Swallowing Problem

Swallowing Therapy Tip: How to Speed Up the Thickening of Nutritional Supplement

Thickening of Resource 2.0 to honey consistency with Nestle Resource ® ThickenUp® Clear

Speech therapists / pathologists in Singapore and around the world assess swallowing with different fluids or diet consistencies. Once the swallowing assessment is carried out, speech therapists will usually prescribe diet and fluids consistencies that are suitable / safer based on the assessment findings. When thickened fluids are recommended, caregiver training on thickening of fluids to the recommended consistency will usually be performed.

One of the common challenges faced by many speech therapists, nurses and caregivers is thickening of nutritional supplement with thickener. I did a search online and found out from the Resource ® ThickenUp® Clear official website (https://www.thickenupclear.com/products/resource-thickenup-clear) that it takes milk and oral nutrition supplements up to 15 minutes to reach desired consistency. It is just too time consuming to prepare thickened supplement.

I might have a way to speed up the thickening of nutritional supplements!

Many years ago, I did a project for a nutritional company in Singapore on thickening of nutritional supplement using Xanthan gum thickener (the brand that I was using in the project was Nestle Resource ® ThickenUp® Clear). I came out with the following “Manual Shake” method to thicken up the nutritional supplement (** However, this method does not work on fruit juice-based supplement). I did a quick search on google but could not find any and not sure if any speech therapists / any institutions in the world are using this method.

We have used this method to thicken up supplement in some hospitals and it has successfully reduced the timing of thickened supplement preparation time. With this method, thickening of supplement process can be achieved within 2 minutes. The thickened supplement remains stable even after 10 minutes. In the following videos (taken in 2015), I show the process of thickening of Nestle Resource 2.0 and Nestle Isocal to honey consistency (moderately thick consistency) and the consistency remains stable after 5 minutes or longer. For Nestle Resource 2.0 and Nestle Isocal, I followed the thickener dosage as listed on Nestle Resource ® ThickenUp® Clear can or dosage chart: https://www.thickenupclear.com/products/resource-thickenup-clear

You can try to use this ‘Manual Shake’ method to thicken up other nutritional supplement but the thickness might vary. I would suggest to trial and error to find out the amount of thickener required for the nutritional supplement(s) that you are using in your hospital. For patient(s) who intend to use this method to thicken up your supplement, please consult your speech therapist/pathologist for advice on the consistency and the amount of thickener powder that might be required.

As the video was done in 2015, I did not do an IDDSI (International Dysphagia Diet Standardization Initiative) flow test on the texture. We just started following IDDSI standard in Singapore and we are planning to conduct another research on this soon. For speech therapists, or dietitian or healthcare professionals who would like to ensure that the texture meet the IDDSI standard, I would suggest that you perform your own IDDSI flow test and I would be grateful if you could share with me or others. You may email me at speechtherapyworks@gmail.com and I would be most happy to post it on my blog.

I collaborated with the nurses in St Luke’s Hospital, Singapore to run a project on thickening of nutritional supplement and the project won 2 quality improvement award and the research poster was presented the International Forum on Quality and Safety in Healthcare, Taipei in 2019.

Jose, R., Rendom, J., Yoon, W.L., Abillar, L., Low, P.S., Su, A.Q., (2019 September). New Practices in Thickener Mixing for Effective Care. Poster session presented at c

Awarded:

  • Agency for Intergrated Care (AIC) Quality Improvement Award (2018)
    • St Luke’s Hospital Clinical Quality Improvement Merit Award (2017)

Here are the steps to thicken up nutritional supplement (non-juice based supplement):

  1. Measure the amount of supplement in a measuring bottle (I would recommend to use a measuring bottle or cup with cover that allows you to shake and serve / drink from)
  2. Mix the amount of thickening powder (Xanthan Gum) required as your stir the supplement.
    • For Nestle Resource 2.0 and Nestle Isocal, I follow the thickener dosage as listed on Nestle Resource ® ThickenUp® Clear can or dosage chart: https://www.thickenupclear.com/products/resource-thickenup-clear
    • Yes, the way I mix it is different as compared to the method recommended by Nestle Resource ® ThickenUp® Clear. Either way of mixing is fine. The reason I mix it the way I did was because it is not easy to ensure that the cup is always dry and pouring in thickener powder into wet cup might cause clump formation.
  3. Cover the bottle / cup and shake it for approximately 2 minutes. *You will feel the gradual thickening up and the slowing of flow of the supplement as your shake the mixture.
  4. Open up the cover and serve / drink. Please ensure safety in drinking the thickened supplement by following the strategies that have been recommended by your speech therapist/pathologist.

