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					2011 Annual Membership Meeting




                                 SPEECH & SWALLOWING
                                 Anne G. Lefton, M.A. / CCC-SLP
                                 Nancy Sedat & Associates
“It feels like there’s something stuck in my throat!”
Swallowing
   Transference of material from:

     Mouth                  Esophagus


                  Throat                Stomach
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.


                              Lips
                             Teeth
                           Tongue
                             Bolus
Normal Swallow Sequence


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



                    Nasal Cavity
                       Pharynx
                           Bolus
Normal Swallow Sequence


   Bolus is propelled 
    esophagus
   As esophagus entrance
    opens: Epiglottis helps
    guard against access to
    the lungs.
                              Epiglottis
                          Vocal Cords
           Trachea/Airway to the Lungs
                   Esophagus 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 cough
    2.   Heimlich Maneuver
    3.   Stack breathing
    4.   Portable suction
    5.   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
     Avoidproblem 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
     Takewith 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:
     Articulatorysystem (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
       Paradoxicalmovements (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-SLP
                                 Nancy 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.

				
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