Beruflich Dokumente
Kultur Dokumente
Information for Slides 3-71 taken from DPNS Manual by Karlene Stefanakos and VitalStim manual by Yorick Wijting
LINGUAL MUSCLES
Your tongue is comprised of both intrinsic and
extrinsic muscles.
INTRINSIC MUSCLES
Shapes the tongue
Reflexes
Tongue Base Retraction-propels bolus into pharynx
Reflexive lingual groove-maintains cohesive bolus for
pharyngeal transfer.
Innervated by CN XII
No sensory pathways, all motor.
Sensory is CN V, VII, IX
XII meets with above nerves at nucleus solitarius in the
brainstem.
INTRINSIC MUSCLES OF THE TONGUE
Transverse
Vertical
Superior longitudinal
Inferior longitudinal
TRANSVERSE
Origin: tongue septum, median portion
Insertion: mucosa at sides of tongue
Reflexes:
Tongue base retraction-propels bolus into pharynx.
Reflexive lingual groove-maintain cohesive bolus for
pharyngeal transfer.
Reflexive protective retraction-prevents pharyngeal
infiltrate, or premature lingual spillover during
mastication.
Innervation: CN XII
EXTRINSIC MUSCLES OF THE TONGUE
Styloglossus
Genioglossus
Hyoglossus
STYLOGLOSSUS
Innervation: CN XII.
INTRINSIC MUSCLES OF MASTICATION
Reflex: jaw jerk reflex-generates rotary mastication
pattern. (Returns jaw from lateral to midline).
Mastication Patterns:
Rotary-normal.
Vertical-no lateral jaw movement, jaw jerk reflex absent
(trigeminal affected.)
Suck-swallow-primitive, motoric innervation, oral XII,
pharyngeal X
Absent O-M pattern-bilateral destruction of CN motor lines V,
X, XII.
Tonic bite: Contraction of temporal, masseter and
internal pterygoid bilateral deficit muscles exterior
pterygoid, platysmus, digastric, mylohyoid,
geniohyoid.
INTRINSIC MUSCLES OF MASTICATION
Temporal
Masseter
Internal pterygoid
External pterygoid
TEMPORAL
Uvula
Glossopalatine
Pharyngopalatine
LEVATOR VELI PALATINE
Origin: apex of the petrous portion of the temporal
bone; eustachian tube
Insertion: aponeurosis of soft palate
Action:
Raises soft palate to meet posterior pharyngeal wall
Dilates eustachian tube orfice
Innervation: CN X (Pharyngeal plexus)
TENSOR VELI PALATINE
Origin: scaphoid fossa; medial pterygoid plate
spine; posterior border of hard palate.
Insertion: palatine aponeurosis; eustachian tube.
Action:
Tenses the soft palate
Opens the eustachian tube during swallowing
Innervation: CN V (mandibular division)
UVULA
Action:
Raises posterior portion of tongue
Constricts isthmus of fauces
Depresses side of palate
Innervation: CN X (pharyngeal plexus)
PHARYNGOPALATINE
Action:
Depresses the soft palate
aids in elevating larynx and pharynx
Constricts faucial isthmus
Innervation: CN X (pharyngeal plexus)
MUSCLES OF THE PHARYNX
Reflex:
Peristalsis reflex: propels the bolus to the esophagus
Sensory and motor innervation CN IX, X, XI
SUPERIOR CONSTRICTOR
Origin: Lower posterior border of medial pterygoid
plate; pterygomandibular ligament and raphe;
mylohyoid ridge of the mandible; mucous
membrane of oral cavity; sides of tongue.
Insertion: Posterior median raphe of pharynx.
CN X (pharyngeal plexus)
PHARYNGEAL LEVATOR MUSCLES
STYLOPHARYNGEAL
Origin: base of styloid process of temporal bone.
Insertion: mucous membrane of pharynx and
thyroid cartilage.
Action: elevates and widens pharynx.
CN X (pharyngeal plexus)
INTRINSIC MUSCLES OF THE LARYNX
Lingual-laryngeal connection=CN XII
Reflexes:
Glottal Effort Closure Reflex which generates the
airway.
Reflexive throat clearing/cough reflex.
CRICOTHYROID
Origin: anterior and lateral surfaces of arch of
cricoid cartilage.
Insertion: caudal border of the thyroid cartilage;
anterior surface of lower cornu of thyroid cartilage.
