Feeling happy and honoured to see my name listed as one of the reviewer along side with all the world reknown dysphagia experts on the acknowledgment of reviewers page in the Dysphagia Journal for 2014. It has a great experience being a reviewer for this distinguished international journal for the very first time. Hope to have the opportunity to review more papers in future.
The Cerebral Palsy Alliance Singapore (CPAS) is organising the 8th CP Symposium from 10–12 September 2015.
Workshop “Dysphagia Assessment and Treatment for Adults and Children: Practical Applications and Cutting Edge Updates” by Dr Julie Cichero, BA, BSpThy (Hons), PhD Australia.
Date: 10 & 11 September 2015
Venue: Max Atria @ Singapore Expo
Target audiences: Speech-Language Pathologists / Therapists
Please click SLP e-brochure for registration details.
Fiberoptic Endoscopic Examination of Swallowing (Basic FEES) Workshop 2015
Hosted by The Chinese University of Hong Kong
The FEES workshops are structured to provide speech therapists and doctors with updates on dysphagia and serve to promote the use of FEES in the assessment of dysphagia, in rehabilitation planning and as a biofeedback tool. Clinical updates of dysphagia management and intervention methods will also be discussed. The workshops will also provide hands-on opportunities to participants which bridge the theory to practice. Organisers: Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, & Institute of Human Communicative Research, The Chinese University of Hong Kong Target participants: Speech Therapists, Otorhinolaryngologists and Medical Doctors.
Learning Objectives: The objectives of the 2-day workshop are to present:
The anatomy and neurology for swallowing
An overview of dysphagia
Swallowing assessment – principles and the diagnostic tools
Assessment of voice and laryngeal function
FEES –normal vs abnormal videos
Diagnostic options for patients – VFSS / FEES
Tips on endoscopy
Provide 3-4 hours of supervised hands-on practical passing the endoscope on other participant(s) and / or on dummies
Course Day: 14 & 15 December 2015 (Monday – Tuesday)
Venue: Prince of Wales Hospital, Shatin, Hong Kong
Registration is now opened, please go to the following link for the registration:
For the details of the workshop, please kindly refer to the attached flyer or visit our website: http://www.ihcr.cuhk.edu.hk/eng/events/main.htm
Due to the intensive nature of training, spaces are limited and processed on a first come first serve basis.
For overseas participants, you can email the secretariat for advice and special arrangements.
Applicants will be notified of the results of their application by email.
Should you need any further information, please feel free to contact the secretariat of the Program, Ms Rina To at (852) 3943 9609 or email@example.com.
The Singapore Nasopharyngeal Cancer (NPC) Support Group will be organizing the above mentioned talk.
Date: 21/5/2015 (Thursday)
Venue: CareConnect, Tan Tock Seng Hospital, Singapore
This talk is open to all NPC survivors / caregivers.
Speaker: Mr Yoon Wai Lam (Director of Speech Therapy Works, Part-time lecturer in the Master in Speech Pathology Programme, National University of Singapore)
Topic: How does NPC affect speech and swallowing? Can speech and swallowing function be maintained after radiotherapy?
Speech and swallowing difficulties can occur at the time when the diagnosis of NPC is made or it can also occur during and/or after treatment. In this talk, how speech and swallowing problem happen and its management will be discussed. Simple speech and swallowing exercises that may be useful to maintain speech and swallowing function would be demonstrated during the talk.
A comprehensive dysphagia (swallowing disorders / difficulties) management is not only limited to diet recommendation, compensatory strategies or rehab exercises. Providing crucial feedback to the medical team is equally important.
The following case is one case example:
I was consulted by my speech-language pathologist / therapist colleague regarding a case of worsening dysphagia within days in a rehabilitation hospital. The patient (pt) had a stroke (left MCA infarct) diagnosed 2 weeks ago. According to the medical report from the acute hospital, the pt presents with global aphasia and dense right hemiplegia.
