[Dysphagia] Chin tuck etc

[Catherine.Shaker at wfhc.org (Shaker, Catherine S.)]

Thank you, Suzanne, for your insights that we can all benefit from!

Catherine
Catherine S. Shaker, MS/CCC-SLP, BRS-S
Manager - Pediatric/NICU Therapy Services
Wheaton Franciscan Healthcare-St. Joseph
5000 West Chambers Street
Milwaukee, WI  53210
Phone:  414-447-2797
Fax:      414-874-4104
Catherien.Shaker at wfhc.org
 

-----Original Message-----
From: dysphagia-bounces at b9.com [mailto:dysphagia-bounces at b9.com] On
Behalf Of Suzanne Morris
Sent: Tuesday, November 28, 2006 2:06 PM
To: dysphagia at b9.com; mbuckie at dmc.org
Subject: Re: [Dysphagia] Chin tuck etc

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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