Joanna started at the Carter Swallowing Center being unable to swallow any foods or liquids, including her much needed medication which she could not crush and put in her feeding tube.  Her not being able to eat was made worse by the fact that she is a wonderful chef for whom eating and enjoying food is a huge part of her life.  To say that she was motivated to improve her swallowing is an understatement.

Joanna came the Carter Swallowing Center to do therapy 3 times a week and did a home swallowing exercise program daily between sessions.  In therapy we used VitalStim Therapy as well as sEMG biofeedback and had her practice swallowing with these devices to build back up the strength in her swallowing muscles.   As she says in the news segment, she started to make progress right away and after 6 weeks of treatment she is now able to eat whatever she wants.  

Joanna, whom I have come to know as someone who routinely makes lemonade from lemons, used her culinary skills along the way to create delicious dishes that were within the range of what she could safely swallow.   In fact, she is currently working on a gourmet cookbook for patients with dysphagia.  Stayed tuned for more info on when those tasty recipes become available!

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This patient has progressed to being able to eat solid foods and no longer needs to eat her puree delights, but she is seriously considering creating a gourmet cookbook for other patients with dysphagia.   Below is a sample recipe that she has shared with me.

Black Bean Soup Caribe

Take a trip to the tropics with this luscious soup.  The velvety black beans are given high notes of lime, ginger, and garlic, then finished with a dollop of sour cream and silken smooth avocado.

Serves 4 generously. (“Honey” thick liquid consistency; can be thickened to puree with drink thickener if need be )

Ingredients:

Puree food CAN be delicious

2 Tablespoons butter

1 large clove garlic

1-inch cube fresh ginger

¾ cup onion, fine dice

1 teaspoon smoked paprika

Scant ¼ teaspoon chipotle powder

1 carrot, peeled and diced

3 x 15oz cans of black beans,

including the liquid and sediment

1 cup water

Salt  to taste

 Garnish

 ½ avocado

½ cup sour cream

1 lime

Finely diced red onion

Finely diced tomato

Lime wedges

How to make it:

Finely mince garlic and ginger and add along with onion to the butter in a sauté pan.  Gently sauté until everything is translucent.  Add smoked paprika (also known as Spanish paprika) and the chipotle powder and stir until well blended and fragrant.

Add the carrots and beans*; use the cup of water to rinse the cans out, taking care to get all the juice and sediment. (They add flavor and color to the soup.) Bring to a boil, reduce heat, cover and simmer for 15 minutes.

Remove from heat. Because  bean skins can be tough, you may need to process the soup in batches to get it perfectly smooth, stopping processor and scraping down the bowl every few minutes.  Don’t be alarmed if it seems to be taking a long time – every processor is different.

*If sharing the soup with people who have no swallowing issues, I reserve about ¼ of the beans processing them and add them back to their bowls when serving.

Garnish:

Mash the avocado and push through a fine sieve.  Stir in some salt and a good squeeze of lime juice. Stir sour cream to loosen it and add a dollop to each bowl, followed by a second dollop of avocado.

I garnish my plate as shown in the photo – a pretty plate whets the appetite.  The flowers are to remind me not to eat the garnish from the rim of the bowl

For the folks who are getting the ‘regular’ version, top with the diced  red onion and tomato, and grate a little lime zest on top.

To drink:

Piña Colada

Mango or Guava Nectar

© Joanna Jordan Dyson 2012

If you try this recipe, let us know what you think!

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One of the medical risks for patients who have difficulty swallowing is the threat of aspiration pneumonia.  The safest way to minimize the risk of aspiration pneumonia is to avoid drinking thin liquids if they enter the windpipe when drinking (which is called aspiration).  However, being unable to drink thin liquids can really decrease quality of life.  Fortunately, there is a commonly used program, the Frazier Water Protocol, which allows patients to drink water by minimizing the risk of pneumonia.

Rationale of the program:

The Frazier Water Protocol (FWP), which was first developed at Frazier Rehab Institute in Louisville KY in the 90’s, allow people who have difficulty swallowing to drink water with almost no reported incidence of aspiration pneumonia when adhering to the guidelines.

The human body is about 60% water.  When water is aspirated (enters the windpipe), small amounts of water taken into the lungs can be quickly absorbed into the body.  Unlike soda or coffee, water has a neutral pH level.  Therefore, it can be well tolerated by the lungs since it is quickly absorbed into the bloodstream.