Initial assessment revealed mild oropharyngeal dysphagia and global aphasia. Delayed swallowing initiation was suspected. Meal supervision was performed by the ST and pt was started on soft diet and thin fluids.
Patient’s swallowing presentation appeared to have worsen. Oral control appeared poorer, and oral residues were noted post swallow. Noted reduction in hyolaryngeal elevation and double swallows per bolus. Coughed on thin fluids. Diet was downgraded to minced diet and nectar thick fluids by teaspoon.
Staff nurse reported to the ST that pt is coughing on minced diet and nectar thick fluids during breakfast. On ST review, it was noted that patient presents with tongue pumping with significant amount of oral residue post swallow, delayed swallowing initiation, and multiple swallows per bolus. Wet voice was noted post swallow.
I was asked by my colleague for a second opinion.
**Before I move on to explain our plan for the case, allow me to list down the suggestions by some of the SLPs I spoke to when I presented the case to them.
1) Most SLPs would want to refer the patient for an objective assessment [Videofluoroscopy (VFS) or Fiberoptic Endoscopic Examination for Swallowing (FEES)].
2) Some would want to downgrade the diet accordingly to patient’s presentation and observe as so far no other professionals have reported any significant changes.
3) Some would want to inform the team doctor regarding the worsening dysphagia, and to rule out the potential underlying medical complications.
I asked my SLP colleague the following questions:
Question 1: What are the possible causes of worsening dysphagia?
Answer: Maybe stroke, and maybe other new neurological deficits.
Question 2: Why do you think no one else notice any other changes in status except you?
Answer: Not sure. That’s why I am worried that I am wrong.
My answer: Pt is dense hemiplegia (power = 0), and globally aphasia. Unlikely for anyone else to have noticed any changes functionally as both limbs and language functions are 0.
Question 3: What would be your recommendation?
Answer: What if I am wrong? I don’t dare to ask for a CT scan or MRI as I could be wrong and patient may end up paying for unnecessary procedure and it is not cheap.
Question 4: What if you are right?
Answer: Then the medical team can treat the pt earlier.
Question 5: Now evaluate the pro and cons the decision “what if you are wrong?” vs “what if you are right?”.
Answer: Ok I think it would be better to discuss with team doctor and seek their opinion on this. Will suggest further assessment to rule out new events (such as stroke / neuro issues)
After discussion with the doctor, patient was sent to the acute hospital for urgent CT scan. The new CT scan showed hemorrhagic conversion on the left MCA infarct (worsening of the stroke).
In summary, when we encounter rapid progression of dysphagia, perhaps it would be better to speak to the team doctor to find out the cause(s). Objective swallowing assessment may want to be held off until patient’s medical status is stabilized.
This poster was presented at the recent Dysphagia Research Society 23rd Annual Meeting at Illinois, Chicago, USA (12-14 March 2015).
Title: Surface Electromyography (sEMG) Fatigue Analysis Comparing Chin Tuck against Resistance (CTAR) Against the Shaker Exercise
Both Shaker and Chin Tuck against Resistance (CTAR) exercises were designed to improve swallowing through the strengthening of the suprahyoid muscles. However, a major limitation of the Shaker exercise was its early fatiguing of the sternocleidomastoid (SCM)(White et al., 2008). In this study, we investigated the extent CTAR recruits the suprahyoid and whether it fatigues SCM. Amplitude and fatigue analyses on sEMG data from 39 adults revealed that unlike Shaker exercise, CTAR was able to recruit the suprahyoid muscle, without substantially fatiguing SCM.
- Shaker exercise increases UES opening by improving contraction of suprahyoid muscles (Shaker et al., 1997).
- However, patient compliance was poor (50% attrition; e.g., Easterling et al., 2005).
- Poor compliance of Shaker exercise was linked to muscle fatigue of auxiliary muscles, namely SCM (White et al., 2008). CTAR exercise was a response to this limitation.
- Preliminary evidence for CTAR (N = 40 healthy adults; Yoon et al., 2014): (a) Greater sEMG values (amplitude) obtained from Suprahyoid during CTAR than during Shaker exercise. (b) Overall, participants reported CTAR as less strenuous.