I hope you will find this ‘manual shake’ supplement thickening method useful. Please like and share with your friends and others so that the information will reach to those who might needs it.

I will post more useful information on dysphagia from time to time. Please follow my blog and like my Facebook at https://www.facebook.com/SGSwallowingSpecialists/

Please feel free to email me at speechtherapyworks@gmail.com if you have any questions.

Thickening of Resource 2.0 to honey consistency with Nestle Resource ® ThickenUp® Clear
Thickened Isocal and Resource 2.0 remain stable after more than 5 minutes

Disclaimer: When choosing food thickeners or nutritional supplements/beverages, please consult with your speech therapist/pathologist or dietitian or health care professional as to what product is appropriate for your individual needs, as consistencies vary between nutritional supplements and manufacturers. As this method is not tested using IDDSI method, health care professionals who would like to adopt this method are encouraged to perform IDDSI flow test to ensure that the thickened supplement(s) of different brands meet the standard.

Swallowing Problem

How does dysphagia from mechanical obstruction sounds like?

The following patient presents with dysphagia (swallowing difficulties) secondary to the presence of prominent anterior cervical osteophytes at the level of C3-C6, most prominent at C4.

Dysphagia symptoms include:

  • Occasional coughing noted when eating solids as well as drinking fluids.
  • Multiple swallows per bolus

I managed to record the patient’s usual swallowing sound using my IPhone 6s. Could this be the sound of mechanical obstruction?

osteophytes
MRI Cervical Spine shows cervical myelopathy. Prominent anterior cervical osteophytes from C3-C6.
osteophytes label

The sound of patient swallowing 10ml water recorded using an IPhone 6s. Note multiple swallows & loud squish sound.

Cost effective treatment, dysphagia research, Dysphagia Therapy, Singapore, speech therapy singapore, speech-language therapy, Swallowing Problem, Teaching, Uncategorized

Second Publication on Chin Tuck Against Resistance (CTAR)

We are happy to announce that the follow up study on CTAR has been published online (online first version) in Dysphagia Journal.

Original Paper

Dysphagia

pp 1-11

First online: 02 February 2016

Evaluating the Training Effects of Two Swallowing Rehabilitation Therapies Using Surface Electromyography—Chin Tuck Against Resistance (CTAR) Exercise and the Shaker Exercise

  • Wei Ping Sze 
  • , Wai Lam Yoon
  • , Nicolas Escoffier
  • , Susan J. Rickard Liow

Abstract

In this study, the efficacy of two dysphagia interventions, the Chin Tuck against Resistance (CTAR) and Shaker exercises, were evaluated based on two principles in exercise science—muscle-specificity and training intensity. Both exercises were developed to strengthen the suprahyoid muscles, whose contractions facilitate the opening of the upper esophageal sphincter, thereby improving bolus transfer. Thirty-nine healthy adults performed two trials of both exercises in counter-balanced order. Surface electromyography (sEMG) recordings were simultaneously collected from suprahyoid muscle group and sternocleidomastoid muscle during the exercises. Converging results using sEMG amplitude analyses suggested that the CTAR was more specific in targeting the suprahyoid muscles than the Shaker exercise. Fatigue analyses on sEMG signals further indicated that the suprahyoid muscle group were equally or significantly fatigued (depending on metric), when participants carried out CTAR compared to the Shaker exercise. Importantly, unlike during Shaker exercise, the sternocleidomastoid muscles were significantly less activated and fatigued during CTAR. Lowering the chin against resistance is therefore sufficiently specific and intense to fatigue the suprahyoid muscles.

Details of the journal can be found at http://link.springer.com/article/10.1007%2Fs00455-015-9678-2

We are happy to announce that we are starting our third CTAR research at the National University of Singapore.

CTAR research 3
CTAR research 3 in progress

materials for CTAR 3
Materials used in CTAR 3

Dysphagia Therapy, Featured clinicians, Singapore, Swallowing Problem, Teaching, Uncategorized

Workshop on ‘Best Practices in the Management of Oropharyngeal Dysphagia’

Dear all,

JurongHealth Speech Therapy department will be organising a 2 day workshop next year entitled ‘Best Practices in the Management of Oropharyngeal Dysphagia’. The workshop will be conducted by Dr. Catriona Steele and will be held on 20 – 21 May, 2016 at Ng Teng Fong General Hospital, Singapore.

