Speech Therapy Works | Singapore Swallowing Specialists have been invited to participate in this upcoming Facebook Live Talk Show organized by the Society of Speech & Language Therapists, Bangladesh.

This is also a Global Dysphagia Movement initiative to create better dysphagia awareness to international community.

#SSLT

All are welcome to watch the 9th episode of our SSLT TALK SHOW ‘Provision of Dysphagia Services Between Developed and Developing Country’ program.

Program Time (Event Time):

Bangladesh Time:

September 18, 2020 (Friday 8 pm).

Singapore Time:

18th September, 2020 (Friday, 10:00pm)

You can watch the FB Live talk show via this link:

https://www.facebook.com/SocietyofSLTs/

Public awareness

FB Presentation Video and Handouts: Speech, swallowing and hearing difficulties in nasopharyngeal cancer (NPC) before, during and after radiotherapy. Why and how to manage ok?

17/07/202018/10/2020 Yoon Wai Lam

Speech Therapy Works and Singapore Swallowing Specialists collaborated with 20dB Hearing Sdn Bhd, Malaysia to present this interesting topic Live on Facebook on 22 July 2020 at 8.00pm (SGT).

We had audiences from all around the world. Great questions were asked during the presentation. Feedback on the live presentation has been good.

Speech Therapy Works and Singapore Swallowing Specialists will organize more Live Facebook presentation in future. Topic would include speech, language and swallowing difficulties for stroke / dementia / neurodegenerative diseases including Parkinson’s disease and etc. Do follow our blog or Facebook to receive notification on the future Facebook Live presentation.

We are happy to announce that the president from the OneHeart Support Group (A Nasopharyngeal Cancer support group in Singapore) has opened their support to individuals or cancer survivors especially the NPC survivors. OneHeart Support Group will provide emotional and psychological support. For those interested to seek support from OneHeart, please contact Dave at +65 9101 8223. We will include a copy of OneHeart Support group brochure in this post once we receive it.

Please see attached for the handouts for this presentation.

handouts-for-speech-swallowing-hearing-difficulties-in-npc-post-rtx-Download

dysphagia research

Swallow with CTAR (S-CTAR) Poster presented at DRS 2017 @ Portland, Oregon

06/04/201703/07/2020 Yoon Wai Lam

Life has been so busy since I came back from DRS 2017. Finally, I have some time to put up this blog.

I was honored to be invited to present a research poster at DRS this year.

This is probably one of the best year for dysphagia research representation from Singapore as we have 2 oral presentations from Singapore General Hospital and 1 poster presentation (presented by me) from National University of Singapore.

My poster presentation was on Swallow with Chin Tuck Against Resistance (S-CTAR).

Some of the happy moments at DRS:

Portland, Oregon is really beautiful and … cold.
Finally get a chance to meet my Facebook pal, Nabil from Canada in person. We share a common interest in dysphagia. Lots of interesting discussion on dysphagia via WhatsApp and Facebook messenger.
Get to meet some old friends and made more new friends from all around the world.
managed to take a selfie with Dr Reza Shaker!
Happy to know that CTAR or Chin Tuck Against Resistance is a well known and well like exercise in USA and Brazil. Brazil Speech Pathologists informed me that they have started research on CTAR! I really hope that clinical study on CTAR will be out soon.
Most Speech-Language Pathologists were excited to know that S-CTAR can be used as a task specific exercise and foresee that they will use it in their dysphagia therapy or management.

Nabil = my FB Pal — My FB Pal, SLP from Canada – Nabil

Kotomi - SLP from Japan — Kotomi Sakai – SLP from Japan

Poster presentation — Demonstrating CTAR to a dentist from Japan

Demonstrating CTAR & S-CTAR — Demonstrating CTAR and S-CTAR

I am a new DRS Member — I am a new DRS member.

This is new to me… Ironing sandwiches?!!!

