[Dysphagia] Chin tuck etc

[justjanetlynn at msn.com (JANET Finger)]

I am not a believer in the chin tuck as a cure-all, but every so often I do 
find (during instrumental study) a pt who benefits from chin tuck. When I 
explain it to pts & families, often I ask if they have ever had a CPR class. 
If so, I remind them that we are taught during mouth-to-mouth to tilt the 
head back to open the airway. I point out that that position is great for 
breathing, but not so great for swallowing. So then I explain that we do the 
opposite (tilt the head down a bit) during swallowing sometimes to help 
narrow the airway. I know it's not exactly accurate but I think accurate 
enough for a layperson to understand & follow.




>From: Suzanne Morris <sem at new-vis.com>
>To: dysphagia at b9.com, mbuckie at dmc.org
>Subject: Re: [Dysphagia] Chin tuck etc
>Date: Tue, 28 Nov 2006 15:06:13 -0500
>
>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."
>
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