Peer / Product Review Services

Central place to find out more on dysphagia, guiding clinicians and the public through the online dysphagia world of websites and resources.

Karen provides honest and ethical expert opinion. Companies and organizations have benefited from her ability to see the fine details without losing sight of the big picture. She has peer reviewed courses for MedBridge, the American Board of Swallowing and Swallowing Disorders (ABSSD) and more. See examples of her product reviews below.

Smoothe Foods for a Pureed Diet

Smoothe Foods is a company founded by Karen Betz, who was inspired to make great tasting pureed foods after being a caretaker for her father who had Alzheimer’s Disease with dysphagia. If you require smooth and blended foods, do not compromise on taste and nutrition. If you cannot make the pureed foods yourself, then the next best thing is to have fresh foods sent to your home.

Financial Disclosure: I receive a small commission as an affiliate member on every purchase referred by this website.


 

Information provided by Smoothe Foods:

Smoothe Foods are pureed foods made with a healthy blend of ingredients.

They make a great meal for any day of the week.

People who love great tasting nutritious foods sometimes need pureed meals

as part of their dietary plan.

You should not have to be downgraded to powdered, canned, or boxed foods.”

Smoothe Foods offers you easy to eat and swallow nutritious pureed foods that you can enjoy when you are facing conditions such as:

  • Swallowing difficulties (Dysphagia) caused by issues such as cancer, Alzheimer’s, Parkinson’s, stroke, AIDS, ALS, head injuries, etc.
  • Poor digestive functions due to a gastrointestinal condition
  • Chewing sensitivity due to dental issues including surgery
  • Bariatric, dental & general surgery recovery
  • Eating Disorders
  • Malnutrition

My Review of Smoothe Foods / Pureed Foods for People with Difficulty Swallowing (Dysphagia)

Smoothe Foods (along with CWI Medical) made this coupon to support SwallowStudy.com and its followers. I believe it is so important to not compromise on quality of life and taste if you have difficulty swallowing and need pureed foods. If you have a problem with your oral, pharyngeal or esophageal stages of swallowing, make sure your Speech-Language Pathologist has fully tested your swallow function to determine that puree is the best consistency. For some people, puree is not always the easiest texture. Based on the Speech-Language Pathologist’s recommendations, your doctor may have prescribed a Pureed Diet for you.

Of course, anyone can enjoy pureed foods. We eat naturally pureed foods all the time (e.g., yogurt, pudding, squash, mashed potatoes, etc). 

Karen Betz, the owner of Smoothe Foods, sent me samples to taste and analyze. I’m happy to report the results of my taste test! I was fortunate to have the help from my son, who has an excellent palate. He never orders off a kid’s menu, and his Daddy is a great cook!

Here are our findings:

  • Handy small containers that will stack in the refrigerator or freezer.
  • Perfect one-portion sizes.
  • Meals are fully cooked and come frozen.
  • Easy microwave instructions, such as “remove lid, heat for 90 seconds, stir, and heat for another 60 seconds.” I found that with my high powered microwave, I needed only an additional 30 rather than the 60 seconds suggested.
  • Easily pop out of the plastic container to heat them in the microwave in a glass bowl or ceramic dish.
  • Great smell right out of the microwave. The Mac-n-Cheese, Chili and Spinach Lasagna really smelled exactly like the “real thing.”

My son created a 10-point rating scale (with 1 being “lame” and 10 being “super yummy and like real-homemade”).

1. Three Bean Chili got our top vote.  He said if Daddy’s homemade Chili is a “10,” he would rate this Three Bean Chili a 9 3/4! (He loves fractions.) I totally agree with his rating. We found the Chili to be moist, smooth, easy to swallow. It is important to mention, it is not hot/spicy at all. This is good to know for reflux precautions or if your mouth is very sensitive. It has 480mg of Sodium. 140 calories.

Look at the ingredients! I can actually read them all.

INGREDIENTS: DICED TOMATOES, BLACK BEANS, KIDNEY BEANS, WHITE BEANS,

ONION, TOMATO CRUSHED, GARLIC, GROUND PEPPER, GARLIC POWDER,

SOYBEAN OIL, AND SPICES.

2. Spinach Lasagna is another favorite. The ingredients are also very natural, and the consistency was very smooth. It does contain wheat and soy. Sodium is 430mg. Wonderful blend of herbs, such as nutmeg, basil and oregano. With my son, I played “close your eyes and open your mouth.” When he did not know what he was tasting, his initial rating of “yumminess” was 8 1/2 – 9 out of 10. When I told him it was Spinach Lasagna, he said the closeness to homemade lasagna was 9 1/2 – 10 out of 10! Again, I firmly agree with his high ratings! As we know, the taste buds and palate of children are very acute. Even my total foodie husband said, “wow, not bad!”

3. Mac-N-Cheese got a score of 8 out of 10. It was a little sticky, but this could be fixed with a little milk or butter after cooking. This item is good for people who need to put on weight, especially if having difficulty swallowing is causing weight loss. It has heavy cream. Saturated fat is 4.5g, but there is no trans fat. Sodium is 500mg. It really tastes like real Mac-n-cheese, but the only downfall is that it contains partially hydrogenated soybean oil. 

4. Pancakes with Ricotta and Blueberries were best when we drizzled our real maple syrup on top. Adding moisture is a good idea for people with difficulty swallowing who need food to be smooth and moist. It is always tricky to make puree foods out of bread products. They tend to become sticky. Without syrup, my son described the pancakes as “plain,” and that they “don’t taste like much.” However, the syrup really brought out the pancake flavor, and he said: “Yum, yeah, that really tastes like a pancake now!” The downside is the use of high fructose corn syrup in the blueberry filling. We also did not taste much blueberry flavor. Rating would be a 5 out of 10.