Action: draws thyroid down and forward; elevates
cricoid arch; lengthens, tenses vocal folds.
CN X (superior laryngeal nerve)
CRICOARYTENOIDS LATERAL
Origin: superior borders of cricoid cartilage.
Insertion: anterior surface of muscular process.
CN VII
DIGASTRIC
Origin: anterior belly arises from internal aspect of
mandible close to midline, posterior belly arises on
medial side of mastoid process of temporal bone.
Insertion: intermediate tendon and the hyoid bone.
CN V.
GENIOHYOID
Origin: internal surface of the mandible at the
inferior mental spine.
Insertion: anterior surface of the hyoid bone.
CN XII.
INFRAHYOID
Unsupervised cup drinking and straw usage.
Goes with larynx muscles.
STERNOHYOID C1-C3
Origin: medial extremity of clavicle; superior and
posterior portion of the sternum; sternoclavicular
ligament.
Insertion: body of the hyoid bone, inferior surface.
CN XII.
STERNOTHYROID C1-C3
Origin: superior and posterior portion of the
sternum and first costal cartilage.
Insertion: oblique line of thyroid cartilage.
CN XII
THYROHYOID
Origin: oblique line of the thyroid cartilage.
Insertion: body and greater cornu of hyoid bone.
CN XII
OMOHYOID C1
Origin: superior margin of scapula.
Insertion: inferior border of the body of the hyoid
bone.
Action: depress and retracts the hyoid bone.
CN XII.
MUSCLES OF FACIAL EXPRESSION
Control levels:
Cortical (conscious): middle brain
Brainstem (oral stage swallow)
QUADRATUS LABIL SUPERIOR
Origin: frontal process maxilla; lower margin of
orbit; zygomatic bone.
Insertion: upper lip at midline.
CN VII
ZYGOMATIC MINOR
Origin: canine fossa of the maxilla.
Insertion: angle of mouth, upper lip.
CN VII.
ZYGOMATIC MAJOR
Origin: zygomatic bone.
Insertion: angle of mouth; upper lip.
CN VII.
RISORIUS
Origin: fascia over masseter.
Insertion: skin at angle of mouth.
CN VII.
DEPRESSOR ANGULI
Origin: oblique line of mandible.
Insertion: angle of mouth, lower lip.
CN VII.
QUADRATUS LABII INFERIOR
Origin: oblique line of mandible (anterior).
Insertion: lower lip at angle of mouth.
CN VII.
MENTAL
Origin: incisive fossa of mandible.
Insertion: integument of chin.
CN VII.
ORBICULARIS ORIS
Origin: a sphincteric muscle, driving from others of
the area, with no definite origins or insertions.
Action: closes mouth and puckers lip.
CN VII.
BUCCINATOR
Origin: alvoelar ridges of maxilla and mandible;
pterygomandibular raphe.
Insertion: angle of the mouth mingling with fibers of
mm forming upper and lower lips.
Actions: flattens cheek.
CN VII.
PLATYSMA
Origin: thoracic fascia over pectoralis major, deltoid
and trapezious mm.
Insertion: mental protuberance of the mandible,
skin of cheek and corner of mouth.
Action: depresses mandible; aids in pouting
reaction; depresses corner of mouth, wrinkles skin
of neck and chin.
CN VII.
CRANIAL NERVE V: TRIGEMINAL
Cutaneous pressure sensation to anteror 2/3 of tongue.
Thermal sensation hot/cold (safety).
Oral pain.
Cutaneous pressure sensation to all teeth, lips, chin, tongue, oral gums,
hard and soft palate.
Salivary flow to major and minor glands.
Mouth opening (ext. pterygoids).
Mandible movement (temporalis, masseter, lat/med pterygoids)-moves
mandible from side to side, elevate and protrude the jaw.
Innervates muscles of mastication.
Innervates floor muscles with aid in elevation of larynx (mylohyoid, ant.
Belly of digastric)-depresses mandible, raises hyoid bone, stabilizes
hyoid bone.
Aids in velopharyngeal closure (tensor veli palatine)-tenses soft palate
prior to elevation.
Everything powered to contraction by V is mandibular (mastication).
Reflex: jaw jerk reflex.
Also innervates tensor tympani.
