Sunday, January 25, 2015

ACP and sEMG: Synchrony for Dysphagia

Surface Electromyography (sEMG) has been used in dysphagia therapy for several years with research to support it's use.

sEMG is a use of visual biofeedback.  Electrodes are attached to the submental muscles, or those hyolaryngeal complex elevators.  This is measuring the "strength" or muscle contraction of the swallow as you have your patient swallow, then swallow with greater effort.

The electrodes are attached to a box or computer that gives a visual output and measures the strength of the swallow, allowing the patient to see their effort, rather than relying on simply feeling the effort.
The Promethius Group is one of the  companies that manufactures and sells sEMG devices.

ACP (Accelerated Care Plus) has been around for quite some time.  They supply neuromuscular electrical stimulation (estim) equipment for PT and OT in Skilled Nursing Facilities (SNF) and rehabilitation centers.  They are also the company that provides the Omnicycle and OmniVR (similar to the Wii with rehabilitation goals programmed into the product.

ACP was at the 2014 ASHA Convention with a brand new product!!  Synchrony was introduced as ACP's new contribution to sEMG in dysphagia therapy.

One of the components of Synchrony is Omnistim FX:  Patterned Electrical Neuromuscular Stimulation (PENS).  This is the ACP brand of estim for dysphagia.

Synchrony also offers OmnisEMG, which is a great way to let your patient visualize the length of time they hold a Mendelsohn Maneuver or the increased strength they apply to the effortful swallow.

You are able to evaluate your patient's swallow using Synchrony to start your baseline data to create your treatment plan.


There are various screens from which your patient can work.

ACP states that the system includes:

"System Installation and Speech Language Pathologist Training"  

  • Initial installation includes basic system operation.
  • All subsequent training includes CEU-Approved Education and Lab Training.
  • A 5-hour "on-site" course around ACP's OmnisEMG system.
  • A 7-hour "seminar-style" course can be provided for multiple facilities.
  • A 2.5 hour "on-site" course for the Omnistim FX2 PENS system is provided
  • ACP is an ASHA Approved Continuing Education Provider

With extensive training and support provided, the OmnisEMG seems like a viable option for sEMG.  

I was most impressed with the size of the screen, which allows our patients with decreased vision or visual deficits to be able to see the graphs and images on the screen.  

The system seemed incredibly easy to use and easy to learn.  If you work in a facility that utilizes ACP equipment, it may be worthwhile looking into the Synchrony system for sEMG.  




First you take the electrode and apply it to the patient:


                                      



Enter the patient history:



You can choose assessment or exercise.  Assessment allows you to set the baseline and measure progress.



You can select the muscle group which you will measure contraction.

                                    

There are 4 ways to visual the exercises.  Bar graph, line graph, Work-rest cycle and Kangaroo Exercise:

                                     


You also set the parameters.

                                     

Bar graph:



Line graph:


                                      


Kangaroo:









Monday, December 29, 2014

Phagia Puree Mixes

As you may be able to see from previous posts, I am always up for a challenge.  From sampling pureed foods to thickened liquids, I like to find the best available product for my patients.

The ASHA Convention

At the ASHA convention this year, the Dysphagia Divas were back with some new pureed mixes.  I was able to get samples of each type to take home and try.

The Phagia Puree Mixes are supposed to be available at www.dysphagia-diet.com or by calling 1-855-397-7424.  I have been unable to find the Phagia products on the website.

The Product

There are 7 products available:  Pureed Bread (12 3 oz packets for $15.25), French Toast (12 3.5 oz packets for $18.50), Bread Pudding (12 3.5 oz packets for $18.50), Egg and Toast (6 5 oz packets for $15.25), Peanut Butter Sandwich (6 4.5 oz packets for $22.50), Caramel Apple Pie (6 3 oz packets for $24.50) and Phagia Pureed Food Enhancer (6 5.5 oz packets for $24.50).

All packets contain a powder that you mix with either hot or boiling water.  You mix the packet with the water, use a whisk to combine the water and powder mixture and then let it sit for a specific number of minutes.

The Results

The products were really actually fairly palatable.  The egg and toast did taste like eggs.  The french toast was good, even given the texture of the pureed.  The caramel apple pie was a good dessert and my very picky 9 year old daughter even gave it a thumbs up!  The peanut butter sandwich had a very good flavor, mostly of peanut butter.  I, personally, wasn't a big fan of the bread, which had a strange, almost cardboard flavor to it or the bread pudding.

Overall, the food had good taste to it.  I think with food molds, it wouldn't have been difficult to tell that it was pureed.

