[Dysphagia] Chin tuck etc

[sem at new-vis.com (Suzanne Morris)]

The practicality of encouraging a "chin tuck" to improve swallowing  
skills has interested me since I first began working with children  
with feeding and swallowing difficulties.   I'd like to add a common- 
sense perspective to the debate.   In recent years therapists and  
researchers have tried to justify encouraging a chin tuck in patients  
because of debatable anatomical reasons and as ways to prevent  
aspiration and pneumonia. The argument is made that there is no clear  
research that shows that swallowing is improved or aspiration is  
reduced when the chin tuck is used.  When I was introduced to the  
strategy back in the early 60s the reason cited was to increase the  
overall efficiency with which the oral-pharyngeal mechanism could  
function.  When the head is tipped back, even slightly, there is a  
slight drag on the larynx and hyoid.  As the head goes further back  
into capital extension, the tongue and lips/cheeks also tend to pull  
back as the muscles are placed at a greater disadvantage.    This is  
related to the mechanical relationship of the different body parts.  
it's not that we can't suck and swallow with the head in  
hyperextension.  We can, but it takes more muscle effort to  
compensate for the need to counteract the backward pull of the  
muscles and structure.  If a client has a neurological problem that  
increases the strength of reflexive extensor patterns, there may also  
be an increase in muscle tone that makes swallowing efficiently even  
more of a challenge.

There are several personal explorations that i use when I am teaching  
parents or workshop groups.  These activities allow others to  
appreciate subtle differences and build greater awareness of the  
swallowing mechanism.  1) Begin with the head and neck in good upward  
alignment with the back of the neck straight and the chin tipped  
slightly down toward the chest (i.e. a chin tuck) as if the head were  
nodding slightly when saying "yes".  Drink water with the head in  
this position and simply notice the feeling of the muscles and the  
overall coordination and speed of the jaw, tongue, lips/cheeks and  
the larynx/hyoid.   Secondly, drink the water as you very slowly tip  
the chin up toward the ceiling.  Notice the point where there is a  
very slight change in the feeling of these same muscles and muscle  
groups.  Continue tipping the chin upward as far as possible;   
finally bend the neck back into full hyperextension while drinking.    
As a third exploration, begin with the head in full hyperextension  
and very slowly bring it forward into the well-aligned head and neck  
position with the chin tuck.   It is very easy for most people to  
experience the difference and the way in which they make certain  
internal adjustments to be able to continue drinking safely.   2) A  
second experiment is to explore the same basic head and neck  
alignment activity while repeating the syllable sequence of / 
mamamamama/.  In this activity you experience more of the impact on  
the jaw and the lips (as they are connected to the jaw).  This is a  
great activity to do in a group.   Get everyone to repeat the / 
mamama/ sequence as fast as they can and keep it going as long as  
they can with the head in good chin tuck alignment.   Then have them  
do it as the chin begins to point up toward the ceiling.   In the  
first exploration the syllables are very fast and well sustained.    
However, in the second exploration as the chin tips upward, the jaw  
is more biased toward opening and there is a very slight pull-back of  
the lips.  The whole group suddenly begins to slow down in their  
syllable repetition.  It can lead to a very dramatic awareness of how  
head position is related to the efficiency of the oral mechanism.

Many years ago I was invited to present a workshop that was held in  
one of the old traditional medical school amphitheaters.  The rows of  
seats were very steep and it was a challenge to maintain eye contact  
with the whole group.  When I teach I rely heavily on eye contact  
with the group to create an interactive connection and also to be  
aware of group non-verbal feedback that allows me to make slight  
modifications in how I teach.  I have learned to pace myself in  
teaching so that my voice never gets tired or strained even when  
speaking continuously for 3-4 days in a row.   However, during this  
particular workshop, I developed a slight laryngitis by the end of  
the first day and I was very tired.   I knew I wasn't coming down  
with a cold, which could have accounted for the vocal strain.   I  
realized that I had spent the entire day teaching with my chin tipped  
up and my head in slight hyperextension in order to use eye contact  
with those in the upper rows.   So the next day, I very consciously,  
kept my head in good chin tuck alignment and dissociated my upward  
eye gaze from my head and neck position.   I had no problems with my  
voice for the last 2 days of the workshop.  It was amazing to me to  
see how a very small tip-back of my head could place my larynx at  
enough of a disadvantage that vocal strain developed.

So my common sense question is: do we really need to create fancy  
explanations for a chin tuck technique in relationship to pneumonia  
or other conditions that have many many coexisting variables?   Could  
we simply talk about how the body just functions more efficiently  
when its parts are in alignment and don't have to work so hard?  This  
is a concept that is very familiar to anyone who appreciates sports,  
dance or other activities involving physical coordination.   It is so  
easy to demonstrate how this works for nurses and care providers, who  
once they understand the principle in their own body are more likely  
to implement the strategy with others.
__________________________________
Suzanne Evans Morris, Ph.D.
Speech-Language Pathologist
New Visions
1124 Roberts Mountain Rd.
Faber, VA 22938
(434) 361-2285 ext. 5
www.new-vis.com


>
> mbuckie at dmc.org wrote:
>
>   I haven't looked at this study in depth, but I have long seen the  
> chin
>   tuck as the "magic bullet" by nurses, therapists and the summary  
> that
>   was posted said patients who use chin tuck still got pneumonia. I  
> wasn't
>   aware that was the purpose of the chin tuck..that's a pretty big  
> leap to
>   make.
>   *** That has been the response I have always received when I  
> asked about the reason for its use due to the belief that  
> aspiration inevitably leads to pneumonia and "chin tuck prevents  
> aspiration". That, I submit, is the "big leap."