CRANIAL NERVE V: TRIGEMINAL
Motor
Mastication
HLE
Tenses velum
o Sensory
o cheek
o anterior 2/3 tongue (not taste)
**(trouble chewing)
CRANIAL NERVE VII: FACIAL
Taste receptors: anterior 2/3 of tongue (sweet, sour,
salty).
Autonomic salivary glands (submandibulars and
sublinguals).
Muscles of facial expression.
Lip shape and movement (orbicularis oris).
Closure of lips, cheeks and tongue (buccinator- aids in
mastication by pressing the bolus laterally into the molar
teeth, platysma-depresses the mandible, stylohyoid-
elevates the hyoid, retracts hyoid distally, stapedius)-
Lip closure and prep of bolus for transfer (orbicularis
oris).
Assists in hyoid bone elevation by raising and stabilizing
the hyoid bone (mylohyoid, post belly of digastric).
Raises larynx for airway protection (epiglottic ROM).
CRANIAL NERVE VII: FACIAL
Motor
Lip closure
Buccal tone
HLE
Sensory
Taste anterior 2/3 of tongue
Salivation
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
SWALLOW IN DETAIL
Chewing
Bolus in mouth. CN VII ensures good lip seal (orbicularis oris) while CN
V relays sensory info to brainstem to constantly modify the fine motor
control of bolus prep.
Motor activity to CN V, VII, IX, X, XII to create an enclosed environment
within the mouth to prepare the bolus.
Cheeks provide tone (buccinator CN VII)
Soft palate tense and drawn down towards tongue (tensor veli palatini CN
V and palatopharyngeus CN IX)
Tongue is drawn up towards the soft palate (palatopharyngeus CN X,
styloglossus CN XII)
Hyoid bone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow
movement of the mandible).
Bolus prepared by closing (temporalis, masseter, meial pterygoid, lateral
pterygoid, CN V) and opening (mylohyoid and anterior belly of digastric
CN V, geniohyoid CN XII &C1-C3.)
Bolus pushed around the mouth by actions of the tongue to create a
consistent, homogenous texture (hypoglossus, genioglossus,
styloglossus and 4 groups of intrinsic muscles of the tongue CN XII).
Taste sensations (CN VII and IX) provide info to cortex to stimulate areas
of brain required to coordinate the swallow (insula and cingulate cortex).
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
SWALLOW IN DETAIL
Volutary initiation
Once bolus is adequately prepared.
Soft palate elevates slightly (levator veli palatini and
palatopharyngeus CN X).
Slight elevation of hyoid bone (suprahyoid muscles
contracting on rigid mandible with slight relaxation of
infrahyoid muscles.
Pharyngeal tube is elevated (stylopharyngeus CN IX,
palatopharyngeus and salpingopharyngeus CN X).
Tongue delivers bolus to force bolus distally towards
posterior wall of the pharynx in a “piston-like” manner
using hard palate for resistance.
Sensation by CN XI and by CN X (pharyngeal plexus).
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
SWALLOW IN DETAIL
Larngeal elevation
1st motion for tongue to propel bolus into oropharynx is
elevated anterior direction toward roof of mouth
(mylohyoid and anterior belly of digastric, CN V;
stylohyoid and posterior belly of digastric CN VII;
palatoplossus CN X; genioglossus, hyoglossus and
styloglossus CN XII; geniohyoid CN XII and C1-C3)
affects hyoid elevation in an anterior direction.
Soft palate seals off nasopharynx.
Superior constrictors begin medialization of the lateral
walls.
Larynx elevated and moved anteriorly in relation to
hyoid bone by thyrohyoid CN X.
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
SWALLOW IN DETAIL
Laryngeal closure
During laryngeal elevation-vestibule closes and rises relative to thyroid
cartilage (cricothyroid and intrinsic laryngeal muscles CN X).
Opposition and elevation of arytenoid cartilages provide “medial curtains”
of pyriform recesses (aryeppiglottic folds).
Pressure exerted on base of epiglottis causing it to tip and cover the
laryngeal vestibule.
Medial constrictors (CN X) “strip” the pharynx by medialization following
on from superior constrictors.
Palate descends (palatopharyngeus CN X), constrictors “strip” and
tongue moves posteriorly (styloglossus CN XII) to close oropharynx.
Once the bolus has reached pharyngeal areas innervated by the internal
branch of the superior laryngeal nerve swallow reflexive and cannot be
stopped.