Add your reviews to the CWI Medical website as you taste the products.

This helps people with difficulty swallowing still enjoy food. You CAN be a foodie, even if you can only eat purees.

***************

Thank you for reading this review!

I want to make sure that people analyze any puree for safety before assuming that all purees are easy to swallow.

If your pureed food item at your hospital, nursing facility or home is dry and sticky, you could actually choke on it. It may get more stuck in your mouth and throat than a soft-moist regular food item. Make sure your puree is an Ideal Puree, meaning moist and cohesive.

Play with your food & Evaluate:

  • Does it mash easily with a fork, staying moist and smooth? Does the liquidized puree slip through the tines of a fork? Does the typical pureed food pass the “Spoon Tilt Test,” by sliding easily off a spoon turned sideways? –> Eat and Enjoy

OR

  • Does it stick, clump, or crumble when you mash it with a fork? –> Try adding moisture, like sauce or gravy.

OR

  • Does it pick up in one dry-sticky-hard glob? –> Avoid due to choking risk!

READ MORE: check out this blog for more ideas for pureed diets: Recipes for people with dysphagia; Don’t forget the flavor.

Make sure to include this Smoothe Food coupon codes (SWSTY5) to save money on your purchase and support SwallowStudy.com at the same time. Thank you!

 

*******

2019 Pureed Meals Update:

For another company to try, check out HormelHealthLabs.com‘s new website for their

Thick & Easy® Pureed Meal Kits

Normal & Disordered Swallowing in Adults: Ianessa Humbert

I would personally recommend any course or lecture by Dr Ianessa Humbert (check out her new website – as of May 2020 – with all her teaching opportunities here.) She is a dynamic speaker and her presentation style is easy to follow. She incorporates the best available evidence. I have always valued and trusted her research and expert opinion in the field of dysphagia, anatomy/physiology, neurology, and more.

MedBridge is an ASHA approved Continuing Education provider.

Use Coupon Code: SWALLOWstudy for MedBridge discounts.

Ianessa Humbert, PhD, CCC-SLP: Understanding the Events of Swallowing in Normal and Disordered Adults: A Research-Based Course

Ianessa Humbert’s Dysphagia Course Description:

This course, with Dr. Ianessa Humbert, PhD, CCC-SLP, offers an in depth assessment of six important swallowing events: triggering the swallow, posterior lingual propulsion, velar elevation, pharyngeal constriction and elevation, laryngeal vestibule closure, and upper esophageal sphincter opening. For each swallowing event, normal and abnormal movements and/or sensation are described, and probing strategies are discussed (i.e. modifying the event with bolus volume, head position, swallowing maneuvers). The information presented is based in research literature, including full citations for further review. This course shows each swallowing event using a combination of representative video fluoroscopic studies and anatomical animations of each abnormal swallowing event.

Learning Objectives:

MedBridge Education

Understanding the Events of Swallowing in Normal and Disordered Adults – A Research-Based Course

Ianessa Humbert, PhD, CCC-SLP

Chapter 1: What is Orpharyngeal Swallowing?

The online learners will:

  • Explain the Kahrilas theory that describes what swallowing is in 2 parts
  • Describe the clinical relevance of probing a swallowing event

Chapter 2: Triggering the Swallow

The online learners will:

  • Describe the basic sensory and motor components or triggering a swallow
  • Define Stage Transition Duration or STD
  • Identify the common trigger zones for swallowing
  • Describe normal variation in onset of swallowing triggering
  • Describe normal aging variation in onset of swallowing triggering
  • Indicate population(s) known to have delayed swallowing onset and outcomes
  • Learn impact of bolus type, cueing, and thermal stimulation on triggering swallowing

Chapter 3: Posterior Lingual Propulsion

The online learners will:

  • Describe the basic sensory and motor components of posterior lingual propulsion
  • Identify the primary force behind bolus movement and its kinematics
  • Describe abnormal posterior lingual propulsion
  • Identify tasks that modify posterior lingual propulsion

Chapter 4: Velar Elevation/Velo-Pharyngeal Closure

The online learners will:

  • Describe the basic sensory and motor components of velar elevation/velo-pharyngeal closure
  • Identify the tasks that contribute to velar elevation/velo-pharyngeal closure
  • Describe abnormal velar elevation/velo-pharyngeal closure
  • Identify tasks that modify velar elevation/velo-pharyngeal closure

Chapter 5: Pharyngeal Contraction

The online learners will:

  • Differentiate between longitudinal pharyngeal muscles and pharyngeal constrictormuscles
  • Describe timing and range of motion of the pharynx during swallowing
  • Describe the effects of healthy aging on pharyngeal constriction
  • Describe abnormal pharyngeal constriction
  • Identify tasks that modify pharyngeal constriction

Chapter 6: Laryngeal Vestibule Closure

The online learners will:

  • Identify the events that contribute to laryngeal vestibule closure
  • Describe the motor and sensory components of laryngeal vestibule closure
  • Describe the normal kinematics of laryngeal vestibule closure
  • Describe abnormal laryngeal vestibule closure
  • Identify tasks that modify laryngeal vestibule closure

Chapter 7: Upper Esophageal Sphincter Opening

The online learners will:

  • Describe the relationship between UES pressures and bolus flow
  • List the neuromuscular and biomechanical components of UES opening
  • Describe abnormal UES pressures
  • Identify tasks that modify UES pressures and opening

Chapter 8: Discussion with Dr. Robert Miller

Dr. Ianessa Humbert sits down with Dr. Robert Miller to discuss the current research surrounding the events of swallowing.

 

NOTE:

There are many more Medbridge courses on dysphagia.

Click here for $175 off your annual MedBridge subscription.

This reduces the cost of the subscription to as low as $95 per year, regularly $270.

