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George Banks, 65 y/o, L Ischemic CVA, Acute Stroke Unit (Assessments (MMT…
George Banks, 65 y/o, L Ischemic CVA,
Acute Stroke Unit
Assessments
Observation of mealtime
Closure of Lips was not seen
MMT
Could not elicit R facial muscles, score 1
Labial strength
Goniometry of oral labial muscle
Pain Assessment
Client & Caregiver Interview
Level of assistance available at home and food preferences noted
Cognition Check
Medication evaluation
Guss Swallowing Screen (Trapl et al., 2007)
Results: Score of 10, indicating moderate dysphagia with a risk of aspiration. Recommend all thickened liquids, purees, no liquid medication, crush all pills (Trapl et al, 2007)
Iowa Oral Performance Instrument
Labial/Lip strength and endurance
Tongue strength and endurance
Goals
LTG 1: George will maintain upright, seated position, during eating, mod I, with R. lateral support, with no more than 3 repositions, and no verbal cues to reposition, within 1 week.
STG 1: Within 3 days, George will independently verbalize 3 positioning strategies to caregiver/feeding assistant, during meal times.
STG: 2: Within 3 days, George will be repositioned with minimal assistance from caregiver during feeding, following caregiver education on proper positioning.
LTG 2: George will safely swallow, using a closed mouth and effortful swallow technique, with no more than 5 verbal cues from OT, within 1 week.
STG 2: George will safely swallow, during drinking with verbal assistance to use pacing techniques and use of a timer within 6 days.
.
STG 1: George will safely swallow, nectar consistency for liquids prepared by caregiver, within 3 days.
Frames of Reference
Biomechanical
Improved strength of oral and swallowing muscles to improve labial sealing for speech, drinking, and eating
(Weeks, Dzielak, Hamadain, & Bailey, 2014)
Strengthening of chin and neck muscles
Trunk control for postural support
Reference:
Cole, M. B., & Tufano, R. (2008).
Applied theories in occupational therapy
: A practical approach. Thorofare, NJ: SLACK.
Occupational Adaptation
Modify food consistency and textures
Pacing during meal time
Adaptive feeding tools
R Lateral postural supports and positioning adaption
Reference: Cole, M. B., & Tufano, R. (2008).
Applied theories in occupational therapy:
A practical approach. Thorofare, NJ: SLACK.
Intervention- 4 for each LTG
VitalStim
Applied to face for closure of mouth
Evidence Based Support: "MES efficacy observed in this study may be its theoretical dual mode of action in potentiating standard TDT strategies that target the oropharyngeal muscles in disuse atrophy for strengthening while simultaneously stimulating feedback to the cortical/subcortical swallowing are via the CPG to enhance brain plasticity/recovery of swallowing contro"
(Kushner, Peters, Eroglu, Perless-Carroll, & Johnson-Greene, 2013)
Applied to anterior neck for swallowing
Functional training on body positioning
Chin tucked to neutral
Sitting upright with use of lateral supports and back supports as needed
Side lying to R side 5 degrees to slow transit time
Grade up: Independently positioning himself for feeding in proper position.
Grade down: Use lateral supports to keep him in an upright position; Verbal Cues
Positioning while swallowing thickened liquids
Swallowing thickened liquids and foods of nectar consistency to prevent liquids from involuntarily expelling liquids from R side of mouth and reduce risk of aspiration. Proper body positioning will be considered for different consistencies of liquids. Meals to be prepared by caregiver.
Grade Up: Seated upright, increase pace of feeding, shallower spoon. Swallow thin liquid consistency if safe.
Grade Down: Reclined sitting, slower swallow pace, smaller spoon fulls. Swallow honey consistency if necessary.
Education on proper body positioning techniques for safe swallowing to client and caregiver (Kagaya, Inamoto, Okada, & Saitoh, 2011)
Reclining at 30 degrees w/ neck at extension supported by pillow
Chin tuck - head and neck flexion
Sitting Upright
Side lying against L side to allow food to travel down unaffected side of body.
Tongue Exercises
Tongue Extension
Protrude tongue between lips. Sticking out tongue as far as you can.
Tongue Retraction
Retract tongue, touching the back of your tongue to the roof of your mouth
Tongue Extension and Retraction
Combine the two procedures above, holding each position for 1 to 3 seconds.
Tongue Tip Up
Place tongue on alveolar ridge, (the area behind your top teeth.) If you don't have any teeth, move your tongue tip up to your gum where your top teeth would be. Open mouth as wide as possible maintaining tongue contact.
Tongue Elevation Along The Palate
Tongue tip to alveolar ridge, (The area behind your top teeth.) Move in anteriorly to posteriorly along the palate. (Front to back along the roof of your mouth.)
Grade up: Do more reps
Lip Exercises
Lip Retraction
Smile.
Lip Protrusion
Pucker your lips as if you were going to give someone a kiss.
Lip Retraction and Protrusion
Smile then pucker your lips.
Lip Press
Press lips tightly together for 5 seconds.
Lip Press on Tongue Depressor
Tightly press lips around tongue depressor, while the clinician tries to remove it.
Puff Cheeks
Fill cheeks with air, move air from one cheek to the other 5 to 10 times.
No air should escape from around the lips or the nose.
Grading
Grade Up: Increase amount of exercises to more than 3 out of the 6, and increase reps
Grade down: Select 3 out of the 6 exercises and decrease amount of reps if difficult
Postural Strengthening
Balance Training in sitting balance and trunk control during ADL tasks
Postural awareness
constraint training - Use of hemiparetic arm to support self and improve postural leaning
Problem List
Nectar Thick
R side facial weakness w/ facial drooping
Lip closure
R lateral trunk weakness
Garbled Speech
Kushner, D. S., Peters, K., Eroglu, S. T., Perless-Carroll, M., & Johnson-Greene,
D. (2013). Neuromuscular Electrical Stimulation Efficacy in Acute Stroke Feeding Tube-Dependent Dysphagia During Inpatient Rehabilitation. American Journal of Physical Medicine & Rehabilitation, 92(6), 486–495. Retrieved from
http://prx-usa.lirn.net/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=87777500&site=eds-live
Weeks, K., Dzielak, D., Hamadain, E., Bailey, J. (2014). Examining the relationship between stroke and labial strength.
Contemporary Issues in Communication Science and Disorders, 40,
160-169
Trapl, M., Enderle, P., Nowotny, M., Teuschl, Y., Matz, K., Dachenhausen, A., & Brainin, M. (2007). The Gugging Swallowing Screen. Retrieved from
https://www.donau-uni.ac.at/imperia/md/images/department/kmp/publikationen/guss_e.pdf
Kagaya, H., Inamoto, Y., Okada, S., Saitoh, E. (2011). Body positions and functional training to reduce aspiration in patients with dysphagia.
JMAJ, 54
(1), 35-38.
Cole, M. B., & Tufano, R. (2008).
Applied theories in occupational therapy:
A practical approach. Thorofare, NJ: SLACK.
GROUP MEMBERS: Elise Doan, Landry Gall, Brittany Parker, Kelli Neil, & Zoey Sanchez