The Pictures












Friday, December 26, 2014

My Letter to Healthcare

Dear Healthcare System,

I have to admit.  You never dazzled me at the beginning.  Throughout my college career, I was bound and determined to work in a school system with children.  That was my career goal.

My hospital externship provided my first insight into that world of not only the healthcare system, but adult therapy.  My beginnings with dysphagia therapy, were quite frankly disgusting and completely unappealing to me.

Something changed in that externship and I discovered that the world of adult therapy could be quite rewarding and found that I actually enjoyed it.  A passion and respect grew for that intricate system that is responsible for swallowing solids and liquids.  A system that can be quite fragile.  

I tried my hand in the school system, however my love for the medical field continued to grow.  I became extremely fascinated by the brain, muscles and cranial nerves.  Medications, lab values, tests, disease processes quickly became the area that I sought to learn as much as I possibly could.  

Somewhere, dear healthcare system, my passion has dimmed.  I continue to love my patients and have a passion for the swallowing process.  You have failed me with your demands.

Productivity feels like a roadblock that I can never conquer.  My value as a therapist should be considered by my outcomes or effort to achieve those outcomes.  Instead, my value is based on my productivity.  It doesn't matter that I never sat down the entire eight hour day, that I skipped lunch or documented through my session.  The time I spent educating nurses and family members can't count because the patient wasn't present.  Designing programs and learning new techniques to improve patient outcomes no longer matters.  What matters?  How many minutes I spent during the day with direct patient care or billable minutes.

COTS, RUGS, assessments, therapy caps and G-Codes haunt me.  Patients that aren't appropriate for 45 minutes of therapy are put on my schedule for 50 minutes.  Patients that require more speech minutes are put on my schedule for 30 minutes and heaven forbid, someone is sick or just doesn't want to participate in therapy that day.   I shouldn't go over the given number of minutes because that's just providing free therapy and we don't do that.

Somewhere along the line we have lost our purpose.  Documentation and reimbursement have shadowed patient rights and needs.  

We "justify" our therapy through our documentation.

I have lost my clinical judgement.  Sometimes, I'm not given permission to discharge a patient who has met their max potential and am probed as to whether I have tried "everything possible" with this person.  

We are told to document throughout lunch, however we have to clock out for lunch because it is required.  It is suggested that we clock out before completing documentation because we should have documented during the session.  

I can no longer abide by this human factory of herd the patients in and out, document, document, document.  I want my worth as a Speech Language Pathologist to be measured by the number of patients I help increase quality of life.  I want my worth to be measured by the patients that I help return to their prior level of function.  I don't want to get called back into the office to talk about how to boost my productivity.

So, my dear healthcare system, I will be leaving you.  I am returning to that long forgotten land of school systems, where I may have a large caseload, but my worth is not measured in the number of students I see everyday.  It's the quality of service I provide those students.  Until healthcare can return to that level and I'm allowed to provide services required by my patients, I bid you a fond farewell and a fond farewell to the dress code (color specific) I detest!

Sunday, December 7, 2014

MannaQure







How Did I Ever Find MannaQure?

This always happens to me during the ASHA convention.  I get to a point that I am, well, maybe a bit silly and start Tweeting about crazy things.  This is the time that my following rises the most.

This year was no different.  As I was Tweeting various pictures of our friend Mary, I had a new follower called MannaQure.  Naturally, I was wondering what my Tweets had to do with my nails.

I first looked at the website.   MannaQure is a comprehensive dysphagia and dysarthria evaluation.  Not only is it an evaluation, but it is designed for Spanish speaking patients.

I was wondering about the name.  I couldn't make the connection.  On the website, it states that:  "Manna"-Found in the book of Exodus, the food that was miraculously provided for the Israelites in the wilderness during their flight from Egypt. "Manna"-Mentioned in the bible, spiritual nourishment of divine origin. MannaQure is pronounced Manna."

What Is MannaQure?

I found the MannaQure booth the next day in the exhibit hall.  The protocol for this evaluation has the questions/instructions written in English, in Spanish with pronunciation for those that do not speak Spanish and just in Spanish for those that are able to speak Spanish.  All on the same protocol.

It looked like a fairly comprehensive evaluation, with a few questions regarding cranial nerves.  I would love to have more time to look over this evaluation.

The complete set sells for $225.  The Examiner's Manual alone is $125, 25 Questionnaires are $45 and 25 Protocols are $55.

If you work with Spanish Speaking patients, this may be an evaluation to look at.

Friday, November 28, 2014

ASHA Convention Withdrawal

I seriously cannot believe that I have been home for almost a week following the ASHA convention this year.  I was beyond excited to leave.  How beautiful and warm Orlando Florida was going to be compared to Indiana.   Writing this post has been a little difficult.  For one, the craziness of returning home has been abundant and it just makes me sad to think about my friends that I miss SO much!