The key to success of the Frazier Water Protocol is good oral care.  The mouth is full of bacteria which are colonized very quickly with gram-negative bacillus, staphylococcus aureus, or yeast, which can then be aspirated into the lungs.  If saliva is aspirated, sometimes the amount of bacteria can be so great that it can overwhelm an already weak immune system.  That’s when aspiration pneumonia is likely to develop.

By drinking only water and minimizing the amount of bacteria in the mouth, the risk of the aspirated water resulting in pneumonia can be reduced.

Frazier Water Protocol Guidelines:

• Water intake is unrestricted prior to a meal and allowed 30 minutes after a meal.
• The period of time following the meal allows naturally occurring swallows and gravity to clear any food particles remaining in the throat which could potentially be washed into the lungs when water drinking resumes.
• Also, check for and clear any residual food in mouth before resuming water intake.

• Good oral care is essential to keep oral bacteria from being aspirated.
• Rinse your mouth with a 1.5% hydrogen-peroxide solution 3 times a day.  Most hydrogen peroxide is 3% in the bottle and can be diluted with water to make a mixture that is 1.5%.  Greater than 3% can be harmful and less than 1% has no benefit.
• Twice-daily brushing (the friction helps clear bacteria)
• Suctioning of saliva as needed to decrease bacterial load
• Keep the mouth moist to decrease bacteria growth
• Aggressive oral care should be provided to patients who are unable to clean their own teeth and mouths

• Medications should not be taken with water, as pills may be washed into the lungs.

• Do NOT drink water during meals as particles of food from the meal may be washed into the lungs.  Drink thickened liquids, if prescribed by your speech pathologist, or no liquids during a meal.

Like all medical programs, not all people who aspirate thin liquids are appropriate for the Frazier Water Protocol.  But if you have difficulty swallowing and have been told to avoid drinking thin liquids, you may want to talk with your speech pathologist about if you may be a candidate for this program.

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 photo courtesy of Massdistraction Flickr Creative Commons License

References about the Frazier Water Protocol:

Carlaw C, et al. (2011) Outcomes of a pilot water protocol project in a rehabilitation hospital. Dysphagia (epub) DOI: 10.1007/s00455-011-9366-9.

Frey, K. L. (2011). Comparison of outcomes before and after implementation of a water protocol for patients with cerebrovascular accident and dysphagia. Journal of Neuroscience Nursing, 43(3), 165–171.

Garon, B.R., Engle, M., Ormiston, C. (1997).  A randomized control study to determine the effects of unlimited oral intake of water in patients with identified aspiration. Journal of Neurological Rehabilitation, 11 (3): 139-48.

Gaspar, P.M. (1999). Water intake of nursing home residents. Journal of Gerontological Nursing, 25: 23-29.

Langmore, S.E., Terpenning, M.S., Schork, A., et al. (1998). Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia, 13: 69-81.

Millns, B., et al. (2003). Acute stroke predisposes to oral gram-negative Bacilli: A cause of aspiration pneumonia? Gerontology, 49: 173-76.

Palmer, L.B., et al. (2001). Oral clearance and pathogenic oropharyngeal colonization in the elderly. American Journal of Respiratory Critical Care Medicine, 164 (3): 464-68.

Scannapieco, F.A., Mylotte, J.M. (1996). Relationships between periodontal disease and bacterial pneumonia. Journal of Periodontal Research, 67 (10): 1114-22.

Yoneyama T., Yoshida, M., Ohrui, T., et al. (2002). Oral care reduces pneumonia in older patients in nursing homes. Journal of American Geriatrics Society, 50: 430-33.

Of course the best way to reduce the risk of aspiration pneumonia is to have a thorough swallowing evaluation from an experienced speech pathologist who can identify what foods and drinks are safest for you and what type of therapy may help improve your swallowing.

In addition to consulting with a speech pathologist, there are other things you can do to lessen the chance of pneumonia even more.

Research (Langmore et al, 1998) has identified some surprising factors that put a person who has difficulty swallowing at a greater risk of aspiration pneumonia:

•  Poor oral care/dependency on others for oral care:   The presence of aspiration during swallowing is bad enough already, but it can be further worsened by what is aspirated.   Poor oral care results in higher amounts of bacteria in the mouth, and these oral bacteria can contribute to pneumonia if they make their way to the lungs.  If oral care is not good, food, liquid, and even saliva will pick up this oral bacteria and transport it to the lungs if it is aspirated.   So while it’s bad that the food, liquid, or saliva has entered the lungs, the problem is made even worse by the addition of the oral bacteria as well.   So oral care that includes scrubbing the tongue and gums with a toothbrush and using a good antiseptic mouth rinse reduces the risk of oral bacteria entering the lungs.