Anterior and elevated movement of larynx allows cricopharyngeus to be
stretched (UES) and opened.
Inferior constrictor finishes medialization and bolus in esophagus.
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
SWALLOW IN DETAIL
Resting state
CN X
Cricopharyngeus resumes tonic state.
Glottic opens and larynx lowers.
If bolus present should cough.
Tongue and hyoid and palate return to resting position.
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
MOVEMENTS OF THE SWALLOW
o Larynx elevates 2 cm.
o Arytenoids contact base of epiglottis.
o Movement of tongue base is major pressure generating force
of swallow.
o Posterior movement of tongue base 2/3 of distance to
posterior pharyngeal wall, anterior bulging of pharynx covers
approximately 1/3.
o UES opening involves: relaxation of cricopharyngeus,
hyolaryngeal excursion (anterior movement of cricoid
cartilage, bolus pressure.
o Typically no bolus hesitation in pyriform sinuses, the bolus
head reaches UES as it opens.
o Saliva swallows usually 1-2 cc’s.
o During swallow-bolus divides fairly evenly between valleculae
and pyriform sinuses.
(14)
COMPONENTS OF THE SWALLOW
Lip closure
Hold position/tongue control
Bolus preparation/mastication
Bolus transport/lingual motion
Initiation of the pharyngeal swallow
Soft palate elevation and retraction
Laryngeal elevation
Anterior hyoid excursion
Laryngeal closure
Pharyngeal stripping wave
Pharyngeal contraction
Pharyngoesophageal segment opening
Tongue base retraction
Esophageal clearance
Robbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N.,
Rosenbek J.C. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically
oriented evidence. JSLPR; 51: S276-S300.
NEURAL PLASTICITY
The ability of the brain to change.
May result in behavorial change, not necessarily
vice versa.
Increasing evidence that N.P. Plays a substantial
role in centrally remodeling human function after
cerebral injury.
10 Principles: Use it or lose it; Use it and improve it;
Plasticity is experience specific; Repetition matters;
Intensity matters; Time matters; Salience matters;
Age matters; Transference; Inference.
Robbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N., Rosenbek J.C. (2008).
Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. JSLPR; 51: S276-
S300.
EXERCISE
Exercising healthy muscles=increased muscle tone.
Must overload or tax the muscle beyond the typical use.
(Masako, Mendelsohn, effortful swallow, Shaker)
Swallowing rehab should imitate swallowing
movements. Gains in strength generalize only to
movement very similar to the exercise itself.
Accurate dosage and frequency unknown at this time for
therapeutic levels.
Continue therapeutic exercise beyond levels needed for
minimal functinoal swallow to maintain adequate
functional reserve.
Develop strength training programs that meet the unique
needs of patients with various diagnoses and/or
swallowing impairments.
Clark, H.M. (2005). Therapeutic exercise in dysphagia management: Philosophies, practices and challenges. Swallowing and Swallowing Disorders, 24-27.
EXERCISE
Muscles
Sarcopenia-age-related reduction in muscle fibers affecting
Type II muscles more frequently.
Sarcomes=smallest functional unit in muscle contraction.
Contraction achieved when successful binding of proteins (actin
and myosin) along the sarcomere causing the filaments to slide
toward each other, creating shortening action of contraction.
Bundles of sarcomeres form muscle fibers.
Type I muscles: slow twitch, slow-oxidative fibers, fatigue-
resistant, increased endurance (lingual lateralizers, jaw closers
and in anterior tongue along with Type IIa).
Type II muscles: to propel and move bolus, fast twitch, larger,
generate more force, easily fatigued. (tongue base, pharyngeal
constrictors). No resistance=no need for type II muscles.
Type IIa-fast oxidative/glycolytic.
Type IIb-greatest capacity for force, easily fatigued, uses glycogen.
Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and
directions for future research. Dysphagia; 22: 251-265.
EXERCISE
Exercise efforts that do not force the neuromuscular
system beond the level of usual activity will not elicit
adaptations.
Swallowing is submaximal, meaning it does not
generate maximal force of muscles involved.
Reps: 8-12 most effective, 6-8=greater outcomes for
generating strength.
“If improved swallowing is the goal, then swallowing
would be the optimal training task.”
Transference might explain swallow imprvement with
non-swallow exercise programs (EMST, lingual
strengthening, LSVT, Shaker).
