[Dysphagia] vital stim & mentally retarded population

[Jai.Gupta at SESIAHS.HEALTH.NSW.GOV.AU (Jai Gupta)]

Hi,
Are we asking a right question? it is like asking can I use a surgical
knife (something so specific for a specific task) instead of any knife
in the kitchen. There is no demonstrated evidence or even a trial
(atleast I have not heard so far and I think I am aware of reseach going
in this area ..and I mean good research ) that these two term in the
subject do not go together. My second issue is even if they go together,
what is the purpose of doing so? What is the underlying pathology and is
this tool made do deal with that pathology.. It is like using
supraglottic swallow to improve oral transit time... Hello ..Gday     


Jai Gupta.  
The Sutherland Hospital 
 



-----Original Message-----
From: dysphagia-bounces at dysphagia.com
[mailto:dysphagia-bounces at dysphagia.com] On Behalf Of Barbara Sonies
Sent: Saturday, 8 September 2007 4:16
To: Suzanne Morris; Michele.Graziadei at dhs.state.nj.us; dysphagia at b9.com
Subject: Re: [Dysphagia] vital stim & mentally retarded population

Hurrah!!!!!!


On 9/7/07 1:56 PM, "Suzanne Morris" <sem at new-vis.com> wrote:

> I am not trained in VitalStim and thus, do not consider using it in
> my practice.   I have had extensive experience with individuals who
> have severe and profound developmental disabilities.  Many of these 
> individuals who have severe swallowing problems also have substantial 
> problems with muscle tone and movement coordination throughout their
> body.   The swallowing issues, in my experience, are rarely an issue
> of the oral-pharyngeal mechanism independent of what is going on in
> the rest of the body.   The mouth and pharynx are very much
> influenced by head and trunk position, postural tone and reflexive 
> movements.  You may be able to stimulate specific muscles in the neck 
> that influence the physiological swallow, but this is going to be in 
> strong competition with the shifts in tone and movement that occur on 
> a daily basis with reflexes that respond to the vestibular input of 
> gravity and the proprioceptive stimulation of muscles in the neck.
> 
>  From time to time I view videotapes of children who are receiving
> VitalStim.   Their parents will be participating in an intensive
> workshop that I teach or I will be seeing the kids themselves for
> assessment and treatment at a later time.   I just reviewed one of
> these recordings yesterday which shows a VitalStim session.  It was 
> very similar to others I have viewed in the past.  In this instance 
> the client was a young pre-teen boy who had been in a near-drowning
> accident as a toddler.   He shows stiff extension throughout his body
> and strong hyperextension of his head/neck in all positions. While 
> sitting in his wheelchair his trunk is pulling down toward the left 
> side and there is increased tension and shoulder girdle elevation on 
> the right side.  His ribcage is stiff and shows slight movement 
> predominantly in the upper thoracic and clavicular areas.  His jaw is 
> open widely in a thrust position and there is limited jaw movement.
> There is minimal movement of the facial muscles at rest or with 
> emotion.  The electrodes for the VItalStim are on his neck and I 
> assume that stimulation is occurring throughout the session. In the 
> filmed treatment session the therapist stimulates his mouth with a 
> cotton swab with taste and then with small spoonfuls of pudding.
> The stimulation of the mouth itself elicits greater lip/cheek movement

> and some purse-string closure of the lips; slight downward pressure of

> the spoon on the tongue stimulates a very weak and inconsistent 
> backward-forward suckle motion of the tongue.  There is intermittent 
> coughing up of mucus and food, usually occurring after
> the 3rd or 4th spoonful of pudding.   This suggests to me that a
> swallow is not being triggered (despite the therapists comments that 
> he has swallowed).  I think that food i simply falling over the back 
> of the tongue and disappearing into the valleculae and pyriform
> sinuses until they fill up and trigger the cough.    What concerned
> me the most about this session is that his head was in severe 
> hyperextension the whole time and at times went into greater extension

> with the oral stimulation.  The therapist was working on
> lip closure and swallowing but with a wide-open jaw.   We know that
> neck hyperextension can increase extensor tone in the jaw and reduce 
> oral coordination.  Mechanically it is extremely difficult to get a 
> good and efficient swallow with the head pushing back into extension.
> 
> So my question is a common-sense one.  Why do we choose to use a 
> specialized piece of equipment (VitalStim) to stimulate specific 
> muscles in the neck for swallowing (even assuming that this does
> work) when the underlying foundation for the swallow really isn't
> there?   This therapist and family have continued with VitalStim
> because the child's MBS has shown some "improvement over time" (I 
> haven't seen copies of the MBS reports so I don't know the specifics).

> But even if there is some improvement in this artificial setting, how 
> does this relate to his life and to how we choose to spend our time 
> and money to improve swallowing function?
> 
> I have worked with numerous children whose physical involvement and 
> cognitive impairment was similar to that seen in this boy.  The focus 
> of treatment has been on working in an integrated way with postural 
> tone and movement to reduce tone and the constant stimulation of
> reflexive movements.   A major focus has been to reduce the extension
> patterns in the body and neck and help the child learn how to get a 
> "soft body" or "soft neck" just with a verbal or touch reminder. This 
> is combined with oral stimulation of the suckle to elicit a stronger 
> and more sustained suckle-swallow movement pattern.  I have found that

> this has been highly effective, and children have learned more 
> functional swallowing skills (especially for handling their own 
> secretions and reducing the amount of drooling or need for constant 
> suctioning to clear the airway) without any electrical stimulation of 
> the swallowing muscles.
> 
> Suzanne
> __________________________________
> 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
> 
> 
> On Sep 7, 2007, at 11:36 AM, Michele.Graziadei at dhs.state.nj.us wrote:
> 
>>  Does anyone have any information regarding Vital Stimulation Therapy

>> with the severe and profound developmentally disabled population 
>> (MR)?  I presently am employed at a residental facility for the MR 
>> population -mainly severe & profound whom are not able to follow 
>> directions. Thanks!!!!!
> 
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