Don't let the sunshine fool you.  It was chilly!!

After a long trek to the convention center, well the correct building anyway, I was able to register and pick up my materials.

Wednesday night started with Meet the Masters and a Jeri Logemann memorial pin.  The session was great.  I tweeted as much information as I possibly could!

Thursday was crazy!  SIG 13/BCS-S breakfast was at 7:00 in the morning!  Yes, that's right, I said 7!  After that was a full day of sessions, poster and the exhibit hall, followed by 2 more days of the same!

There is always that excitement of seeing friends that I haven't seen in a year and meeting new friends that I have chatted with on Twitter and Facebook for several years!




It was the year of the selfies and the usies.  I had the pleasure of FINALLY meeting Cyndee Bowen, Jonathon Waller and Kelley Babcock.  Spending time with the SLPeeps is what makes the convention great for me!

Between poster sessions and sessions, I learned a lot of new information that I'm still trying to sort out.  I'm still trying to figure it all out to submit CEUs as well!  

The exhibit hall proved to have so much information as well with several new dysphagia products that I will be sorting through, contacting companies and blogging about to let you know about the new products available!!

One of the saddest parts of the convention for me is the Closing Party.  Not that I don't have a great time, but I know it means saying goodbye.  This year's party was probably the best I've attended, however it was also the worst.  The way it was set up, it was very difficult to spend time with your friends and there were so many I never really had to opportunity to tell goodbye.  The Wizarding World of Harry Potter was amazing all the same!





Yes, I did try a Butter Beer and I did like it!!  

Keep watching for posts looking at a new pureed brand of food, new sEMG, books I discovered, a quick thought of the FEES equipment that attaches to your iPhone.....whew!!  

Knowing I still had a long drive home to see my family, I did have quite a surprise waiting for me at the Indianapolis airport.  My friend Tara flew in to head out to Ohio and JUST HAPPENED to still be there as I waited for my suitcase to arrive!


Is it bad that I'm already so excited for ASHA 15?


Pudding and a Straw



Picture from:  www.busymomboutique.com



Haven't you always wanted a very simple exercise that will work and strengthen the entire swallowing mechanism using resistance?  I do as well.  I have an exercise that I use all the time with my patients.  I am usually chastised by my co-workers when having patients use this exercise.  Patients give me a strange look until they try it.

This exercise has no fancy name.  I call it........Pudding with a Straw.  It is exactly as the name implies.  The patient drinks pudding through a straw.

So first, let's look at the evidence.......  I take into account that, from reading research.....I know using a straw increases labial activation.  A thicker, heavier bolus can add resistance to the swallow and can actually increase the movements both orally and pharyngeally with the swallow.   Using an effortful swallow increases sensory input to the swallowing mechanism.  Swallowing is a sub maximal event as a whole, but when the patient focuses and purposefully uses a more effortful swallow, there is an increase in the muscle contraction of the entire swallowing mechanism.

I take all of this into account and then try the method myself, to see what I feel.  When I drink pudding through a straw, not a Panera smoothie straw, not a regular drinking straw, a cocktail straw/coffee stirrer size straw, I can feel a difference.  My lips purse together with increased effort.  My tongue retracts and tightens, my jaw tightens.  I then suck enough pudding through the straw to swallow and use an effortful swallow.  At one time, I have incorporated straw use with a safe consistency bolus for most, an effortful swallow and a weighted bolus.  I have also used the entire swallowing structure.

I believe it is important and necessary that we look at the swallowing mechanism as a whole, a process, rather than 4 parts.  It's great to break the swallowing system down into phases for descriptive purposes, but every part of the swallow is connected in some manner and every part of the swallow deserves some attention.

Now, keep in mind, not every patient can start at the level of a small cocktail straw/coffee stirrer or even the pudding.  I can modify the straw by either using a larger diameter straw (Panera smoothie straws seem to be the largest I've found at this point).  Regular drinking straws also work very well.  Not only can I change the diameter of the straw, I can change the size of the straw by cutting it in half or in thirds.  The shorter the straw, the easier the task.

Now, keep in mind, the viscosity of pudding can be varied as well.  Many times I will use a thickened liquid or applesauce for patients that are not able to start with pudding.  I may work up to yogurt, without the fruit.  Then with the pudding, in my experience, I have found that sugar-free pudding seems to be the thinnest, followed by home-made, then Snack Pack pudding.  Snack Pudding, the chocolate seems to be the lesser viscous, followed by butterscotch, with vanilla having the thickest viscosity.  Room temperature vs. refrigerated also makes a difference.  Room temperature pudding is a little less tedious for the patients, while with the refrigerated, I'm also adding the temperature aspect to my sensory portion of therapy, in addition to the difficulty of the task.