Combine strength and swallow treatments.
Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and directions for future
research. Dysphagia; 22: 251-265.
DYSPHAGIA THERAPY
Therapy helps return swallow function.
High intensity, aggressive therapy, not diet monitoring
helps patients regain swallow function.
Fewer complications arise when the swallowing system
is rehabilitated. (7).
Volitional swallowing involves bilateral neural
involvement, however some areas are hemisphere-
specific, 63% showing left dominance. (12)
Stroke patients pharyngeal representation in
undamaged hemispere increased significantly with
recovered swallow function. No changes were seen in
the damaged hemisphere. Recovery of swallowing
depends on compensatory reorganization. (13)
DYSPHAGIA THERAPY
Weakness=decreased ability to use force.
Fatigue=weakness that becomes evident during
sustained force productions and over repeated
trials.
Tone=tendency of muscle tissue to resist passive
stretch.
INTERVENTIONS
Exercises
Mendelsohn Manuever
Masako
Shaker
Oral manipulation exercises
Effortful swallow
Cheek/lingual with resistance
Chewing
Weighted bolus
Swallow trials
Suck-swallow
IOPI
MENDELSOHN MANUEVER
Endurance/resistance. Can use a bolus.
Increases extent and duration of UES opening. (2)
Increases tongue-base/pharyngeal wall pressure and contact
duration. (2)
Found to: increase peak pharyngeal pressure, UES
contraction pressure, UES opening duration, duration of
hyoid-UES separation, duration of laryngeal elevation, bolus
transit time, hyoid excursion, distance from the hyoid bone
and the thyroid cartilage, duration of contraction for various
muscles. (4)
May facilitate clearance of residue.
Research: 20 normal subjects, 1 group given 5ml water
swallows compared to 5 ml swallows with Mendelsohn
manuever. Able to sustain laryngeal elevation for 1.5 seconds
or greater with increase in submental muscle group (anterior
belly of the digastric, mylohyoid and geniohyoid.) (23)
MASAKO
Resistance. Boluses not recommended.
Increases anterior motion of the posterior
pharyngeal wall at the level of the tongue base. (2)
Increases strength of tongue base and pharygeal
constriction, increases efferent drive of tongue
base.
Increased pharyngeal clearance.
Toothette
Gauze
EFFORTFUL SWALLOW
Resistance/Endurance.
Increased: base of tongue retraction, tongue propulsive force,
oral pressure, duration and extent of hyoid movement and
laryngeal vestibule closure, longer duration of pharyngeal
pressure and UES relaxation. (2)
Original goal to maximize posterior BOT motion resulting in
improved bolus clearance from valleculae.
Increased force-generating ability of swallowing muscles. (4)
Increased strength for TB, HLE, PC and UES opening,
increased coordination for HLE, PC, UES opening, Increased
afferent (sensory) drive for TB, HLE, PC, UES opening,
increased efferent (motor) drive for TB, HLE, PC, UES.
Evidence of early elevation of the hyoid at initiation of effortful
swallow. (20)
LINGUAL EXERCISES WITH RESISTANCE
Research: Progressive resistance training-8 week
training, 3 sets, 10 reps 3x/day using IOPI, pressing
bulb against palate using tip, blade and dorsum. Lingual
strength increased as a result of non-swallowing
strengthening exercises. Non-swallow strengthening
exercises improved swallow with liquid bolus.
Penetration/Aspiration Scores were reduced. (2, 10)
Research: tested strength and endurance-3 groups, 1
with no exercise, 1 with tongue depressors and 1 with
IOPI. Exercises completed 5 days/week for 1 month, 10
reps 5x/day. Movement 4 directions (with T.D. and
IOPI), left, right, protrusion and elevation. Greater
change in both exercise groups. IOPI did not differ
therapy. No change in endurance. Increased change in
those with initial lower baselines. (9)
LINGUAL EXERCISES WITH RESISTANCE
BOT=base, between tip of uvula and valleculae.
Pull tongue straight back.
Yawn and hold most retracted.
Gargle and hold at most retracted (most BOT movement).
Increased strength with resistance, IOPI, oral
manipulation, swallow trials. Increased ROM with MFR,
stretch (Beckman), oral manipulation, swallow trials.
