Updates

SHAS, Singapore, speech-language therapy, Teaching

Talk on Traumatic Brain Injury ~ The Singapore Context

Yoon Wai Lam

TBI talk2

Traumatic Brain Injury ~ The Singapore Context

Speaker: Ms. Sajlia Binte Jalil

Hosted by Speech and Hearing Association Singapore  (SHAS)

Traumatic Brain Injury (TBI) commonly affects young people and can result in a lifelong disability. Singapore is unique compared to the commonly researched populations in Australia, UK and US – including our language background and healthcare system. In this talk, we will explore how bilingualism impacts TBI sequelae and discuss what we can learn from service delivery models in established TBI units in Australia. It will be a sharing and discussion session, so bring along your best thinking hats and come share your thoughts and experiences!

Outline of the talk:
– Brief overview of TBI

– Bilingualism and TBI: Assessment, management and sharing of PhD findings on code-switching behaviours in TBI

– The NSW BIRU experience and what we can learn from it

Please see below for more details and send all enquiries to Melissa from the SHAS Professional Development Team.

Click here to download the registration form then send it back to  prodevelopment.team@shas.org.sg to secure your place at the talk.

TBI talk
Please RSVP by the 26 May 2015 (Tuesday)

Dysphagia Therapy, Public awareness, Singapore, Swallowing Problem

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

Yoon Wai Lam

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?

Yoon Wai Lam

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.

Cost effective treatment, Dysphagia Therapy, Singapore, Swallowing Problem

Surface Electromyography (sEMG) Fatigue Analysis Comparing Chin Tuck against Resistance (CTAR) Against the Shaker Exercise

Yoon Wai Lam
CTAR Poster
CTAR Poster

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:

  • 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:
  1. 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?
  2. 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)?

Method:

Participants:

  • 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.

sEMG Recording:

  • 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.

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:

  • 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

Discussion:

  • 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.
dysphagia assessment, Objective assessment, Singapore, Teaching

SHAS Special Interest Group Talk: Videofluoroscopy Interpretation Made Easy

Yoon Wai Lam

Videofluoroscopy_Interpretation_talk_poster Videofluoroscopy_Interpretation_Made_Easy_Registration_Form _1_

I will be conducting a talk titled Videofluoroscopy (VFS) Interpretation Made Easy for Speech-Language & Hearing Association Singapore.

Date: 24 April 2015 (Thursday)

Time: 6.15pm – 8.30pm

Venue:

National University Hospital

Group Therapy Room, Main Building Level 1,

5 Lower Kent Ridge Road, 119074

About this talk:

This talk is a short introduction to Videofluoroscopy (VFS) interpretation and is suitable for both clinicians who are experienced or inexperienced in performing VFS. I will introduce pathophysiologies commonly viewed in VFS with the use visual examples. I will also share on how I analyze VFS systematically, and how to select suitable strategies to be trialed during the procedure accordingly to patient’s presentation.

Outline of the talk:

  • Short introduction about VFS
  • Pathophysiologies viewed in VFS
  • Esophageal phase screening
  • How to interpret VFS systematically rienced clinicians to share their experiences and views on VFS as well rienced clinicians to share their experiences and views on VFS as well.
Cost effective treatment, Dysphagia Therapy, Singapore, Swallowing Problem

Chin Tuck Against Resistance (CTAR) Poster that was awarded first place at the DRS 2013

Yoon Wai Lam

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.

CTAR poster 1

CTAR was awarded first place in Scientific Abstract Poster at DRS 2013
CTAR was awarded first place in Scientific Abstract Poster at DRS 2013

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.

  • 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?

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 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

Results

CTAR poster result 1

Discussion

  • 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.
Cost effective treatment, Dysphagia Therapy, Public awareness

Chin Tuck Against Resistance (CTAR) is the top 10 most downloaded article from the Dysphagia Journal

Yoon Wai Lam
CTAR is top 10 most downloaded article in Dysphagia 2014
CTAR is top 10 most downloaded article in Dysphagia 2014

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.

CTAR was awarded first place in Scientific Abstract Poster at DRS 2013
CTAR was awarded first place in Scientific Abstract Poster at DRS 2013

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).

Outcome?

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!

Cost effective treatment, Dysphagia Therapy, Public awareness, Teaching

Must active swallowing therapy or speech therapy be initiated all the time?

Yoon Wai Lam

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.

Why?

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.

Videofluorosocopy (VFS)
Videofluorosocopy (VFS)
FEES assessment of swallowing
FEES assessment of swallowing
sEMG biofeedback as an adjuct to swallowing therapy
sEMG biofeedback as an adjuct to swallowing therapy
Fun Facts

Happy Chinese New Year! * The Spoiler!!

Yoon Wai Lam

Funny but impactful Advertisement. The Chinese New Year Spoiler.

Happy Chinese New Year!!

For those who are going to celebrate CNY, they would look forward to eating all the yum yum food and CNY goodies. Imagine chewing the sweet and buttery pineapple tart and then slowly swallowing it into our throat….. Yum!!
BUT, thanks to the Khoo Teck Puat Hospital campaign. It makes me think twice in deciding what to eat and how much I should eat. What a CNY spoiler LOL. But it’s very good one indeed. For as much as we would like to eat, let’s eat in moderation and stay healthy always.
Singapore Swallowing Specialists would like to wish everyone a Happy and Healthy Chinese New Year!

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