- Research Questions:
- Yoon et al’.s data was based on 10-sec isometric trials. The actual CTAR and Shaker exercises require 60 secs each. Will evidence on suprahyoid muscle strength still hold for CTAR when exercise duration is increased to 60 secs?
- Main disadvantage for Shaker exercise was its fatiguing of auxiliary muscles beyond the suprahyoid, i.e., SCM. Is CTAR able to demonstrate that it does not suffer this same limitation (i.e., fatiguing of SCM)?
- N = 39 healthy adults (20 males, 19 females; mean age = 29.82, SD = 5.09).
- Each participant completed CTAR and Shaker twice in randomized counterbalanced order. 4-min rest in between each exercise.
- Single-use pre-gelled electrode patches used (Figure 1; one placed on suprahyoid, the other on SCM).
- sEMG collected by MyoTrac Infiniti encoder (2048 Hz).
CTAR Exercise (Figure 2):
- Seated upright; shoulders not slouched.
- Executed chin tuck, squeezing an inflatable rubber ball (12 cm diameter) between the base of chin and manubrium sterni for 60 secs.
Shaker Exercise (Figure 3):
- Lie supine on an exercise mat.
- Perform a head lift for 60 secs, shoulder not raised.
First and final 7 secs from each exercise interval discarded to eliminate noise. – MATLAB (Welsch Method) used to generate the power spectra density data.
- 2 x 2 ANOVA was conducted on each variable.
- Suprahyoid registered sig. greater (ps < .001) values during CTAR than Shaker. SCM registered sig. greater (ps < .001) values during Shaker than CTAR.
- Suprahyoid registered sig. greater (ps ≤ .02) fatigue during CTAR than Shaker. SCM registered sig. greater (ps ≤ .002) fatigue during Shaker than CTAR.
- Rate of change in fatigue for Suprahyoid: CTAR = Shaker (ps > .10). Rate of change in fatigue for SCM: Sig. lesser (ps ≤ .01) during CTAR than Shaker
- Converging data across two amplitude measures suggest that motor unit recruitment (thus muscle strength) for Suprahyoid was significantly greater during CTAR.
- Converging data across four fatigue measures suggest that fatigue in SCM was significantly lesser during CTAR than the Shaker exercise.
- Extends supporting evidence on CTAR’s usefulness in targeting Suprahyoid (SCM not as actively recruited), when conducted in its full 60-secs duration.
- Clinical trials of CTAR on dysphagic patients recommended as follow-up.
In March 2013, Mr Jason Khoo (A MSc SLP graduate from NUS) presented this scientific poster on CTAR at the Dysphagia Research Society Meeting at Seattle, Washington, USA in 2013. Little did we expect that CTAR actually drew so much interest at the DRS meeting and was also awarded first place for the Scientific Abstract Poster.
Comparison of suprahyoid muscles activity between chin-tuck-against-resistance (CTAR) and the Shaker exercises
Jason KHOO, Susan J. RICKARD LIOW, YOON Wai Lam
For patients with pharyngeal dysphagia, therapeutic exercise such as the Shaker exercise to strengthen the suprahyoid muscles is effective in restoring oral feeding. However, observations revealed that the Shaker exercise is physically demanding for the elderly patients, thereby affecting compliance of the exercise goals. A less strenuous exercise, CTAR, was compared to the Shaker exercise by measuring the surface electromyography (sEMG) activity of the suprahyoid muscles during both exercises. The sEMG activity of the suprahyoid muscles during CTAR was similar or superior to the Shaker exercise. Therefore, CTAR exercise has the potential to achieve the same therapeutic effect as Shaker exercise and may improve compliance.
Aim: To find out if CTAR is as effective as Shaker exercise in exercising the suprahyoid muscles.
- The Shaker exercise has been shown to be effective for patients with dysphagia due to incomplete upper esophageal sphincter (UES) opening (Shaker et al, 2002).
