Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

March 2016 Independent Eating and Drinking Newsletter

	March Topics: Breathing and Swallowing Feeding and Swallowing Assessments
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Breathing and Swallowing

Throughout our lives we almost always breathe and swallow automatically. When we stop breathing and swallowing for more than a few minutes, we die! However, sometimes breathing is easier than at other times. For example, when we have a cold, breathing can be far more a conscious act than when we are well and have no congestion. Another time when we pay attention to our breathing is after we have exerted ourselves. If we run up a flight of stairs, by the time we get to the top we are breathing heavily and become aware of our inhaling and exhaling. The same type of experience happens with swallowing: most of the time we swallow without thinking about it, particularly the saliva that is constantly produced in our mouth, but on some occasions we are aware and control our swallow. Imagine eating a really exotic desert. You put the first bite in your mouth and savor the flavor; you slowly move the food around in your mouth enjoying the experience. Eventually, you decide that it is time to swallow it. Another time that you are very aware of swallowing is when you take pills. The moment you move the pills to the back of your mouth you are anticipating swallowing them and you control the action of swallowing them.  

Breathing and swallowing should never occur at the same time. Typically, people inhale and exhale a few times, and, when saliva has built up in their mouth, they stop breathing and swallow the saliva. Once the swallow sequence is complete, breathing starts again. Breathing and swallowing work in sequence, not at the same time; the combined process is a very well-coordinated function controlled by the autonomic nervous system and happens without conscious participation. On the rare occasions that they do not work together correctly, the result can be choking or aspiration.

Some illnesses or diseases can impact how well these autonomic systems work, changing our ability to breathe easily or swallow safely. The goal, when this occurs, is to influence how we breathe and swallow to create the safest, least effortful environment possible, for them to function. Examples of problems that can develop are Parkinson’s disease and amyotrophic lateral sclerosis (ALS).

Parkinson’s disease can change the muscles of the body making them stiff and thus the muscles are more difficult to move, causing slowing of movement. This can impact speech production because the muscles of the lips, tongue, larynx and lungs do not function as well as they used to. Common speech problems that occur for those who have Parkinson’s disease are reduced volume (the person seems to be almost whispering), unclear enunciation, and a monotonal voice. A speech-language pathologist can provide therapy to reduce these problems including breathing exercises to increase breath volume, and speech therapy to improve speech clarity and tone. These types of therapy have proved to be very helpful.

For those who have ALS, both speech and swallowing can become compromised. As the disease progresses, the nerve cells (called neurons) that send the messages to muscles for them to move, die. Because they no longer receive messages instructing them to move, the muscles atrophy and thus become weaker. Also, spasticity can affect muscles. Atrophy causes a reduction of the size of the muscle and spasticity causes tightening of the reduced muscle. Both of these complications can significantly impact breathing and swallowing. Because breathing and swallowing use the same muscles as speaking, it is very likely that anyone who is experiencing difficulties talking will also begin to have problems chewing and swallowing. As with Parkinson’s disease, breathing exercises may help maintain respiratory function. Also, elevating your head when you lie down can help breathing during rest and sleep. Conserving energy also helps reduce fatigue. For example, if you have a doctor’s visit, arrange the time so that you can rest once you have awakened, dressed, groomed and eaten breakfast. If you rush to try and do all of these activities without a break, you will become tired and not function as well.  

Regardless of the cause of breathing and/or swallowing problems, it is wise to try to exercise the muscles that are involved in performing these tasks. This is especially important for people who are unable to move around freely, i.e., those who sit or lie down for the majority of their day. This does not mean a workout like you might undertake at a gym, but rather a conscious effort to move the muscles of your body that you are able to control. To help both breathing and swallowing, make sure that your trunk is straight. People with poor muscle control tend to slide to one side or the other over time, as they sit. Additionally, they slide down slightly in their chair causing their body weight to rest on their lower back rather than their buttocks. Many powered wheelchairs have a recline feature that can be used to reposition the occupant in the chair. Ask your wheelchair vendor, or physical therapist, to teach you how to perform this maneuver correctly, if your wheelchair has the feature. Once you have mastered using this maneuver, make it part of your regular routine. If you don’t have this feature on your wheelchair, have your care provide reposition you periodically so that your trunk is straight and you are bearing the weight of your body on your buttocks and not your lower back.

