clinical decisions

If at first you dont succeed...

Part 2: Tools of the trade
In part 1 of this article, Liz Ackroyd reflected on her management of a 46 year old client David who has chronic oropharyngeal dysphagia following basilar meningitis and a left medullary infarct. Part 2 offers more detail about the various tools and procedures she tried out in the course of his treatment.
1. Trophic Electrical Stimulation Trophic Electrical Stimulation (TES) is applied to a muscle to influence its metabolic pathway aiding the natural healing process and preventing or even reversing the changes associated with atrophy. TES aids the nutritional growth and development of the muscle. It operates on similar frequencies to those used by healthy nerves thus impacting on both red (slow) and white (fast) muscle fibres. Muscle toning signals are supplied at a mean of 10pps to red muscle and muscle strengthening is boosted by signals at a mean of 35pps to the white muscle. The repeated signals provide the impetus for the muscle to rebuild itself. TES works by decreasing synaptic resistance, increasing the size of the motor units by increasing axon sprouting and activating dormant axons. David had a dense low motor neurone left side facial palsy with mass over-activity on the right. The facial palsy had a significant impact
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on the intelligibility of his speech and his ability to achieve lip seal. His lack of lip seal was one of the hypotheses for the disorganised and chaotic swallow he initially presented with. The Neuro4 trophic electrical stimulator was utilised twice daily in one-hour blocks. One hour targeted the risorious, levator labii, zygomatic and frontalis and was followed by specific exercises targeted at these muscles (table 1). The second hour targeted the depressor labii and mentalis and was again followed by specific exercises (see table 2).
Table 1 Exercises for upper face (block 1)

2. Resistive tongue / lip exercises The digastric, mylohyoid, geniohyoid and the stylohyoid are collectively the suprahyoid muscles which attach the hyoid bone to the skull and mandible. They are responsible for excursion and elevation of the larynx. These muscles were targeted through exercises in an attempt to increase movement of the hyoid during swallow thus improving laryngeal elevation and excursion. Lip seal was another target. a) Jaw grip I initially trialled a jaw grip to increase selective tongue movements.
Table 2 Exercises for lower face (block 2) chin massage chin tap to affected side buccal cavity pull to muscles below lips

facilitated eyebrow stretch facilitated lip stretch upper lip stretch gentle palpation of depressor septii buccal cavity pull massage to both affected and overactive sides rocking palm exercise to affected side (place base of palm on cheekbone and exert pressure on one cheek by pushing up and into the cheekbone from the centre whilst client leans elbows on table for steady pressure for a count of two) Face Former (www.faceformer.net) gradual increase to 15 per side

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CLINICAL DECISIONS

Although there was no benefit in this specific sense, the stability provided is important for future progress. I stood at the side of David with my arm around his head and held his chin between my index and middle fingers whilst my thumb rested lightly against the side of his face approximately on a level with the middle of the ear. The jaw grip provides a base of support for the head, reduces tone and provides positive sensory feedback. It also allowed me to facilitate movements of the tongue using upward pressure of my finger in the space between the two bony rami of the jaw where the tongue can be felt. Along with use of the jaw grip, Davids positioning was controlled. He was seated in a high backed chair, his feet firmly on the floor and his arms resting on a table in front of him. It was important to increase his stability to maximise function and reduce the influence of abnormal muscle tone. b) Theraspoons I used Theraspoons to target tongue tip and medial tongue accuracy of movement and strength and improve base of tongue strength. Davids lip seal was so impaired he could not achieve lip seal around the Theraspoons. c) Theraband This is a piece of latex used for resistive exercise to provide both positive and negative force on the muscles, and improve strength, range of motion and cooperation of muscle groups. The colour-coded levels of resistance aid in measuring outcome of muscle strength. I held the Theraband in front of Davids lips for him to push his tongue tip against it.

d) FaceFormer I used this to improve tongue movement and encourage better lip seal. In the initial stages the FaceFormer was placed in the middle of Davids lips and then I attempted to pull it out either straight or in an upward or downward direction. This was altered when it became apparent that David was using the stronger side to compensate for his left side and that the muscles on that side were not being innervated. I then placed the FaceFormer on the right first for resistance exercises and then on his left. At the start David was managing to hold it in place for two pulls. The norm for this piece of equipment is 20. This exercise was performed by a speech and language therapy assistant and there was an increase in the number of pulls he was able to hold the FaceFormer in place. This was halted after approximately two months as it was encouraging over-activity of the right side without initiating activity of the oral musculature on the left. Our outcome measure was an increase in the number of pulls and, on reflection, it was inappropriate as it was not an indication of improved performance of the weakened musculature. e) Mirror Due to poor sensory awareness and proprioception, David needed to use a mirror to give him feedback as to the position of his tongue and lips and whether he was achieving the desired movement. f) Facial-flex A facial-flex was introduced. This device was originally utilised with facial burns victims to soften their scar tissue. A secondary effect of improved muscle tone was noted and it has since been used by the beauty industry in an attempt to