I don't write a goal for the patient sucking pudding through a straw.  We may be working on lingual strengthening, pharyngeal strengthening, tongue base retraction, labial seal.  I don't write my notes as "the patient was able to drink a Snack Pack cup of refrigerated chocolate pudding."  We were working on using an effortful swallow, straw sucking for increased labial seal, weighted bolus for resistance.

Now I do time my patients and keep track of the time.  I will time the patient to see how long it takes to complete the task.  As the patient gains strength with the task, the time should decrease.  You can also use e-stim or sEMG with your patient as they are completing the task.

I don't stress if the patient needs the entire session time to complete the task.  This is what I want them to do!!  I want the patient to use an effortful swallow.  I want to apply the rules of neuroplasticity and use a specific swallowing task, applying resistance and specificity.  My patient is swallowing, using both an effortful swallow with a focus of tongue to palate contact and using a weighted bolus with the thick pudding.

I challenge you to try this exercise.  Try the vanilla with the coffee stirrer/cocktail straws and feel what the exercise does for you!

1 Clark, H.M. (2005).  Therapeutic exercise in dysphagia management: Philosophies, practices and challenges.  Perspectives in Swallowing and Swallowing Disorders, 24-27.

2 Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. Journal of Speech, Language, and Hearing Research, 51, S276-300.

3 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.

4 Clark, H.M. (2003). Neuromuscular treatments for speech and swallowing: A tutorial. 

5 Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.

6 Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.

7  Wheeler-Hegland, K.M., Rosenbek, J.C., Sapienza, C.M.  (2008).  Submental sEMG and Hyoid Movement During Mendelsohn Maneuver, Effortful Swallow, and Expiratory Muscle Strength Training.  Journal of Speech, Language and Hearing Research, 51, 1072-1087.

8  Burkhead LM.  Applications of Exercise Science in Dysphagia Rehabilitation.  Perspectives on Swallowing and Swallowing Disorders (Dysphagia) June 2009; 18: 43-48.

9 Park JW, Kim Y, Oh JC, Lee HJ.  Effortful Swallow Training combined with Electrical Stimulation in Post Stroke Dysphagia:  A Randomized Controlled Study.  Dypshagia (2012).  DOI: 10.1007/S00455-012-9403-3.

10  Bulow M, Olsson R, Ekbert O.  Videomanometric Analysis of Supraglottic Swallow, Effortful and Non Effortful Swallow and Chin Tuck in Healthy Volunteers.  Dysphagia.  (1999); 14(2):  67-72.  DOI: 10.1007/PL00009589.

Sunday, November 16, 2014

Blue Tree Publishing Apps Review

App:  Aspiration Disorders

Price:  $4.99

System:  iOS (iPhone, iPod Touch and iPad)

Version:  1.2

App:  Oral Disorders

Price:  $4.99

System:  iOS (iPhone, iPod Touch and iPad)


Version:  1.1

App:  Swallow ID

Price:  $4.99

System:  iOS (iPhone, iPod Touch and iPad)



Version:  1.1

App:  Vocal Folds ID

Price:  $2.99

System:  iOS (iPhone, iPod Touch and iPad)



Version:  1.3

App:  Larynx ID

Price:  $4.99

System:  iOS (iPhone, iPod Touch and iPad)



Version:  1.1

App: Residue Disorders

Price:  $4.99

System:  iOS (iPhone, iPod Touch and iPad)



Version:  1.1

I typically review apps individually.  These apps by Blue Tree Publishing are all very similar, so I decided to review them at once.  

If you've never heard of Blue Tree Publishing, they make incredible educational materials.  They started making educational apps which are great to share with patients, caregivers, physicians, nurses and anyone who may be interested.  The apps can be purchased individually or in a bundle.  


Each app offers a drawing that depicts each structure/function in the title.  The drawing can be viewed still or animated.

There is text that can be used to accompany the drawing or can be removed.  

With the swallowing apps, Aspiration Disorders, Oral Disorders, Swallow ID and Residue Disorders, a video of a modified barium swallow study showing the dysfunction is included on each app.  With the Aspiration Disorders app there is also a FEES video available of aspiration.

The Larynx ID does not have videos, but does have nice animations to show the muscle functions and the structures, including how they move.  Vocal Folds ID does have a video available showing the movement of the vocal cords during phonation.

These apps are definitely worth the money if you need a great educational app.