Increased coordination with oral manipulation, sensory
stim (Beckman, DPNS), suck-swallow, resistance,
swallow trials. Increased afferent drive with chewing
(cold/sour bolus), swallow trials, CN V, VII, XII.
Increased efferent drive with resistance, textured/chewy
bolus, weighted bolus with straw, swallow trials.
CHEWING
Texture
Viscosity
Cold
Sour
WEIGHTED BOLUS
Add viscosity
Thickened liquids/pudding through straw
SWALLOW TRIALS
Challenging boluses-find a safe, challenging
consistency to increase strength.
IOWA ORAL PERFORMANCE INSTRUMENT
IOPI uses a bulb and a hand-held device to
measure tongue strength.
Can be used as a therapeutic tool for visual
feedback.
Available at www.iopi.info
STRETCHES
Myofascial release
Beckman program
MODALITIES
Biofeedback (sEMG)
NMES (VitalStim, Eswallow)
Thermal-Tactile Stimulation
Head Turn
Supraglottic
Super Supraglottic
Head back
Side lying
CHIN TUCK
Research comparing chin tuck with thin liquids to NTL and HTL.
Estimated $200/month for people on thickened liquids. More
aspiration with chin tuck than with NTL or HTL. More adverse
affects with thickened liquids (dehydration, UTI, fever). (3)
Narrows the airway, varies pressures in pharynx and UES during
swallow, duration of timing of swallowing events and
displacement of anatomical structures during the swallow.
Significant change in pharyngeal contraction pressure, duration
of pharyngeal contraction pressure, larynx to hyoid bone
distance, hyoid to mandible distance before the swallow, *angle
between mandible to posterior pharyngeal wall, *angle between
epiglottis to PPW of trachea, *width of airway entrance, *distance
from epiglottis to PPW. (*all decreased). (4)
Chin tuck effective in 72% of patients studied. May be
contraindicated in those with weak pharyngeal contraction
pressure as it decreased pharyngeal contraction pressure and
duration. (10/11)
HEAD TURN
Head rotated to weaker side-Increased pharyngeal
contraction pressure at the level of the valleculae and pyriform
sinus on side of rotation, decreased UES resting pressure on
side opposite rotation, increased duration from peak
pharyngeal pressure in the pyriform sinus to the end of UES
relaxation and increased UES anterior/posterior opening
diameter.
Redirected bolus flow through the pyriform sinus on the strong
side.
Concurrent decrease in UES resistance to bolus flow and
prolongation of UES opening allowing bolus material to flow in
a less obstructed manner through the UES and providing
more time to clear all bolus material from the pharynx. (4)
o Closes weaker side, applies pressure to larynx with closer
approximation of vocal chords to weak side, gravity holds food
longer to stronger side for unilateral oral and/or pharyngeal
dysphagia. If only pharyngeal dysphagia use head turn to weak
side.
SUPER SUPRAGLOTTIC SWALLOW
Facilitates timing and extent of laryngeal closure at
specific levels of the larynx. (2)
For dysphagia secondary to reduced closure of the
airway entrance. Increased UES relaxation prssure
and duration of hyoid excursion and laryngeal
movement, decreased time between UES opening
and onset of hyoid movement and BOT movement
time between UES opening and the onset of vocal
fold adduction and laryngeal closure. (4)
It is indicated that the airway protective sequence
happens early in the swallow.
13/15 subjects with CVA showed abnormal cardiac
findings. (21)
SUPRAGLOTTIC SWALLOW
For dysphagia accompanied by reduced or late
vocal cord closure or delayed pharyngeal swallow.
Changes timing of UES opening, duration and
timing of hyoid excursion and laryngeal closure,
timing of BOT movement.
Close vocal cords earlier in swallow, prolongs
hyolaryngeal excursion-before and during swallow
vocal fold closure.
Logemann recommends 10x/day x5 min with 5-6
swallows each time. (4)
13/15 subjects with CVA showed abnormal cardiac
findings. (21)
HEAD BACK (CHIN UP)
Gravity assistance.
Helps lingual deficits.
Becker R., Neiczaj R., Egge K., Moll A., Meinhardt M., Schulz RJ. (2010). Functional dysphagia therapy and PEG treatment in A clinical geriatric setting.
Dysphagia, Jan 26.
PREDICTORS OF ASPIRATION: LANGMORE, ET
AL STUDY (1998)