Taking deep breaths is also good exercise. With your mouth closed, inhale as much air as you can through your nose. Hold it for a moment and then slowly empty your lungs as fully as possible. You will find that as you breathe in, your trunk and shoulders will move upward. As you exhale, your shoulders and rib cage will lower. Breathe in and out like this 10 times. Repeat this exercise several times a day. Not only does it work the muscles controlling your lungs, but it is also helpful in lowering stress.

Exercise and activity is always a balancing act between getting muscles moving and becoming fatigued. It is best to conduct most activity in the morning after a night of rest. If you intend to be active in the evening, a dinner out with friends, etc., make sure to rest in the afternoon. Conserve your energy for the things in your life that are important and that you enjoy the most.

 

The Mealtime Partner Dining System

Serving a Variety of Textures and Volumes of Food and the Pace of Eating is User Controlled

For those individuals who have chewing and swallowing difficulties, the Mealtime Partner Dining System can serve foods of a wide-range of textures. The device can serve regular table food that has been cut up, or it can serve chopped, minced, or pureed foods. The amount of food present for each bite can be controlled from a level spoonful to a rounded or heaped spoonful. Thus small bites can be provided for those who should eat a small amount at a time. Food volume is controlled by the unique Bowl Covers that are attached to the bowls.

Additionally, because the user controls when they take a bite of food from the spoon, they can pace how quickly or slowly they eat each bite of food.

The Mealtime Partner Dining Device Presenting a Bite of Food

Because the Mealtime Partner is such a flexible device, it can meet the dining needs of a diverse group of individuals. For complete information about the Mealtime Partner Dining System, click here. For additional information, or for assistance selecting the best eating or drinking system(s) to serve your needs, email us at info@mealtimepartners.com, or give us a call at 800-996-8607.

 

Feeding and Swallowing Assessments

After tests conducted by their physician or a speech pathologist, if someone exhibits ongoing problems with swallowing, medical professionals may recommend that a videofluoroscopic swallowing study (VFSS), or videofluoroscopy, be conducted. This is also frequently called a modified barium swallow, or MBS. This type of test is conducted by having the patient eat or drink items that have barium in them. As they swallow, a video x-ray is recorded of their mouth and throat. The barium shows on the x-ray, thus the path of the material being swallowed can be seen and analyzed to determine if and where difficulties occur. An example of a video swallow study can be found on YouTube.

Because x-rays are used in this type of study, the study must be limited to a short time (a few swallows) and cannot be repeated too frequently. A VFSS is felt to be invasive by many parents and family members and for that reason both healthcare professionals and family members need an alternative non-instrumental assessment of swallowing and feeding.

Dysphagia [dis-fa´jah] is the term used to describe difficulty in swallowing. It can also describe problems with chewing, moving a bolus of food around in the mouth, or moving it into the esophagus, and swallowing difficulties in general. Those who suffer from dysphagia are more likely to experience a range of health complications including the possibility of malnutrition, extended times spent in the hospital, a need for more help when they are sent home from the hospital, and the likelihood of medical complications and a higher mortality rate. Malnutrition occurs for both children and adults who have difficulties swallowing. They may eat less because of the difficulties they have chewing and swallowing comfortably and/or safely, Also eating enough calories may take a protracted mealtime.

All of these issues have created a need for non-invasive, (non-instrumental) assessments that can replace or supplement VFSS, as mentioned earlier. Individual groups with specific areas of interest, have developed assessments. For example: Brief Autism Mealtime Behavior Inventory; Child Mealtime Feeding Behavior Questionnaire; Dysphagia Evaluation Protocol; Infant Feeding Style Questionnaire; Preterm Infant Breastfeeding Behavior Scale; Swallow Ability and Function Evaluation; etc.

Knowing that there is a need for this type of assessment, researchers from Australia and the Netherlands conducted a study titled: Systematic Review: Non-Instrumental Swallowing and Feeding Assessments in Pediatrics. After thorough searches of all applicable data bases, 30 assessments were included in the final review.

The assessments can be categorized by respondent: caregiver (11 of the 30 assessments), clinician (18 of the 30); and 1 assessment could be completed by either caregiver or clinician. The populations that the assessments are geared towards varied considerably, as did the areas of assessment covered, and the methods of scoring the assessments.

The study concluded that although there are many assessments available to evaluate swallowing and eating in the pediatric population, there is a lack of instructions available for how to use, and how to score the assessments. Without instructions, the assessments could easily be misused or the data collected misinterpreted.  The study recommended that further research be conducted to validate the psychometric properties of the assessments and to validate the reliability of the data collected. To read the article on the study, click here.