Facial-flex combat the signs of aging. Speech and language therapists have also used it, although there is to date no published research regarding its effectiveness with facial palsy. It is believed that a facial-flex can increase muscle strength, skin tone and firmness as well as improve blood circulation to facial musculature. It is based on the principle of repetitive exercise against increased resistance, with an elastic band in the middle of the apparatus providing the resistance. The three strengths of the band enable the resistance to be increased as the client progresses. It is placed between the corners of the mouth and the lips close around it. David was instructed to contract the two ends for two seconds and then relax but he failed to benefit. It encouraged over-activity of the right side and did not increase activity on the left. 3. Compensatory Strategies There were a number of strategies trialled with David and, although none of these made his swallow safer or more effective, they added to the clinical picture. i) The Shaker exercise was trialled on one occasion with the aim of increasing upper oesophageal opening. David could not raise his head or manage his saliva in this position. (David sleeps in a sitting position due to his poor saliva management and increased reflux.) ii) The Masako Manoeuvre aims to get greater base of tongue

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Clinical decisions

approximation to the posterior pharyngeal wall during swallow. David was unable to hold his tongue between his teeth as required for this manoeuvre. His difficulties were due to poor lingual control, sensation and proprioception. iii) A head turn to the left was trialled to occlude the hypothesised weaker left side following his medullary infarct. There was no functional change in swallow. 4. Other a. A variety of cups and methods of presenting the bolus were introduced to compensate for Davids poor lip seal. Results were variable for each item trialled with no obvious benefits over a number of trials. b. Oral tastes were introduced to increase pleasure and practise swallowing. David failed to use these tastes unless in a therapeutic setting. c. An effortful swallow was also attempted. David struggled with the task and there were no obvious benefits. 5. Surface Electromyography (sEMG) As a literature review had indicated an opportunity to trial sEMG, I contacted the clinical scientists in the Trust to establish whether they had or could produce appropriate equipment for a trial. They provided Biograph Infiniti software (Thought Technology Limited) installed on a laptop. Electromyography is the electrical manifestation of the neuromuscular activation associated with a contracting muscle (Basmajian & De Luca, 1985). In its original state this electricity is measured as an EMG signal in raw form with limited
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value in rehabilitation, although it can be useful in diagnosis. For the purposes of biofeedback, several transformations occur to produce a signal that is more easily understood by a client. The tracing is averaged and amplified to produce a smooth representation of a motor response. In sEMG this tracing represents strength on the vertical axis and timing of contraction on the horizontal. A triode was placed between Davids mandible anteriorly and his hyoid posteriorly (Bryant, 1991). This measures the activity of the collective suprahyoid muscles involved in laryngeal excursion, including some feedback from the floor of the mouth and lingual musculature. When I placed the triode on myself in the submandible region it was apparent that the micro volts recorded were the same as a complete swallow if my tongue was pushed up against the alveolar ridge. We therefore used the subhyoid placement with David in an attempt to overcome this issue.

David tended to move his head in an attempt to control the bolus and to initiate a swallow. This movement interfered with the trace gained by the EMG and so he was facilitated to keep his head still and in midline. He closed his eyes for periods due to the effort he put into initiating a swallow, which impacted on his ability to see the feedback screen. It is fundamental to the principle of biofeedback that the client can see the computer screen as the movement is being performed to effect change. I provided verbal feedback as to the amplitude of the peak and recorded it to allow him to watch it back and increase his understanding of the principles. I hoped that increasing his understanding of what I was doing and why would encourage him to use the feedback whilst swallowing. While there was no change, the recording allowed review of sessions and easy comparison with baseline measures. Liz Ackroyd is a speech and language therapist with South Birmingham Primary Care Trust. Part 1 of this article (When traditional techniques are not enough) is in the Spring 09 issue of Speech & Language Therapy in Practice, pp.12 - 14.

References
Triode placement I administered the bolus to David via a straw to control bolus size. He was unable to do this himself due to poor fine motor control and reduced dexterity. I encouraged David through coaching and visual imagery to perform an effortful swallow despite its lack of functional utility at bedside assessment.

Basmajian, J.V. & De Luca, C.J. (1985) Muscles Alive (5th edn) Baltimore: Williams and Wilkins. Bryant, M. (1991) Biofeedback in the Treatment of a Selected Dysphagia Patient, Dysphagia 6, SLTP pp.140-144.

SPEECH & LANGUAGE THERAPY IN PRACTICE spring 09