I was asked a few interesting questions on CTAR. One of the few interesting question is: are there any devices in the market that you think is good to be used to perform CTAR? I think this is an interesting question as we have seen quite a number of devices (different type of balls, hand held devices etc) being introduced to the market since the first paper on CTAR was published in 2014.

Click S-CTAR Poster to download the poster that I presented at DRS 2017.

I will list out all those questions and answers in separate post soon.

To end this post, I would like to congratulate and express my appreciation to all the DRS committees for this successful and enlightening meeting.

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)

04/02/201604/02/2016 Yoon Wai Lam

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.

materials for CTAR 3 — Materials used in CTAR 3

Cost effective treatment, Dysphagia Therapy, speech therapy singapore, speech-language therapy, Teaching

Beckman Oral Motor Assessment and Intervention © Course

30/11/2015 Yoon Wai Lam

About the Workshop:

Oral motor impairment presents a variety of challenges for both the individual affected, and for the care team providing intervention. Often the individual experiencing oral motor difficulties is not able to follow commands. The person may not be eating or taking fluids orally, which reduces the opportunities for observation of oral movement patterns. The majority of baseline protocols currently available require at least minimal direction-following skills. The protocol developed by Beckman uses mechanical muscle responses, which are not mediated cognitively, to baseline the response to pressure and movement, range of movement, variety of movement, strength of movement and control of movement for the lips, cheeks, jaw, and tongue. In this two day course, participants will actively participate in hands-on practice for compensatory handling techniques for the following concerns: tonic bite, tonic bite on a utensil, slow oral transit, tongue thrust, cough, gag and vomit. The participants will complete an oral motor protocol with each other, analyze the results, and discuss data tracking. The participants will also complete hands-on practice for specific oral motor interventions to address the deficit areas discovered during baseline assessment. Additional topics of discussion may include: goal writing, diet texture progression, tube to oral issues, adaptive mealtime utensils, oral hygiene issues, medication administration issues, oral function for individuals with tracheotomy, facilitating improved articulation through oral motor techniques, research issues, videofluroscopy issues for motorically involved individuals.

Speaker: Mr Stephen Chan (Occupational Therapist)

Target Participants: Licensed Occupational Therapists AND Speech and Language Pathologists/Speech Therapists

Date &Time: 9th & 10th March, 2016 (Wed & Thur) 9:30am – 5:30pm

Venue: Room 706, Peninsula Tower, No. 538, Castle Peak Road, Kowloon, HONG KONG

Seat Availability: 30 seats

Course Fee:

Early Bird registration by 9th January, 2016: HK$4,000 (including course materials)
Standard registration by 9th February, 2016: HK$4,500 (including course materials)

Certification: Upon 100% attendance, participants are awarded the Certificate of Completion by Beckman & Associates, Inc. And after the completion of the course, participants’ name can be listed (optional) on the website http://www.beckmanoralmotor.com.

Enquiry: To learn more about the course, please visit the website: http://www.beckmanoralmotor.com

Registration form can be downloaded from: http://www.crest.hk/wp-content/uploads/2014/07/Beckman-Certificate-Course-Information-by-CREST-2016.03-revised.pdf

For any enquiries, please feel free to contact Mr. Stephen Chan at stephen@crest.hk or (852) 3628 3443

SHAS, Singapore, speech-language therapy, Teaching

Talk on Traumatic Brain Injury ~ The Singapore Context

20/05/201520/05/2015 Yoon Wai Lam

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.

Please RSVP by the 26 May 2015 (Tuesday)

Cost effective treatment, Dysphagia Therapy, Singapore, Swallowing Problem

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

07/04/2015 Yoon Wai Lam

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:

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)?

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

07/04/201507/04/2015 Yoon Wai Lam

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

29/03/2015 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 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, Teaching

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

26/02/201527/02/2015 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.

sEMG biofeedback as an adjuct to swallowing therapy

Tag: Rehabilitation

FB Live SSLT Talk Show: Provision of Dysphagia Services Between Developed and Developing Country