- Performing Shaker exercise significantly increased the anteroposterior diameter of the UES (Easterling et al, 2005) and significantly reduced post-swallow aspiration (Logemann et al, 2009).
- A key component of Shaker exercise is in exercising the suprahyoid muscles, thereby strengthening it (Shaker et al, 2002).
- Easterling et al (2005) found out that muscle discomfort or time constraints were main reasons for the failure of their participants in attaining the Shaker exercise goals.
- Clinical observations suggest the Shaker exercise may pose a physical challenge for elderly dysphagic with chronic disease (Yoshida et al, 2007).
- Developing a less strenuous therapeutic exercise would potentially benefit patients who find Shaker exercise physically challenging, thereby facilitating the attainment of the exercise goals.
- The CTAR exercise, performed in a seated position, is less strenuous as the patient is not required to lift the weight of her head.
- Performing the CTAR exercise in a seated position would make it more convenient for dysphagic patients who are actively mobile to comply with, thereby improving compliance.
- The CTAR will adopt the same regime as Shaker exercise; a set of isometric (sustaining the effort) and isokinetic (repetitions) exercise with equal time base.
Research question: Would the sEMG activity of the suprahyoid muscles be higher during CTAR exercise?
N=40 healthy adults (21-40 yrs). Each participant performed a total of 4 exercise tasks, with a minimum 5 minute rest in between each task. The order of the 4 tasks are randomly assigned and counter-balanced across participants.
4 exercise tasks:
- CTAR isometric
- CTAR isokinetic
- Shaker isometric
- Shaker isokinetic
CTAR exercise (see Figure b):
- Seated upright in chair
- An inflatable rubber ball (diameter 12cm) is placed between chin and base of neck to provide resistance
- Chin tuck against the ball and sustaining it for 10 sec (isometric)
- Chin tuck against rubber ball for 10 repetitions (isokinetic)
Shaker exercise (see Figure c):
- Supine position
- Lift head high enough to see their toes
- Sustaining the head lift for 10 sec (isometric)
- Lift head for 10 repetitions (isokinetic)
sEMG (see Figure a):
- The activity of the suprahyoid muscles was measured using sEMG via an electrode patch attached to the participant’s suprahyoid area
- The CTAR exercise appears to be similarly effective or superior to Shaker exercise in utilising the suprahyoid muscles.
- If Shaker exercise is effective in strengthening the suprahyoid muscles and increasing the anteroposterior diameter of the UES, CTAR exercise may be able to achieve a similar or greater effect.
- CTAR exercise may be a potential alternative for elderly dysphagic patients who find Shaker exercise physically challenging.
- This study is limited to healthy young adults. Replication of this study on an older population will enable further understanding of the impact of age.
- Future clinical studies are necessary to evaluate the therapeutic potential of CTAR in dysphagic patients with incomplete UES opening and the compliance of CTAR exercise amongst the elderly patients.
Chin Tuck Against Resistance (CTAR) is the top 10 most downloaded article from the Dysphagia Journal in 2014
I would like to take this opportunity to thank Speech-Language Pathologists / Therapists around the world for all the interest, support and word of encouragement for the Chin Tuck Against Resistance (CTAR) exercise and researches.
The National University of Singapore MSc SLP team will continue to try our best to come out with more quality researches.
The surprise news came from Mr Sze Wei Ping (A MSc graduate from National University of Singapore) 2 weeks ago when he went to present the follow up study on CTAR at the 23rd Dysphagia Research Meeting at Chicago, 2015. The first CTAR publication is actually the top 10 most downloaded article for the Dysphagia journal for year 2014.
Chin tuck against resistance (CTAR): new method for enhancing suprahyoid muscle activity using a Shaker-type exercise. Dysphagia. 2014 Apr;29(2):243-8. doi: 10.1007/s00455-013-9502-9. Epub 2013 Dec 15.