Or check out general pricing info here: https://www.medbridgeeducation.com/pricing/slp/

USE COUPON CODE:

SWALLOWstudy

at checkout for those discounts!

Thanks in advance for the small affiliate member donation you are making to my efforts at SwallowStudy.com!

CWI Medical Supplies for People with Dysphagia

This medical supplies company is “Minority/Women-Owned Business Enterprise Certified” & they provide a wide variety of medical supplies, including products for people with difficulty swallowing (dysphagia).

CWI Medical provided SwallowStudy.com with a coupon code to pass discounts on to you! Click on coupon.

Financial Disclosure: SwallowStudy.com receives a very small percentage of the sale.

 


 

Click on coupon for your dysphagia medical supplies & more. Use CODE: SWSTY5 to support SwallowStudy.com with every purchase. Thank you.

Medical Supplies for People with Dysphagia

I have been impressed by this medical supplies company, CWI Medical, out of New York.

Not only are they Minority/Women-Owned Business Enterprise Certified, but they also provide convenient home delivery of medical supplies.

Particularly helpful to people with dysphagia, CWI provides: thickener powders and gels (in the preferred gum-based thickeners), pre-thickened liquids, protein shakes and nutritional supplements, pureed meals, and more.

The categories of medical supplies are as follows: 

Nutrition, Incontinence, Mobility and Ambulatory, Daily Living Aides, Personal Hygiene, First Aid, Bathroom Safety, Braces and Supports, Home Diagnostics, Patient Room and Homecare, Drug Screening Tests, Bariatric Care, Babies and Kids, Samples, Healthy and Helpful Gifts, and even Halloween Props (seasonally)!

Some of the brands they cover are: 

Hormel Thick & Easy Nutrition, Thick-It, ThickenUp, Simply Thick, Smoothe Foods Puree Meals, Pro-Stat Liquid Protein, Proteinex Protein Supplements

CWI is responsive to calls and emails, and their website is easy to navigate. My partnership with them will provide ongoing access to reliable coupons and discounts on medical supplies for people with difficulty swallowing. I receive a very small commission on every purchase. 

Read More About Medical Supplies for People with Dysphagia:

Product review of Thickened Liquids.

Thickened Liquids post – for even more information.

Why Puree?

Use CODE: SWSTY5 to support SwallowStudy.com with every purchase. Thank you.

SaveSave

The course formally known as “Critical Thinking in Dysphagia Management…”

Dr Ianessa Humbert and Dr Emily Plowman, experts in our field, addressed the need for improved critical thinking when it comes to dysphagia evaluations and treatment planning.

However,

Per the HopeIsInTheScience.com website, the Critical Thinking in Dysphagia Management (CTDM) course has stopped accepting enrollments as of December 31, 2019

Dr Humbert’s 2020 update:

First, Dr. Humbert notified the SLP world via social media in March 2020 that she is developing a new course. See info here:

NEW SLP CEU course called: “Collecting Clinical Evidence”

Watch the trailer:
https://youtu.be/S8Sn0ebvpRs

Download course content with link: https://www.dropbox.com/…/Collecting%20Clinical%20Evidence%…

This course will be available through Swallowology.com launching in Summer of 2020!

As of May 2020, Dr. Humbert informed the dysphagia world that she has created a new one-stop-shop for all her learning opportunities. She notes that this course is coming soon…

Check out her new IanessaHumbert website & the Learn tab for all her latest course updates:

Learn

If you are looking for her other excellent resources such as:

Critical Thinking in Dysphagia Management (CTDM), Normal Swallowing 101, Dysphagia Grand Rounds, Down The Hatch (also available on SoundCloud & similar) –> then go to her Swallowing Training & Education Portal (STEP) on her website, which takes you to this link: https://www.stepcommunity.com

Product updated 5/2020.

 

Thickened Liquids

Have you been advised to thicken all your liquids to prevent liquids getting down the wrong way into your lungs? Hopefully, you have had a comprehensive evaluation by a swallowing specialist. Read more about thickened liquids. I cannot recommend one brand over another.

Ongoing work by the International Dysphagia Diet Standardisation Initiative (www.iddsi.org) will hopefully help industry to continue advancements. This will make thickened liquids more palatable, more standardized and safer for people who need them.

 

Click on coupon for your dysphagia medical supplies & more. Use CODE: SWSTY5 to support SwallowStudy.com with every purchase. Thank you.

 


 

A brief review of thickened liquids:

by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

According to the best evidence we have to date, thickeners with gums, like xanthan gum, are the most stable in the mouth, through the throat, and in response to changing temperatures. See list of some of the gum-based thickeners at the end of this review.

There are some major issues with thickeners that are made with modified corn-starch or modified food starch (tapioca and corn). These come in powder form and in pre-thickened liquid form.

Examples of modified corn and food-starch thickener products are: Resource ThickenUp, Hormel Thick & Easy, Hormel Thick & Easy Thickened Dairy, and Thick-it Instant Food & Beverage thickener.

Why should I be concerned about starch-based thickeners?

There has been a lot of variability in the thickness across these companies with these starch-based thickeners, even when testing the pre-thickened liquids right out of the container. Recently, per liquid flow tests, IDDSI found that Hormel’s Thick & Easy Thickened Dairy / Nectar Consistency (Mildly Thick), was actually measuring on flow tests at a honey thick level (Moderately Thick). When a pre-thickened liquid out of the container appears too thick, that will immediately affect the visual appeal.

Thickening with starch-based thickeners also tends to make the liquid appear cloudy. Therefore, water does not look like water.

Starch thickeners affect the taste and give the mouth a gritty feeling. When sampling corn-starch based powdered thickeners versus gum-based powdered thickeners, I was struck by how you could feel the little particles in the water with the corn-starch based thickener. The gum-based thickeners all felt smooth in my mouth and did not change the taste of the water.