•  Dependency on others for feeding.    An unfortunate fact is that in many health care facilities the people who assist patients in eating are often under pressure to feed as many patients as possible in a short amount of time.   This can result in large bites of food being presented too quickly, and a rushed meal doesn’t allow for strategies that can help with swallowing difficulty such as doing extra swallows for each bite or taking sips of liquid to rinse away particles of food.   This all adds up to a greater risk of aspiration and pneumonia.  If you have a family member in a health care setting with difficulty swallowing, inquire about if the staff has been trained on dysphagia and the risk of aspiration during feeding.   The caregivers who feed patients likely do not know that they may be putting their patients at risk with the feeding techniques they use.

• Poor pulmonary clearance and weak cough.  Speech pathologists love it when people cough.  OK, that sounds a little strange, but coughing is the body’s natural protection against aspiration so a strong cough reflex, particularly for someone who has dysphagia, is good.   If the cough is weak, that can often be improved in swallowing therapy.  In addition to having a strong cough, another natural deterrent of pneumonia is being physically active, and any amount of physical activity is better than sitting still in a bed or chair all day.  A person who gets out of bed and moves around is less likely to develop pneumonia than someone who is not as active.  

• A dry mouth fosters increased oral bacteria.  A common side effect of many medications is a dry mouth or Xerostomia.   When saliva is decreased, oral bacteria can build up and increase the risk of gingivitis and tooth decay.   This brings us back to the first point about oral bacteria traveling to the lungs.  Lungs and oral bacteria just do not mix.   If your medications cause dry mouth, talk with the doctor who prescribed the medication to see if another medication that does not have that side effect could be substituted.

• Lying down after eating.   The risk of aspiration doesn’t go away after the meal is over.   People with difficulty swallowing can have small particles of food remain in the throat after swallowing.  Gravity is our friend in these instances, and the longer a person stays upright the better chance these particles have in making their way to the stomach.  If the food particles stay in the throat, it is much easier for them to fall into the airway as soon as the person lies down.    There is also the risk of stomach contents, which increase after eating, coming back up into the throat and being aspirated when lying down.  So stay upright and let gravity work in your favor for as long as possible after eating.

• Smoking.   Add aspiration pneumonia to the long list of health risks that can result from smoking.    Smoking increases the “pollution” in the mouth and decreases pulmonary function for clearing aspiration.   A dirty mouth and poor ability to cough is a recipe for disaster for someone with dysphagia.   So the risk of aspiration pneumonia is yet another reason to quit smoking.

So in addition to following the medical advice provided by your doctor or speech pathologist, arm yourself with these defense mechanisms to further decrease your chances of aspiration pneumonia.

Staying healthy while you recover from dysphagia  is what it’s all about!

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Langmore S, Terpenning M, Schork A, Chen Y, Murray J, Lopatin D, Loesche W.  Predictors of Aspiration Pneumonia: How Important Is Dysphagia? Dysphagia 13:69–81 (1998).

photo courtesy of Massdistraction Flickr Creative Commons License

What is LSVT?    The program is based on some key principles of why specifically patients with Parkinson’s have reduced clarity of speech and subsequently diminished ability to communicate.   Part of the disease process of PD results in a decreased ability of the patient to accurately sense and hear the loudness of their own speech.     Thus patients with this condition speak at a very soft volume because when speech is at a normal loudness, the speech is perceived as being too loud.    When cued to speak loudly, PD patient hear themselves as yelling or screaming.   So just telling a patient with Parkinson’s to “speak up!” won’t work because the disease has impaired the person’s ability to self-regulate the volume of their speech.

So the LSVT program intensely works to increase loud speech and “recalibrate” a person with PD’s ability to judge the loudness of their speech so that they can internally cue themselves to be loud enough.  This means that the person with PD will be able to speak loud enough to be heard without someone else constantly reminding them to speak louder.     The dramatic impact this has on communication is simply amazing.

