP – Geriatric Population
 Assess Cause(s):
― Posterior Pelvic Tilt
― Kyphosis
― Tightness of pecs/upper trapezius
― Weakness
― W/C Device Issue: Back Hammock, Chair too wide, Improper
supportive seat cushion
 Assess Effect(s) on Function:
― Increased Neck Extension
― Increased Aspiration Risk
― Difficulty obtaining eye contact
― Pain
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Poor Head Control
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Forward Flexion or Hyperextension
Lateral Flexion
Rotation
 Assess Possible Causes:
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Muscle Weakness
Abnormal Tone
Poor Trunk Stability / Positioning
W/C Device Issue
 Assess Effects of Posture on Function:
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Neck Extension with increased oropharyngeal opening
Difficulty obtaining a postural movement to decrease aspiration risk
Anterior Spillage
Self- Feeding Difficulties
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Abnormal Head Position
 Intervention:
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Use a reclining backrest
Use a reclining backrest with headrest
Use a tilt in space option
Use a headrest with head-band to maintain proper position
Treatment of underlying impairments in strength and ROM
 Considerations/Alternatives:
― A patient with poor head control almost always requires a
commercial head-rest and custom seating system
― Patients with severe fixed kyphotic deformities that
result in forward head posture must be
accommodated with a reclining wheelchair or
tilt in space option
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Position in Space?
• Where is the head and neck position?
• What is the effect of gravity on swallow
function?
• What is the effect of position in space with
regards to ability to self-feed?
• Is the patient able to gain eye contact with
caregiver?
Treatment Objectives:
• Upright in Midline with neutral head/neck
position
• Provide supportive seat to decrease sliding
• “Right-Size” device to increase support
• If at all possible, position to allow feet on
floor for meals
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Effects of Tilt – in – Space Chairs
Studies indicate improved swallow efficacy with a 20 degree tilt versus 90
degree upright posture.
Attributed to:
 Improved bolus transport to the pharynx
 Gravity and position facilitate bolus transit down posterior pharynx and
esophagus
J Oral Rehabilitation 2006 June; 33(6): 402-8 Ayuse, et al
JMAJ Jan/Feb 2011 Vol 54 No.1 Kagaya, Hitoshi et al
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Tongue Placement and Posture
 The tongue is the “rudder” of the upper body
― Postural “reset” each time we swallow (pressure on
palate compresses sensory receptors for nasopalatine
branch of trigeminal nerve)
 Swallow occurs 600-1000x/day, but tongue and jaw
rest position is more important
 Changes in placement of tongue on palate changed
posture (Ferrante & Scoppa, 2005)
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Oral Phase Changes
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Oral Phase Changes, cont.
 May lead to class II
malocclusion
― TMJ
― Bruxism
― Pain
― Fatigue with
chewing
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Pharyngeal Phase Changes
(Noh, et.al., 2010)
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Summary of SLP Assessment
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Overall posture (FHP, symmetry, lateral lean)
Nasal vs. Oral breathing
Xerostomia
Lip/tongue position at rest
Chewing: one sided?
Temporal Mandibular Joint Dysfunction (TMJD)
Bruxism (Teeth grinding)
Positioning while eating
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Key SLP Assessment Questions
1)
2)
Does your client demonstrate a forward head
posture at rest?
Do they breathe through their nose or their
mouth?
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Additional Assessment Tools
 Eating Assessment Tool – 10 (EAT-10)
 Geriatric Depression Scale (GDS)
 Brief Anxiety and Depression Scale (BADS)
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SLP Treatment of Posture and Dysphagia
 Progressive resistance exercises targeting deficits
identified during oral-mech exam
 Xerostomia management
 Compensatory strategies
 Energy conservation techniques
 Dietary modifications
 Reinforcement of improved posture during po intake
 RNP/FMP/HEP development
 Refer to and/or co-treat with PT/OT as appropriate
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Interdisciplinary Opportunities
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Case study: Janelle (5/27/74 – 7/17/14)
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Janelle and her Reese’s
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Summary of Dysphagia Recommendations
(Nov. 2013)
 Thin liquids via nosey cup, no straws
 Puree diet with favorite mech soft snacks allowed if sitting at
midline and oral care provided after
 Allow additional time for task recognition
― Touch lower lip with cup and wait for labial closure
― Allow consecutive drinks if JB actively removing liquid from cup, single
sips if not
 Sensory integration techniques to promote safe swallow function
― Alternate tastes/temperatures of food to promote quicker swallow
function
― Downward pressure on tongue blade with spoon to promote labial
closure
 RA program to provide oral sensory stimulation, promote labial
closure and frequent swallowing during implementation
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JB Interdisciplinary Treatment
 PT developed stretching RNP with specific attention
to turn schedule in bed to prevent contractures
 OT recommended lateral supports for Broda chair
and created a lateral support bolster system for
recliner to facilitate positioning at midline
 Tilt-in-space chair was utilized to facilitate stretching
during times of hypertonicity
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The Effects of Posture…
 Are far-reaching
 Significantly affect your
outcomes
 Are probably a more
prevalent factor in your
treatment and outcomes
than you realize!
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References
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Ayuse, T et al, (2006). Effect of reclining and chin-tuck position on the coordination between
respiration and swallowing. J Oral Rehabilitation 2006 June; 33(6); 402-8
Ferrante, A., & Scoppa, F. (2005). Tongue position and postural control. Double blind random
study in 360 post-puberal subjects. Gait & Posture; XVIIth Confrence on Postural and Gait
Research; Marseille, May.
Hruska, RJ Jr. (1997). Influences of dysfunctional respiratory mechanics on orofacial pain.
Dental Clinics of North America, 41 (2): 211-27.
Huggare, JA, & Laine-Alava, MT. (1997). Nasorespiratory function and head posture. Am J
Orthod Dentofacial Orthop. 112 (5): 507-11.
Jankovic, J. (2008). Parkinson’s disease: clinical features and diagnosis. J Neurol Neurosurg
Psychiatry. 79:368-376.
Junqueira, P., Marchesan, I.Q., De Oliveira, L.R., Ciccone, E., Haddad, L., Rizzo, M.C., (2010)
Speech-language pathology findings in patients with mouth breathing: multidisciplinary
diagnosis according to etiology. Int J Orofacial Myology. Nov; 36: 27-32.
Kagaya, Hitoshi et al, (2011). Body Positions and Functional Training to Reduce Aspiration in
Patients with Dysphagia. JMAJ Jan/Feb 2011 Vol 54 No.1 ; 35-38.
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References, cont.
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Noh, E.J., Park, M.I, Park, S.J., Moon, W., Jung, H.J., (2010). A case of amyotrophic lateral
sclerosis presented as oropharyngeal Dysphagia. J Neurogastroenterol Motil; 16(3): 319-22.
Okuro, RT, Morcillo, AM, Ribeiro, M, Sakano, E, Conti, P, & Riberio, J. (2011). Mouth breathing
and forward head posture: effects on respiratory biomechanics and exercise capacity in
children. J Bras Pneumol. 37(4): 471-79.
Sakaguchi, K., Mehta., N.R., Abdallah, E.F., Hirayama, H., Kawasaki, T., Yokoyama, A., (2007).
Examination of the relationship between mandibular position and body posture. Cranio;
25(4): 237-49.
Woda, A., Pionchon, P., Palla, S., (2001). Regulation of mandibular postures: mechanisms and
clinical implications. Crit Rev Oral Biol Med; 12(2); 166-78.
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