Hormel, Resource and Thick-It now all make a “clear” version, which uses the xanthan gum and other gums. See list at the bottom of this review of some of the companies that make “clear” thickeners.

 

These are both water! See the cloudy starch-based thickener on the left. A clearer gum-based thickener on the right.

 

NO thickener company has provided products at truly consistent viscosity ranges yet, per Dr Catriona Steele, PhD, CCC-SLP, BCS-S, ASHA Fellow and member of www.IDDSI.org (International Dysphagia Diet Standardisation Initiative). This lack of standardization really poses patient safety issues. READ MORE on my previous blog on Diet Safety.

Steele described how xanthan gum thickeners may be more stable, as you avoid the issue of enzymes in your saliva that cause a breakdown in the starch-based thickeners.

Research has showed how this enzyme, salivary amylase, dramatically reduces the thickness of the liquid you are drinking when thickened with starch-based thickeners. Therefore, the thickened liquid prescribed to you by your Speech-Language Pathologist and doctor, based on a swallow study, may not be consistent with what you are drinking. In other words, your mildly thick/nectar thick liquid may thin down to a regular-thin liquid as saliva contaminates the cup. This could cause the liquid to get down the wrong way into your lungs.

What if you are still aspirating your thickened liquids?

If thickened liquids are still aspirated, it may be harmful to the lungs. The lungs have a harder time clearing a very thick liquid (moderately thick/honey thick) out of the lungs. Make sure you are on the right level of thickness. If you are prescribed a nectar thick liquid (aka, mildly thick per IDDSI), make sure that it is not given to you at a honey thick or pudding thick level (aka, moderately thick or extremely thick liquid). If the spoon stands up in it, it is likely a honey thick (moderately thick) liquid. If it plops off the spoon or sticks to the spoon, it is likely a pudding thick (extremely thick) liquid or even mud!!

Thicker is not always better or safer. It could cause increased residue in your throat, which could spill into your airway after the swallow. Please have your swallowing specialist (Speech-Language Pathologist who specializing in swallowing) perform a comprehensive evaluation of your swallowing. 

Also, if the mouth is full of bad bacteria, a corn-starch based thickening agent in your liquid may bind with your saliva, carrying the bad bacteria to the lungs along with the liquid.

Other cautions regarding thickened liquids:

1. Please read the ingredients on all labels.

  • Many of these pre-thickened liquid milk and juice boxes have added sugar.
    • The Hormel Thick & Easy Dairy dropped its sugar down to 15 grams for Nectar Thick (mildly thick) and 16 grams for Honey Thick (moderately thick). It used to be higher.
    • The old Hormel Thick & Easy Hydrolyte Water with modified corn starch had high fructose corn syrup added. However, now the Thick & Easy CLEAR Hydrolyte has 0 grams of sugar and only lemon flavor, citric acid and sucralose added.
    • Thick-It AquaCare H20 brand with xanthan gum still has 36 grams of sugar in the cranberry juice, whereas Thick & Easy Clear Cran Juice has 23 grams. 
  • Check for artificial flavors and colors if that is important to you. The Thick-it AquaCare H20 Cranberry has Red 40, artificial flavors and carmel color added. Thick & Easy Clear Cran Juice also has artificial flavor, Red 40 and Blue 1.
  • If sugars and added ingredients are of concern, and you want the convenience of a pre-thickened liquid, you will have to buy just the waters or Thick-It has a regular and decaffeinated coffee with 0 grams of sugar. Otherwise, if you have your preferred beverage that is low in sugar, you will have to use the gum-based powders or gels to create a the thickened liquid yourself. 

2. I CANNOT RECOMMEND ANY THICKENER PRODUCTS FOR THE INFANT POPULATION. TOO MANY RISKS and QUESTIONS:

  • Can Infants clear the thick liquid out of the airway if they aspirate a thick liquid?
  • How does it affect an infant’s brain development? Neuroplasticity. If we teach an infant the swallowing physiology needed to swallow a thick substance, than how will they develop the ability to swallow a faster moving liquid.
  • Will an infant’s immature digestive system absorb and process the thickener to make the fluid fully “bioavailable” to the body for adequate hydration?
  • Even SimplyThick, a xanthan gum fully-hydrated gel product, caused an adverse reaction in an infant due to bacterial contamination at the manufacturing plant.

Gum-Based Thickeners:

  • Hormel Thick & Easy CLEAR (powder & pre-thickened liquids)
  • Resource ThickenUp CLEAR (powder)
  • Thick-it AquaCare H20 and Clear Advantage (powder, pre-thickened, resealable personal-sized bottles)
  • SimplyThick (Water-soluble gum in a fully-hydrated solution form. Per the company materials and FDA findings in 1993, fully-hydrated solutions do NOT cause risk of powder particles swelling to cause asphyxiation or esophageal obstruction. Whereas, undissolved/unhydrated gum powder thickeners could cause a blockage if not properly mixed). However, SimplyThick is a bit harder to mix if you do not have a sealed container to shake it up. SimplyThick does not recommend mixing with a spoon. You have to either shake vigorously or mix briskly with a fork in an “egg-beating” fashion for 20-30 seconds.
  • Nutricia Nutilis Clear (powder)
  • Purathick (powder)

If you need thickened liquids, I can recommend this company to make your purchase:

 

Click on coupon for your dysphagia medical supplies & more. Use CODE: SWSTY5 to support SwallowStudy.com with every purchase. Thank you.

READ MORE: Thickened Liquids Page

SafeStraw by Bionix

SafeStraw: A Volume Limiting Drinking Aid,

by Bionix Medical Technologies (Bionix Health At Home)

These straws deliver only 6.2ml when the patient sucks on the straw. A smaller sip volume may be safer and prevent aspiration in people with dysphagia.