The other unique aspect to the LSVT program is that it is designed to make the significant improvements in communication by focusing on the most effective, yet most simple instruction for the patient.  The reason for this is the more simple the instructions, the easier to generalize and use outside of speech therapy.   By just training a patient to be “LOUD”,  the program has been found to improve the rate of speech, articulation precision, intonation, breath support, facial expression, and of course, the volume of speech.

The impact this treatment can have on a person’s speech is dramatic which you can see in this before/after video…

What does the research say about LSVT?:    There have been numerous studies showing that after LSVT patients with PD can demonstrate a 2-4 decibel increase in loudness which equates to a 40% perceptual change in volume.   And the even better news is that these changes have been found to last for 2 years after treatment.   The LSVT instructors said that the changes can actually last longer 2 years, but that is just the amount of time that was monitored in the study.

Some other interesting findings in the research about LSVT include….

•  PD patients have been found to have improvements in dysphagia (difficulty swallowing)  following LSVT which include better oral transit time (how long it takes to move food/drinks in the mouth toward the throat), decreased oral residue (food remaining in the mouth after the swallow), improved bolus formation (holding the food or drink cohesively in the mouth), and decreased pharyngeal stasis (food remaining in the throat after the swallow).   So speech AND swallowing can both get better with this program.

•  LSVT is also emerging as being effective for a broader range of diagnoses besides Parkinson’s disease.  The other conditions that this treatment may be appropriate for include Parkinson’s Plus, stroke, Multiple Sclerosis, Ataxia, and changes in voice related to normal aging.

•  Children with Cerebral Palsy and Down Syndrome have also benefited from LSVT…not just adults.   Research has found a significant improvement in communication for children with these diagnoses after LSVT.

•  A new program, LSVT BIG, has also been developed to help improve the functional movement of patients with Parkinson’s disease using the same concepts of intensity, amplitude, calibration as LSVT LOUD.  So the program helps patients maintain the speed and amplitude of movements which are impacted by Parkinson’s disease.   Check out this video about the impact LSVT BIG has on patients’ lives…

Given how LSVT can dramatically change the lives of people with Parkinson’s disease, I am proud that it is one of the many  speech and swallowing programs offered at the Carter Swallowing Center!

Have you treated someone using LSVT or been a patient treated with the LSVT program?  Please share your LSVT success stories!

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photo courtesy of deovolenti Flickr Creative Commons License

Happy New Year! I am eager to start the new year and launch all my new plans for the Carter Swallowing Center. For me 2012 will be all about Reaching Dysphagia Patients and Teaching Dysphagia Clinicians…

Reaching dysphagia patients:   Anyone who has ever heard me talk about my swallowing center for more than 5 minutes has probably heard about my dream for the clinic:  I want any patients who have dysphagia and want to get better to be able to find my clinic so that I can help them recover their swallowing function.   My previous job as a dysphagia clinical specialist for VitalStim allowed me an opportunity to learn about all the latest treatments for difficulty swallowing so that I could then teach VitalStim customers about these dysphagia treatments.   While that was a fun and intellectually stimulating job, the more I learned the more I missed treating my own patients.   In January 2011 my dream of creating my own swallowing clinic where patients can have access to all of these great new treatments began to take form (see my blog about that journey).

So, for 2012 my quest continues to spread the word about all of the new possibilities for treating dysphagia and to let patients and doctors know that difficulty swallowing CAN get better!    I have plans to speak to more patient groups and physician offices about the latest treatments for dysphagia.  One group that I feel can particularly benefit from these new treatments are patients who have been treated for head and neck cancer and are unable to swallow after the cancer treatment.   Check out my other blog post about the treatments for this population.   What is so exciting about reaching out to this group is that until very recently, swallowing therapy for this population was just not that effective.  The tough fibrotic tissue that forms on the neck after radiation treatment limited what could be done.   It has been exciting to see several of my patients that had not benefited from previous attempts at swallowing therapy successfully respond to the new dysphagia treatments I provided.  In 2012 I hope to help a lot more patients know about the new options available that could help their swallowing.

