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 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.
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.
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
Abstract:
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.
Introduction:
Method:
Participants:
sEMG Recording:
CTAR Exercise (Figure 2):
Shaker Exercise (Figure 3):
Data Processing:
First and final 7 secs from each exercise interval discarded to eliminate noise. – MATLAB (Welsch Method) used to generate the power spectra density data.
Results:
Discussion:
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
Summary
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.
Introduction
Aim: To find out if CTAR is as effective as Shaker exercise in exercising the suprahyoid muscles.
Research question: Would the sEMG activity of the suprahyoid muscles be higher during CTAR exercise?
Method
Participants:
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 exercise (see Figure b):
Shaker exercise (see Figure c):
sEMG (see Figure a):
Results
Discussion
Singapore Swallowing Specialists 