  • Great when a patient has difficulty remembering to take a small sip.
  • Need to have enough strength to sip from straw.
  • Not for everyone. Ask your Speech-Language Pathologist.

Individuals can purchase these from Bionix Health At Home.

Note: I do NOT receive any commission from a click or a purchase.

I have received NO financial compensation for writing this product review.

 


 

TAKE A SMALL SIP!

Product Review: SafeStraw by Bionix

by Karen Sheffler, MS, CCC-SLP, BCS-S of www.SwallowStudy.com

White / SafeStraw Drinking Aid for Thin Liquid. Blue / SafeStraw Drinking Aid for Thick Liquid (Nectar thick / mildly thick)

Straw Drinking & Dysphagia: A Background

Do you find yourself choking when you are chugging your drinks?

Does fast drinking from a cup or straw make you cough, like liquid is going down the wrong pipe?

Maybe it is. Maybe a Speech-language Pathologist (SLP) needs to evaluate your swallowing function. See post on “How do I know I need a swallow study?” 

Speech-Language Pathologists (SLPs) specializing in difficulty swallowing (dysphagia) have lots of tricks to make it easier to swallow. Frequently, SLPs recommend the strategy of taking small sips, based on the person’s swallow study.

However, is that realistic?

Lawless, et al., (2003) noted that average cup sips are 25ml or 20ml for healthy men and healthy women, respectively. Recently, Steele, et al., (2015) found that when given a full cup of water, people tend to take sip sizes of 16ml, on average.

We may note on a person’s swallow study, that a teaspoon-size sip (5ml) of a thin liquid is safe, but who drinks out of a spoon? How would that affect the person’s hydration and quality of life?

We also may report on a swallow study that a small sip by cup prevented liquids from going down the wrong way, but who will sit next to that person all day and everyday to remind him to take small sips? If a 25ml size sip is his automatic-natural way of drinking, then a 5ml sip is a big change.

Furthermore, the swallow study may show that liquids go down the wrong way when taken rapidly by a straw (sequential drinking). However, it tends to be challenging to get staff and family to remember to avoid straws.

What if the person prefers to drink out of a straws? What if the dependent patient in the hospital is easier to feed when using a straw?

A straw may make it easier to get the liquid in the mouth. Veiga et al., (2014) found that it was easier for healthy elderly adults to take sequential sips via a straw from an oral point of view. The liquid did not spill out of the mouth as much as with sequential cup drinking. This study was done with healthy elderly with a mean age of 72.8 years. None of the healthy elderly had airway compromise, meaning no liquid got into the top of the airway/laryngeal vestibule (penetration) or below the level of the vocal cords (aspiration), but only 100ml was taken.

Do people aspirate more via straw than cup? Daniels, et al., (2004) studied healthy young and elderly individuals. They found inherent problems with sequential straw drinking that increase risks. Sequential straw drinking, no matter young or older, tends to allow the volume of liquid to drop too low in the throat before the swallow (i.e., bolus head was inferior to the valleculae in the hypopharynx before the onset of the swallow in 66% of adults). Additionally, older adults (ranging in age from 60-83 years old) had more airway compromise (penetration and aspiration) during sequential drinking of 300ml.

These studies were on healthy elderly. What if the elderly person is weak, lethargic, confused and sick? Is straw drinking safe and possible? This is why a formal swallowing evaluation may be needed by an SLP to rule-out aspiration and dysphagia, and to determine the best safe-swallow strategies.

The amount of risk could be significantly higher in people with dysphagia (difficulty swallowing). Your Speech-Language Pathologist (SLP) can fully evaluate your swallowing function with a Modified Barium Swallow Study (aka, MBSS or Videofluoroscopic Swallow Study – VFSS) or a Flexible/Fiberoptic Endoscopic Evaluation of Swallowing (FEES). Depending on your specific structural and physiological swallowing difficulties, the SLP may recommend small sips to prevent penetration and aspiration of liquids into your airway. See post on “How is my swallow evaluated.” 

Sometimes thickened liquids are recommended, especially if a person cannot modify his/her sip size and follow safe-swallow strategies. However, thickened liquids may effect the person’s intake and quality of life.

Potentially, a device that modifies the sip size for the patient could keep the patient off thickened liquids and enjoying any regular thin liquid beverage safely (per testing by an SLP and your medical team’s advice). See *Key Points section below.

SafeStraw Product Review for People with Dysphagia to Liquids:

The specific device I tested was the SafeStraw: A Volume Limiting Drinking Aid, by Bionix. For individual purchases of the straws, go to: Bionix Health At Home website and check out the Product Directory. Again, I receive no financial compensation for this recommendation.

I particularly like the White / SafeStraw Drinking Aid for Thin Liquid. I found the sip size was consistent when drinking water via the SafeStraw. The sip volume was equal to a full plastic teaspoon (roughly 5ml in a medicine cup). When SLPs test swallowing with X-ray or endoscopy, one of the methods to test liquids is via a plastic teaspoon, but some spoons are bigger than others.The testing per the company is obviously more accurate, and they report consistent 6.2 ml size sips. The company describes how it works as follows:

As the patient sucks on the straw, fluid flows through the one way valve and into the fluid chamber. When the fluid travels through the chamber to the straw, the float rises. After around 6.2ml’s, the float reaches the top of the chamber, closing it off, preventing the patient from receiving more fluid. Once they stop sucking, the float sinks to the bottom of the chamber.”