Teaching dysphagia clinicians:   As a speech pathologist that treats patients with dysphagia, I feel fortunate to have a job that I absolutely love.  I enjoy my job so much that even when I’m not at work, I love talking about dysphagia (OK, I admit that’s a little geeky).  So an equally rewarding part of my job is being able to teach other clinicians who treat dysphagia and hopefully help enhance the swallowing therapy that their patients receive.  For 2012, I will be continuing to teach the CIAO Seminars VitalStim certification course around the country.   After I took the certification course myself in 2005, VitalStim Therapy changed the way I do swallowing therapy.  So it is very rewarding to be able to “pass the torch” and show other clinicians how to use this modality.   I will also continue teaching a 2-day Dysphagia Evaluation and Treatment course.  This course really dives into all of the latest swallowing treatments so it again allows me the opportunity to not only share what I have been able to learn about dysphagia but also to hear great ideas from other dysphagia clinicians.  I always say that we clinicians all have a lot to learn from each other, so I am also excited to be starting the Denver Dysphagia Rounds which will allow us Denver dysphagia clinicians a chance to come together 4 times a year to share ideas and learn from one another.

In addition to traveling to teach speech pathologists around the country, I am excited to announce that I have 2 webinars about dysphagia that should be available on the CIAO Seminars website any day now (links to the courses to follow).  One is a 3 hour course on esophageal dysphagia and the role of the SLP, and the other is a 1 hour course on the neurophysiology of swallowing.  I hope that both of these tools will be valuable to dysphagia clinicians out there and that the format of an on-demand webinar will be able to reach a broader audience.

To me, it’s all about spreading the word about therapy for difficulty swallowing.   Letting patients and doctors know that treatment is now much more than just thickening liquids (yuck) and helping other clinicians learn about all of the new advances in dysphagia treatment.  So here’s to 2012…may that many more people be able to recover their swallowing function this year!

What are your plans and goals for 2012??

 photo courtesy of Ludie Cochran Flickr Creative Commons License

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Speech pathologists from all over the world meet at the Dysphagia Research Society conference every year to present and discuss the latest and greatest in swallowing research.  Many of these studies eventually go on to be published in peer-reviewed journals, but since publication can be a time-consuming process, the DRS presentations allow a sneak peek at the most current findings in dysphagia research before they are even “hot off the press”.

Of the dozens and dozens of presentations given at the 2011 conference, below are the hot topics that I believe might lead to significant differences in swallowing therapy…

Adherence to Swallowing Exercises on Swallowing Outcomes for Head and Neck Cancer Patients.

This study evaluated the effectiveness of prescribed swallowing exercises on improving therapy outcomes with patients following treatment for head and neck cancer.   The exercises prescribed included the Shaker, Mendelsohn maneuver, supraglottic swallow, falsetto glides, Masako, and effortful swallow.

Conclusion:  Patients who performed swallowing exercises during radiation treatment had significantly higher outcomes at 6 months, 1 year, and 2 years after radiation treatment.  These results suggest that adherence to swallowing exercises may be effective in preventing decline in swallowing-related quality of life after radiation treatment. University of Texas MD Anderson Cancer Center (Shinn E, et al).

Jen’s comments:  The study further supports the hopefully growing trend of referring patients who are being treated for head and neck cancer to a speech pathologist BEFORE they develop swallowing problems.   There are increasing reports that doing swallowing exercises and myofascial release before, during, and immediately following radiation treatment (vs. years after radiation when dysphagia has gotten severe) can significantly help preserve strength and range of motion of the swallowing mechanism.

Training for Dysphagia with Metronome Improves Swallowing Function in Parkinson’s Disease

Twenty patients with Parkinson’s Disease and moderate dysphagia were divided into 2 groups.  The experimental therapy consisted of cervical stretching, lingual exercise, and deglutition of jelly to the rhythm of six beats of a metronome.  The control therapy was identical but without the metronome.  When the subjects were evaluated with a Modified Barium Swallow study, the amount of residuals in the valleculae and pyriform sinuses when swallowing jelly was decreased after training with the metronome vs. training without the metronome.

Conclusion:  Training with the metronome during swallowing was effective for shortening oral transit time and decreasing the amount of residuals in the pharynx for patients with Parkinson’s disease.  University of Health Science, Kobe, Hyogo, Japan.  (Nozaki S, et al.)

Jen’ comments:   Patient’s with Parkinson’s disease often have significant difficulty with coordination of the swallow which eventually leads to weakness and dysphagia.  The use of the metronome likely helps improve coordination and control during the swallow, which are some of the most challenging aspects to treat with this population.   It will be interesting to see more details about this type of therapy as it is researched further.

