Dysphagia Training

Free Webinar by NFOSD: Managing Dysphagia in Adults with Intellectual Disability

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

Click here to register for the FREE webinar:

https://register.gotowebinar.com/register/76969519229535757

NFOSD website:

Dysphagia & Special Populations: Managing Dysphagia in Adults with Intellectual Disability

swallowing therapy

(Recommended article) Moving Forward with Dysphagia Care: Implementing Strategies during the COVID-19 Pandemic and Beyond

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.

Click here to access full article (Open access):

Dysphagia
https://doi.org/10.1007/s00455-020-10144-9

swallowing therapy

Dysphagia Swallowing Therapy – Chin Tuck Against Resistance (CTAR) with Rubber Ball

Video on CTAR by using the rubber ball

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)

  1. Sit / stand upright and pull your shoulders back. Maintain this posture during the exercise.
  2. Hold the ball under your chin with your hand and keep it in position during the exercise.
  3. Sustain chin tuck against the ball for as hard as possible; for the duration of _______ sec.
  4. Repeat _______ sets as recommended by your speech therapist / pathologist.
  5. Rest for 1 minute in between each set of the exercise.

Part 2: Repetitive CTAR (Isokinetic)

  1. Sit / stand upright and pull your shoulders back. Maintain this posture during the exercise.
  2. Hold the ball under your chin with your hand and keep it in position during the exercise.
  3. Tuck your chin in, as hard as possible against the ball; then lift your chin.
  4. Repeat the above steps for ________ times and ________ sets as recommended by your speech therapist / pathologist.
  5. 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:

YouTube video URL: https://youtu.be/zBoZSr19zWo

CTAR with Rubber Ball Exercise videos are available in the following languages:

* Click to view CTAR videos in the following languages.

Chin Tuck Against Resistance (CTAR) exercise is suitable for most patients with swallowing difficulties / dysphagia:

  • dysphagia or swallowing difficulties following strokes,
  • dysphagia following head and neck cancer,
  • dysphagia following Parkinson’s disease,
  • dysphagia due to late effect of radiotherapy i.e. Nasopharyngeal cancer
  • etc.
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.

dysphagia research

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

S-CTAR Poster

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 Oregon
Portland, Oregon
Portland
Portland, Oregon
  • With Dr Shaker
    with Dr Reza Shaker
    Nabil = my FB Pal
    My FB Pal, SLP from Canada – Nabil
    Kotomi - SLP from Japan
    Kotomi Sakai – SLP from Japan
    Brazil SLP
    SLP from Brazil
    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.
    Ironing sandwich
    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. 

    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.

    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 assessment, Dysphagia Therapy, speech therapy singapore

    Workshop “Dysphagia Assessment and Treatment for Adults and Children: Practical Applications and Cutting Edge Updates” by Dr Julie Cichero

    Dysphagia workshop

    The Cerebral Palsy Alliance Singapore (CPAS) is organising the 8th CP Symposium from 1012 September 2015.

    Workshop “Dysphagia Assessment and Treatment for Adults and Children: Practical Applications and Cutting Edge Updates” by Dr Julie Cichero, BA, BSpThy (Hons), PhD Australia.

    Date: 10 & 11 September 2015

    Venue: Max Atria @ Singapore Expo

    Target audiences: Speech-Language Pathologists / Therapists

    Please click SLP e-brochure for registration details.