SafeStraw Pluses:

  • Lightweight: put it in your pocket when you go out to eat.
  • Thin: drop it into any water/juice bottle with a narrow top.
  • Short: no one will see it. It just looks like part of a normal straw, especially the White/SafeStraw Drinking Aid for Thin liquid. (Whereas, the Blue/SafeStraw Drinking Aide for Thick Liquid is bright blue and more visible. However, the color coding is needed as the floats are different materials.)
  • Versatile: you can attach a normal plastic drinking straw to the top of it.
  • Adaptable: Cut any straw to attach a smaller straw to the top of the device. A shorter straw may make it easier to drink: reducing the amount of pressure you need to build up in your mouth and reducing the amount of time you need to be sucking. (Cichero & Murdoch 2006; Groher & Crary, 2010)
  • Less waste: The device is NOT a one-time use; therefore, it is more affordable and less waste than some adaptive straws on the market.
  • Easy to take apart and clean: It comes assembled, but there is an assembly diagram in the package. Don’t loose the float piece when you take it apart. You can soak all parts it in hot soapy water. I would imaging you could run rubbing alcohol through it to disinfect, and then thoroughly rinse.

What do you need to know about SafeStraw?

  • You cannot take sequential sips from this device. It prevents rapid chugging to hopefully improve your swallowing safety. It is like a little helpful reminder! However, if the person gets easily agitated, this may increase frustration.
  • Wait time between sips: Unfortunately, you cannot take another full sip until the float falls back to the bottom of the cylinder. This takes 3 seconds for the White/SafeStraw Drinking Aid for Thin Liquid.
  • Your first sip when you first start your drink is a priming sip, and you may not get any liquid at all. Once it is primed (i.e., liquid in the chamber/cylinder), the rest of the sips will be consistent for the white SafeStraw for thin liquids.
  • I found the Blue / SafeStraw Drinking Aid for Thick Liquid to be a bit challenging and too variable. I tried it on a “nectar thick” milkshake. The metal float did not consistently drop back down. A shorter straw did not help. I discussed this with a representative from Bionix, and he noted that the Blue SafeStraw is made with a food-grade-rust-proof stainless steel float. It is supposed to be heavier than typical nectar thick liquids. However, there may be too much variability in the true viscosity or thickness of nectar thick liquids, as well as solid particle/fat content. For example, my smoothie made with yogurt, and almond milk, as well as my vegetable and juice smoothie, really made the float get stuck. Whereas, my pudding and milk smoothie may have been thinner and the float fell to the bottom of the cylinder easily.

Note: SafeStraw instructions indicate that it takes 6-9 seconds for the float to sink to the bottom with the Blue / SafeStraw Drinking Aide for Thick Liquid.

  • The intraoral pressure needed to pull the thick liquid up through the straw may be too significant for many patients with dysphagia who require thick liquids.

SafeStraws are good for thin liquids, except carbonated liquids (use the white one – SafeStraw Drinking Aide for Thin Liquid). The Blue SafeStraw Drinking Aid for Thick Liquid  is made for a mildly-thick or nectar thick liquid, but not for thicker liquids (i.e., NOT for moderately to extremely thick liquids, like “honey” thick or “pudding” thick liquids).

SafeStraws are good for thin liquids, except carbonated liquids (White Thin Liquid SafeStraw). The Blue Thick Lliquid SafeStraw is made for a mildly-thick or Nectar thick liquid, but not any thicker (i.e., NOT for moderately to extremely thick liquids like Honey thick or Pudding thick).

SafeStraws are good for thin liquids, except carbonated liquids (use the white one – SafeStraw Drinking Aide for Thin Liquid). The Blue SafeStraw Drinking Aid for Thick Liquid  is made for a mildly-thick or nectar thick liquid, but not for thicker liquids (i.e., NOT for moderately to extremely thick liquids, like “honey” thick or “pudding” thick liquids).

* Key Point:

Not every patient with dysphagia will be able to use this device, as some people may have weaknesses or cognitive deficits that prevent them from being able to use a straw at all. The company notes that the SafeStraw is for “deficient oropharyngeal or oral motor skills;” however, some types of oral-motor weakness and oropharyngeal dysfunction will make it hard to use this straw device.

What is required for straw drinking?

  1. First of all, the patient has to recognize what to do with a straw. (Unfortunately, in very advanced Dementia, people loose the ability to recognize what to do with common utensils like straws.)
  2. Adequate lip strength to seal around the straw.
  3. Ability to build up intraoral pressure, which requires:
  4. Good soft-palate closure (aka, velopharyngeal closure) to block off the nasal cavity.
  5. Good swallowing-breathing coordination.

 

Summary:

Ultimately, it is your medical team and your Speech-Language Pathologist who will help you determine if you are a good candidate for SafeStraw. Why not bring the SafeStraw devices with you to your instrumental evaluation and drink thin and thick barium contrast through it? Just perform many trials with the SafeStraw to make sure it is safe and consistent (i.e., 6 trials with a thin liquid). It will be easy to rinse the barium out when you are done!

I am glad to test a device that can really have an impact on a patient’s safe hydration, quality of life, aspiration prevention, and potentially aspiration pneumonia prevention, especially if it can help the patient avoid thickened liquids and drink regular liquids. We always want to see our patients on the “least restrictive fluid” (i.e., thinnest liquid) possible. This device could be a big help!

References:

Cichero, JAY & Murdoch, BE. (2006). Dysphagia: Foundation, Theory & Practice. West Sussex, England: John Wiley & Sons Ltd.

Daniels, SK, Corey, DM, Hadskey, LD, Legendre, C, Priestly, DH & Rosenbek, JC. (2004). Mechanism of sequential swallowing during straw drinking in healthy young and older adults. Journal of Speech-Language and Hearing Research, 47 (1), 33-45.

Groher, ME & Crary, MA. (2010). Dysphagia: Clinical Management in Adults & Children. Maryland Heights, Missouri, Mosby/Elsevier.

Lawless, HT, Bender, S, Oman, C & Pelletier, C. (2003). Gender, age, vessel size, cup vs straw sipping, and sequence effects on sip volume. Dysphagia, 18 (3), 196-202.