Effects of Effortful Swallow on Esophageal Peristalsis

Esophageal dysfunctions are typically treated using medications with varying success.  This study manometrically examined the effects of an effortful pharyngeal swallow to assess the impact it may have on esophageal function.  The effortful swallow yielded greater esophageal amplitudes and longer esophageal duration which decreased incomplete bolus clearance.

Conclusion:  The effortful swallow may offer a behavioral manipulation of esophageal dysfunction.  Further studies will determine its clinical potential in patients with esophageal dysmotility. Wake Forest University, Winston-Salem NC (Butler, et al)

Jen’s comments:  While speech pathologists have many available treatments to effectively treat oral and pharyngeal dysphagia, we currently have no tools to actively improve esophageal dysfunction.  So these are very promising findings.

McNeill Dysphagia Therapy Program (MDTP) (2 studies)

Independent Evaluation and Outcome Data with Moderate to Severe Chronic Oropharyngeal Dysphagia

Five patients (1 stroke, 4 head and neck cancer) who were an average of 7.7 years post onset who had all failed previous trials of traditional swallowing therapy completed 15 sessions of MDTP.  Four out of five showed marked improvements in all measurements of swallowing.

Conclusion:  The positive outcomes of MDTP can be generalized to different clinical programs.  MDTP is emerging as a promising therapy for patients with chronic, mod-severe oropharyngeal dysphagia.  Antwerp University Hospital (VanNuffelen G, et al)

Jen’s comments:  Previously the research about MDTP had only been conducted by the developers of the program at University of Florida, so it is great to see that the high level of success with this program  for patients with chronic dysphagia is being replicated elsewhere.

Improved Temporal Coordination of Swallowing Following MDTP

Eight patients with chronic dysphagia completed 15 sessions of MDTP.  The patients demonstrated significant changes in timing of swallowing speed.

Conclusion:  Dysphagia therapy with MDTP improves timing of physiologic events during swallowing. University of Florida (Lan Y, et al)

Jen’s comments:  Since the MDTP program is designed to restore both strength and speed of swallowing function, both which are vital for normal swallowing, it is not a surprise that the program would result in improved swallowing speed.  This is likely one of the first studies about MDTP to objectively document this change in swallowing speed as a result of the treatment.

A complete list of all the presentations given at the 2011 DRS conference can be found in the December issue of Dysphagia (2011) 26:432–47.

 photo courtesy of rosefirerising Flickr Creative Commons License

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The movie debuted at the ASHA convention last week (followed by roaring applause from the audience of speech pathologists). As Dr. Peter Belafsky (an ENT at UC Davis) says in the movie, swallowing difficulty is “underrated in the medical community”. This movie was created to increase awareness and bring much needed attention to the millions of people living with this condition.

I’m so glad to see that this film is now available for millions to see on YouTube.  It’s a short 15 minute documentary-

I’d love to hear what you think of the movie- please shoot me an email or post on the Carter Swallowing Center Facebook page after you have a chance to watch it. And if you like it, pass it on to someone you know. It’s things like this that can help put dysphagia on the medical radar!

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Gastroesophageal reflux disease (GERD) is when reflux from the stomach leaks backward to the esophagus (food tube from the lower throat to the stomach).   Laryngopharyngeal reflux  (LPR) is when the stomach contents reflux into the esophagus and then progress further into the larynx (voice box) and pharynx (food tube in the upper throat).   While GERD and LPR are very similar in nature, the symptoms of these 2 conditions are actually quite different depending on where the reflux goes.

GERD:   GERD is one of the most common medical conditions in the Western hemisphere, which has a lot to do with the diet and lifestyle of this culture.  It is estimated that 44% of people experience some sort of esophageal reflux on a regular basis.   The hallmark of GERD is heartburn, and if you’ve watch TV lately no doubt you’ve seen that there are numerous medications on the market for the treatment of heartburn and GERD.  The diagnosis of GERD is made by a gastroenterologist who can determine which type of medication would be most appropriate for treating a particular patient’s symptoms.

LPR: When the acidic stomach contents reflux to the throat, significant damage can be done to the throat which includes the voice box (larynx), airway (trachea), and food tube (pharynx).    The symptoms of LPR include hoarseness, excessive throat clearing or coughing, copious amounts of mucous, a feeling of a lump in the throat, and difficulty swallowing.    LPR is often called “silent” reflux because the symptoms of this condition rarely include the heartburn that most people think of when they hear the term reflux.   The reason that patients with LPR do not generally suffer from heartburn is that the reflux spends little time in the esophagus and actually does most of its damage in the throat.  As a speech pathologist, I see many, many patients with the diagnosis of LPR and almost all of them are not aware that they have “reflux”.   While the diagnosis of GERD is typically made by a gastroenterologist, a diagnosis of LPR is usually made by an otolaryngologist (ear, nose and throat doctor).  ENTs and speech pathologists work together to manage LPR with patients who have the symptoms of hoarseness, throat clearing, and difficulty swallowing.