The interest on CTAR has started in Singapore long before it was announced to the world in 2013. In March 2013, Mr Jason Khoo (A MSc SLP graduate from NUS) presented the first scientific poster on CTAR at the Dysphagia Research Society Meeting at Seattle, Washington, USA in 2013. Little did we expect that CTAR actually drew so much interest at the DRS meeting and was also awarded first place for the Scientific Abstract Poster.
Some wrote in to enquire on how CTAR started?
Here is how it all begins….
The hunt for stretch ball was started in the year 2002 when I was still a junior SLP at Singapore General Hospital. I drew the inspiration from my geriatric patients who kept complaining that the Shaker’s exercise are too strenuous and they declined to perform it. After some thought, I came out with the idea of performing the chin tuck in a sitting position and conveniently use one of the stretch ball belongs to one of the patient and placed it under the patient’s chin as resistance. The geriatric patient was more willing to perform it and complaint of soreness felt at the chin area (Suprahyoid area) – that’s the sign of muscle fatigue! So I started to hunt for stretch balls on the very same night, bought at least 10 pieces. But I did not take into consideration the variation in neck length. The stretch ball was too small and hard for those with longer neck to hold it in between their chin and chest. A bigger ball was used (~10cm) and it seems to fit in nicely for most patients.
I actually prefer to use my palm to provide resistance. Why?
What about for patients who were just too weak to even initiate chin tuck with effort against the ball resistance? I noticed these patients were just resting their chin on the ball. I decided to use my palm to support the chin and found out that the effort for some of this patients were just so minimal as a result of their weakness. I did some search and found out from some dental journals indicated that the Suprahyoid muscles will only be activated when the chin is tucked down for at least 20 degrees, and the greater the degree, more suprahyoid muscle activities were noted. Also taking into consideration the principle of muscle strengthening, that for muscle to be strengthen, it has to be resisting about 60-80% of one repetition maximum. At least by using my palm I can estimate patient’s maximum effort and attempt to adjust my resistance accordingly to their effort (~60-80% of their max effort).
I have been performing CTAR for my patients for more than 10 years and I have seen good clinical outcomes in even severe dysphagia cases (i.e. lateral medullary syndrome).
Why I use a 12cm diameter ball in my study?
Making exercise easy and cost effective has always been my aim. The ball was chosen because it suits most neck length. Also, in research all subjects should be given the same type of resistance.
In the next coming blogs, I will be posting all the CTAR posters. Stay tuned!
The answer is NO.
Most patients have the perception that when they see or being referred to a speech therapist, they must receive some form of active treatment that involves active exercises. This may not be true all the time.
From speech therapy perspective, a medical diagnosis that explains the presentation of speech/ language/ voice / swallowing difficulties is required before any active therapy can be initiated.
That is because these difficulties are usually symptoms presented as a result of certain medical condition(s). For example, a new onset of swallowing difficulty is actually a symptom of neurological disorder(s) or brain related problem(s) that require further diagnosis by a neurologist. The causes may include stroke, neurodegenerative diseases, myasthenia gravis and etc.
Some active treatment may contraindicate the presenting medical diagnosis. For example, for myasthenia gravis (MG), the muscles will weaken further as one gets more tired/fatigue. As such strengthening exercises would not be appropriate for this condition. In fact, compensatory methods such as eating small amount but frequent meals if patient gets fatigue easily and unable to finish up full meal safely may be a better choice of management. In fact treatment for MG that has been shown to be more effective in improving functions include medical intervention and/or surgical intervention. Speech therapist plays the role in assessing suitability for oral feeding, teaching compensatory strategies and providing information counseling.
So for any presenting symptoms that do not associate with any preexisting medical diagnoses, perhaps the next best management is to refer the patient to see a medical specialist who can assess and potentially provide a diagnosis that may explain the presenting symptoms.
In summary, active speech therapy that involves exercises need not be the choice of management all the time especially if there is no confirmed medical diagnoses. Finding out the cause(s) of the symptom(s) / presentation(s) will allow us to make better clinical diagnosis which will lead to better management / treatment that is usually more cost effective. This is especially so with the rising cost of healthcare in Singapore and Worldwide.