Steele, CM, Peladeau-Pigeon, M, Tam, KL, Zohouri-Haghian, N & Makhurjee, R. (2015, March). Variations in Sip Volume as a Function of Pre-Sip Cup Volume. Poster presented at the Dysphagia Research Society 23rd Annual Meeting, Chicago, IL.

Veiga, HP, Fonseca, HV & Bianchini, EM. (2014). Sequential swallowing of liquid in elderly adults: cup or straw? Dysphagia, 29 (2), 249-255. doi: 10.1007/s00455-013-9503-8.

Pureed Meals by “Mom’s Meals”

These Pureed Meals (main dish, plus 2 sides and a dessert cup) are prepared by Mom’s Meals: Nourish Care with a team of food scientists, chefs and registered dietitians.

Please see my product review below, where I critically analyze 6 of the meals for appearance, texture, taste, and safety. Not all purees are created equal. I want to make sure the puree is tasty and easy to swallow for people who have difficulty swallowing.

Three Ways To Order:

  1. Check out details on the Gourmet Pureed website. When meals are ordered through www.GourmetPureed.com, you get a free pureed meal with every order using the code: PUREED. Call 866-971-6667 if questions.
  2. If you call Mom’s Meals directly: 1-866-716-3257, mention “Gourmet Pureed” to get your free meal offer.
  3. If you order directly from www.MomsMeals.com, again, use coupon CODE: PUREED to get your free meal offer.

Disclosures:

No financial disclosures. I do not receive any commission on orders. I am reviewing this product to keep consumers well-informed.

I am specifically reviewing Gourmet Pureed since they support the National Foundation of Swallowing Disorders (NFOSD). NFOSD is helping people cope with the challenges of having difficulty swallowing (dysphagia).

 


 

Mom’s Meals: NourishCare

Product Reviews on 6 Pureed Meals

by Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

First, I’ll give you the pureed bottom-line:

Not all purees are created equal; however,

I can recommend both Smoothe Foods and Mom’s Meals. Check out the product reviews on Smoothe Foods. Read on to discover more about Mom’s Meals. My favorite Mom’s Meals: The Pork Patty with BBQ Sauce (for it’s true southern BBQ-style flavor) and the Roast Chicken meal (as the chicken and carrots make the meal). For breakfast, you can enjoy a pureed bread! I never would have believed it, but the French Toast with the Cinnamon Apples are smooth and easy to swallow.

Mom’s Meals NourishCare – Pureed Meals – Product Review

Thank you George, of Gourmet Pureed (affiliate partner of Mom’s Meals), for sending me 6 different pureed meals to test.

General information:

  • Meals come fresh and not frozen, and can stay in your refrigerator for 2 weeks.
  • The meals come with pudding and/or applesauce snack packs. These last for weeks in the refrigerator. I really liked the blueberry and raspberry applesauces. The desserts were all smooth, moist and easy to swallow.
  • Instructions are easy and written in large print on the cover of the plastic container. Example of instructions: Microwave 60 seconds, stir, then microwave for an addition 45 seconds, and then to let it stand for 1 minute.
  • Sodium content tends to be high, with a range of 580 to 900 mg. You can see more nutritional information on the Gourmet Puree website. 
  • Protein content is high, with 29 grams typical in a meal containing meat.
  • Full meal at an affordable price.
  • I’m not a fan of how some of these foods are artificially flavored. The “butter alternate” gives an artificial buttery flavor with a “liquid and hydrogenated soybean oil.” The “mapleberry syrup” is corn syrup, high fructose corn syrup, maple syrup and caramel color. However, if you are unable to prepare fresh foods at home and blend them yourself, then these packaged pureed foods provide you with the assurance that you are getting all your necessary nutrients.
  • I would not suggest freezing the meals. The appearance after heating was more watery:My photo: Pureed Roast Beef with Gravy, Mashed potatoes and Brown sugar glazed carrots

Big Tip for Pastas and Bread Products: These caused the biggest variability in ease of swallowing, with some being so sticky that the food got stuck to the roof of my mouth. However, the pasta was much smoother and more moist if I let the pasta dish sit covered for a while in between heating rounds. Here is what I did:

  1. Peel back the corner of the plastic cover for a vent. Could transfer into a glass container with lid popped open.
  2. Heat for 60 seconds on high in microwave.
  3. Let the meal sit in the microwave covered for a few minutes (i.e., 5 minutes).
  4. Stir contents and place meal onto my plate.
  5. Heat it back up for 30-45 seconds.
  6. Test the moisture of the bread or pasta, and add syrup or sauce as needed.

Rating Scale: 1 — 10

1 means: “I am not going to take another bite of that” to

10 mean: “Tastes homemade, and just like my husband makes!”

1. Pureed Pork Patty with BBQ Sauce, Cheesy Mashed Potatoes and Green Beans

Pureed meal from Gourmet Puree

Picture provided by Gourmet Puree: Pureed Pork Loin Patty with BBQ Sauce, Cheesy Mashed Potatoes & Green Beans

 

My photo of the pureed meal in the container provided to show actual product.

My photo in container provided: Pureed Pork Loin Patty with BBQ Sauce, Cheesy Mashed Potatoes & Green Beans

 

 

 

 

 

 

 

 

a. Pork: 8/10. My initial reaction: “No way, that is good!” The barbecue sauce was so good that there could have been more! The flavor may have been from the natural hickory smoke flavor and spices, but it does also have high fructose corn syrup. This pork was pureed carefully, without any chewing needed and no small chunks of meat or gristle (i.e., cartilage or inedible tissue in meat). The meat stayed smooth in the mouth. No effort to move around the ball of meat. Not stuck to the roof of my mouth. I ate the whole portion.

b. Cheesy Mashed Potatoes: 9/10. The added cheese sauce to the mashed potatoes made them easy to swallow. Did not get stuck on the roof of my mouth. It was so smooth and cohesive. I ate the whole portion.

c. Green Beans: 4/10. Appear more green than the green beans in other meals, which is good. They were moist and easy to swallow, but the buttery flavoring made me not want to eat them after 3 bites.  