NTFGHJCHoverview
NTFGH  

 

About the speaker:

Dr. Catriona M. Steele is a clinician scientist working in the area of swallowing and swallowing disorders. She has a background as a medical speech-language pathologist, and is Director of the Swallowing Rehabilitation Research Laboratory at the Toronto Rehabilitation Institute – University Health Network. Dr. Steele is a Professor in the Department of Speech-Language Pathology at the University of Toronto and is in demand as a teacher and workshop instructor around the world. Dr. Steele holds research funding from the National Institutes of Health (USA) and has more than 100 peer-reviewed publications.

 

Brief outline of workshop

> Best Practices in the Identification and Assessment of Oropharyngeal Dysphagia

–   Sensitivity and specificity of different dysphagia screening tools

–   Purpose, protocols and important technical considerations of videofluoroscopy

– Using information from research to quantify observations during a clinical bedside swallowing assessment

> Management and Rehabilitation of Oropharyngeal Dysphagia

–  Evidence behind texture modification and postural approaches

–  Direct and indirect swallowing/exercise approaches including the use of IOPI and sEMG biofeedback

–  Other approaches in the literature: respiratory interventions, electrical stimulation, vibratory stimulation

 

Estimated cost:  $400 – $500 per participant for the full workshop.

 

 

Registration Correspondent: Ms Wong Wan Xin

Wong Wan Xin| Speech Therapist, Rehabilitation | Ng Teng Fong General Hospital & Jurong Community Hospital | Jurong Health Services
1 Jurong East Street 21, Singapore 609606 | T: (65) 67161674 | E: Wan_Xin_Wong@juronghealth.com.sg

dysphagia assessment, Dysphagia Therapy, SHAS, speech therapy singapore, speech-language therapy, Swallowing Problem

SHAS SIG : Sharing on Paediatric Feeding Services Available in Singapore

Host: Speech-Language and Hearing Association Singapore (SHAS)

The SHAS will be holding a Special Interest Group : Sharing on Paediatric Feeding Services Available in Singapore

Date: 26 November 2015 (Thursday).

Venue: KK Women’s and Children’s Hospital, Women’s Tower (Level 1), Seminar Room 1, 100 Bukit Timah Rd, Singapore 229899

There will be sharing session by various representatives from different organisations:

  • Cerebral Palsy Alliance Singapore
  • KK Women’s & Children’s Hospital
  • National University Hospital
  • Rainbow Centre
  • Thomson Paediatric Centre

SHAS paediatric feeding
If you are interested in attending the session, please email the completed registration form to pd.shas@gmail.com by 20 November 2015 (Friday). 

Dysphagia Therapy, speech therapy singapore, speech-language therapy, Swallowing Problem

Workshop on Dysphagia Management: NMES / sEMG Guardian Way in Hong Kong

Guardian Way Workshop

Workshop on Dysphagia Management: NMES / sEMG Guardian Way

Instructors: Teresa Biber, M.S., CCC-SLP

Nancy Calamusa, MA, CCC-SLP

Date: 26-27 September 2015 (NMES / sEMG Guardian Way)

Date: 28 September 2015 (Paediatric Workshop)

Venue: Kowloon Bay International Trade and Exhibition Centre (KITEC) Room 631, Hong Kong

Contact:  GSBE Company Ltd at 9190-0180 or or GSBECOMPANYLTD@GMAIL.COM

Co-organizer: SpectraMed, Inc. and GSBE Company Ltd

Please refer to attached registration forms for details.

pdf_SEPT2015_Form

pdf_SEP2015_GuardianWay

pdf_Paed_Workshop_SEP2015

Dysphagia Therapy, speech therapy singapore, Swallowing Problem

Dysphagia Journal Reviewer for 2014

Dysphagia Reviewer 2014

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.

Dysphagia Therapy, Public awareness, Singapore, Swallowing Problem

Nasopharyngeal Cancer Support Group Talk: How does NPC affect speech and swallowing?

NPC support group brochure0001NPC support group brochure0002

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.

Cost effective treatment, Dysphagia Therapy, Singapore, Swallowing Problem

Worsening dysphagia. How would you manage?

worsening of dysphagia

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.

Day 1:

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.

Day 2:

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.

Day 3:

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.