The Voice and Swallowing Clinic at UC Davis has developed a validated a 9-item Reflux Symptom Index (RSI) to assess the severity of LPR symptoms.  A RSI score greater than 10 may indicate significant reflux.

From http://www.ucdvoice.org/lpr.html

Medical treatment for GERD and LPR:   Even though the symptoms of these 2 conditions can be quite different, the treatments, which aim to reduce the backflow of stomach contents, are similar.

Some medications decrease the amount of acid produced in the stomach (proton pump inhibitors or PPIs) and some medications lower the amount of acid released in the stomach (H2 blockers).   A gastroenterologist can determine which type of medication would be most appropriate for reducing the backflow of stomach acid for each particular patient.

Behavior treatment for GERD and LPR:  When talking with my swallowing therapy patients that have been diagnosed with GERD and LPR, I emphasize that lifestyle changes related to reflux play a role equally important to medications in effective treatment of these conditions.    Behavioral changes that I suggest as part of swallowing therapy include the following:

• Minimize caffeine, alcohol, and peppermint.  These items relax the sphincter between the stomach and the esophagus which may allow more backflow of the stomach contents into the esophagus.
• Lose weight loss, if overweight
• Avoid foods that may incite more acid production or have a higher acid content: citrus, tomato, vinegar, high fat foods, olives and olive oil, nuts, dairy,  and coffee
• Elevate the head of the bed 6-8 inches.  The elevation needs to be a gradual angle rather than bending at the waist with extra pillows which can pinch the stomach and make the problem worse.   There are bed frames can be purchased online that can create this gradual angle of elevation, or a less expensive option is to elevate the head of the bed 2-6 inches on both sides with wood blocks or bricks.
• Avoid eating 3-4 hours prior to lying down or sleeping.
• Avoid wearing abdominally restrictive clothing such as tight pants
• Eat smaller meals

More next time on “why are patients with LPR and GERD seeing a swallowing therapist?”….

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Medicare benefits for speech therapy are in danger of becoming limited by arbitrary financial limits unless Congress takes action.  This could result in many seniors not being able to receive all the therapy they need even when they have the potential to make additional progress.

Speech pathologists, physical therapists, and occupational therapists are lobbying Congress to make sure that therapy services remain appropriately covered by Medicare for the patients who need them.  As Congress continues its attempts to rein in Medicare costs, it is important that clinicians and patients join in the fight and let our voices be heard on Capitol Hill!  You can help protect therapy benefits by telling your local U.S. Congressmen and U.S. Senators to pass legislation to extend the Medicare therapy cap exceptions process beyond December 31, 2011.

The Medicare therapy cap is a financial limit that has been placed on the amount of therapy services Medicare will cover. In 2011, it caps coverage of outpatient rehabilitation services to $1,870 for physical therapy and speech therapy services combined. Not all patients will exceed the cap, but Medicare beneficiaries who suffer from a stroke, have Parkinson’s disease, or multiples instances of care are very likely to need more treatment than the cap permits.

Congress has recognized the problem with the cap on therapy services in the past. Since the therapy caps were passed by Congress in the Balanced Budget Act of 1997, Congress has passed several moratoriums which allow patients to exceed the cap if ongoing progress can be documented in therapy.   If the exceptions process is not extended or completely repealed then patients will be denied services when this financial limit has been reached.

It is important that we send a strong message to our Members of Congress and request that they pass legislation to extend the Medicare therapy cap exceptions process beyond December 31, 2011.

Action couldn’t be easier….

• Call your Members of Congress.   You can find out who your current Members of Congress are and their phone numbers online.
  • Ask your member of congress to sign onto the Medicare Access to Rehabilitation Services Act of 2011 (H.R. 1546/S. 829) which repeals the cap once and for all.
•  Utilize the American Speech Language Hearing Association (ASHA) action center to send an email message to your Members of Congress.     All you have to do is enter your name and address, and the website will automatically send the message to your Members of Congress.