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.
Date and time: Thu, Jul 23, 2020 8:00 AM – 9:30 AM SGT
Webinar Description:
This webinar is for healthcare providers, patients and caregivers impacted by dysphagia, and students learning about swallowing disorders.
This presentation will define and categorize types of transitional foods. We will discuss the potential benefits of improved choices, increased textures and ultimately improved dining enjoyment. Use of transitional foods in the pediatric population will be discussed with examples of use presented in specific special needs populations. The IDDSI testing method for transitional foods will be reviewed and the variation in results obtained with this test will be demonstrated between known transitional foods. We will share two research methods of evaluating the dissolution patterns of transitional foods in the oral environment will be described with relevant clinical implications. The external environment (air, humidity, length of exposure) play a significant role in the transitional behavior of these foods and ultimately their safety. The oral environment (amount of saliva, degree of tongue pressure, anterior-posterior transit time) also has a significant impact as well. Both groups of factors will be discussed in detail providing a broader scope of understanding of patient selection, and proper use. Ultimately expanding our knowledge of transitional foods will improve our understanding of use with the goal of improving patient engagement and outcomes.
Learner Outcomes:
Understand the difference between transitional food behaviors in the mouth in comparison to IDDSI benchtop methods.
Classification of transitional foods and the importance of the oral environment
Learn the role transitional foods can play in dysphagia management
Date and Time: Wednesday, June 17, 5:00 pm Pacific (June 18, 8.00am Singapore / Malaysia / Philippine )
Webinar Description:
Adults with intellectual disability are at risk for dysphagia. The unique swallowing, feeding, and behavioral challenges experienced in this population are vital considerations in the assessment and treatment of these patients. This webinar will discuss the nature of dysphagia management in adults with intellectual disability by exploring the current evidence in this area and discuss the clinical experiences of speech pathologists who assess and treat adults with intellectual disability in the Intermediate Care Setting.
At the completion of this webinar, participants will:
Understand the impacts of dysphagia in people with intellectual disability
Identify the systems that must be considered in the assessment and treatment of dysphagia in those with intellectual disability
Anticipate the physical-nutritional needs of those with intellectual disability as they age
Describe the interdisciplinary team collaborations required to manage dysphagia in this population
Mark A. Fritz · Rebecca J. Howell · Martin B. Brodsky · Debra M. Suiter · Shumon I. Dhar · Anais Rameau · Theresa Richard · Michelle Skelley · John R. Ashford · Ashli K. O’Rourke · Maggie A. Kuhn
Abstract Growing numbers of SARS-CoV-2 cases coupled with limited understanding of transmissibility and virulence, have challenged the current workfow and clinical care pathways for the dysphagia provider. At the same time, the need for non-COVID-19-related dysphagia care persists. Increased awareness of asymptomatic virus carriers and variable expression of the disease have also focused attention to appropriate patient care in the context of protection for the healthcare workforce. The objective of this review was to create a clinical algorithm and reference for dysphagia clinicians across clinical settings to minimize spread of COVID-19 cases while providing optimal care to patients sufering from swallowing disorders. Every practitioner and healthcare system will likely have different constraints or preferences leading to the utilization of one technique over another. Knowledge about this pandemic increases every day, but the algorithms provided here will help in considering the best options for proceeding with safe and effective dysphagia care in this new era.
Singapore Swallowing Specialists (SSS) network has just released their very first swallowing therapy video on Chin Tuck Against Resistance (CTAR) by using the rubber ball (Series 1). We plan to produce more series on CTAR and other swallowing therapy exercises / strategies and translate all the videos to different languages from around the world. SSS hope to reach out to benefit more people worldwide.
The following is the CTAR exercise instructions. You may download a PDF copy of this instructions at the bottom of this page.
For clinicians, you may download the above QR code and print it on your exercise handouts to facilitate clients’ search for the above YouTube Video.
Chin Tuck Against Resistance (CTAR) with a Rubber Ball
Purpose: To strengthen the suprahyoid muscles used in swallowing. The suprahyoid muscles are important to open your upper food pipe sphincter (upper esophageal sphincter) to allow food to enter your stomach.
Equipment: a)Rubber ball, b)Air pump and ball pump needle valve (optional) – to increase diameter and pressure of the ball
Instructions:
Part 1: Sustained CTAR (Isometric)
Sit / stand upright and pull your shoulders back. Maintain this posture during the exercise.
Hold the ball under your chin with your hand and keep it in position during the exercise.
Sustain chin tuck against the ball for as hard as possible; for the duration of _______ sec.
Repeat _______ sets as recommended by your speech therapist / pathologist.
Rest for 1 minute in between each set of the exercise.
Part 2: Repetitive CTAR (Isokinetic)
Sit / stand upright and pull your shoulders back. Maintain this posture during the exercise.
Hold the ball under your chin with your hand and keep it in position during the exercise.
Tuck your chin in, as hard as possible against the ball; then lift your chin.
Repeat the above steps for ________ times and ________ sets as recommended by your speech therapist / pathologist.
Rest for 1 minute in between each set of the exercise.
Click on the following to download the exercise instructions and/or the QR code to access the YouTube video:
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):
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)
Mix the amount of thickening powder (Xanthan Gum) required as your stir the supplement.
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.
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.
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.
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.
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.
Portland, OregonPortland, Oregon
with Dr Reza ShakerMy FB Pal, SLP from Canada – NabilKotomi Sakai – SLP from JapanSLP from BrazilDemonstrating CTAR to a dentist from JapanDemonstrating CTAR and S-CTARI 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.
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?
Singapore Swallowing Specialists 