 

2. Pureed Roast Beef with Gravy, Mashed Potatoes and Brown Sugar Glazed Carrots

Picture provided by Gourmet Puree: Roast Beef with Gravy, Mashed Potatoes and Brown Sugar Glazed Carrots. This brown glaze sauce was not provided with the meal.

Picture provided by Gourmet Puree: Roast Beef with Gravy, Mashed Potatoes and Brown Sugar Glazed Carrots. This brown glaze sauce was not provided with the meal.

My photo: Pureed Roast Beef with Gravy, Mashed potatoes and Brown sugar glazed carrots

My photo: Pureed Roast Beef with Gravy, Mashed potatoes and Brown sugar glazed carrots. As noted above, I tried freezing this one.

 

 

 

 

 

 

 

 

 

a. Roast Beef: 2/10. Some very large gristle pieces (i.e., the size of my pointer-finger nail). I found there to be 3 to 7 gristle pieces per teaspoon size bite. This is dangerous for someone with decreased sensation and awareness of small pieces. Some people may not have the ability to separate them and spit them out. 

b. Mashed Potatoes: 7/10. Moist and smooth. I could taste the gravy. Easy to piecemeal swallow (swallow a little bit at a time).

c. Carrots: 9/10. The color, flavor and texture were perfect. Easy to swallow. No chewing necessary. The brown sugar glaze must have masked the “butter alternate.” 

 

3. Pureed Meat Patty Loaf with Pasta & Cheese Sauce and Green Beans

a. Meat Patty Loaf: <5/10. Strange pickle flavor. This meat also has the gristle pieces that need to be spit out.  

b. Pasta & Cheese Sauce: 7/10. Pretty good flavor. Smooth texture. I compared this pasta directly to the Smoothe Food‘s Shells and Cheese. The Smoothe Food pasta item smelled better and tasted better than the pasta from Mom’s Meals, but the Mom’s Meals pasta had a smoother texture versus a slight graininess in the Smoothe Food item.

c. Green Beans: <3/10. “Not inedible, but I don’t like the butter flavor and paste flavor,” per my husband. 

 

4. Pureed Roasted White Chicken with Gravy, Mashed Potatoes & Vegetables

My photo: Pureed Roasted White Chicken with Gravy, Mashed Potatoes & Vegetables.

My photo: Pureed Roasted White Chicken with Gravy, Mashed Potatoes & Green Beans.

Picture Provided by Gourmet Puree: Pureed Roasted White Chicken with Gravy, Mashed Potatoes & Vegetables

Picture Provided by Gourmet Puree: Pureed Roasted White Chicken with Gravy, Mashed Potatoes & Vegetables.

 

 

 

 

 

 

 

 

 

a. Chicken: 8.5-9/10. “Smells like real chicken. Tastes like real chicken, but only mashed,” per my son. He also added wisely: “Eating the chicken with the mashed potatoes brings in more taste, but it does make the chicken sticky.”

b. Mashed Potato: 5/10. This mashed potato was really sticky. I felt it was like a paste on my hard palate. It required at least 3 swallows to clear a small bite. “I don’t think that is a good one,” per my son.  

c. Carrots: 8/10. My son tried this one too and said: “Taste like real carrots; like the real thing fresh out of the ground.”

d. Grean Beans: 3/10. We could only identify them as a green puree. The taste and the smell were vague and only slighty saying “green bean.” Again, the buttery flavor does not help. 

 

5. Pureed Pasta with Marinara Sauce and Broccoli

a. Pasta: 6-7/10. Smells good. The taste is “functional if you doctor it up with spices,” per my neighbor. However, it required some full rotary chewing (remember, this is where you place the food between your back teeth and grind in a circular chewing motion). It also got stuck on the roof of my mouth, requiring more tongue strength than some people with dysphagia might have. This item may have benefited from sitting covered for longer between heating rounds. I did not do that extra trick on this one.

b. Broccoli: 3/10. This had a bland cardboard flavor with a hint of butter! It was very light green, as one may see in overcooked broccoli. However, it was smooth, moist and easy to swallow. 

 

6. Pureed French Toast with Pork Breakfast Patty and Cinnamon Apples

a. French Toast: 7/10. I was skeptical of a pureed bread! My son reported: “In the first place, it had to be chewed a lot, but it was not that sticky like the mashed potatoes.” My husband, who is an amazing cook, said: “actually, not bad!” This bread product benefited from letting it stand covered to steam and moisten. Otherwise, as it sat drying out, it did become more solid, requiring the rotary chewing. If it is not chewed it just gets stuck on the roof of the mouth. Syrup and/or the cinnamon apples are a must.

b. The Cinnamon Apples mixed with the French Toast: 9/10. There was plenty of this smooth and yummy apple puree to make the other items easier to swallow. My son said: “I don’t have to chew. I can just put my tongue against my palate and then rub.” My husband also added: “Good job blending flavors without making it overpowering with artificial flavor;” “I would eat that for breakfast;” and “For pureed food this is one of the better ones.”

c. Pork Breakfast Patty: 7/10. Smell was good. Flavor was pretty good. Thoughts on the spicing ranged from: “nicely spiced,” to “a little overly seasoned.” The cinnamon apples may help the overall appearance, as my son first thought: “cat food.” From a swallowing standpoint, it did require chewing. The texture was gritty or grainy, requiring a strong tongue sweep to clear it from the mouth. 

 

Thank you for reading this review!

I want to make sure that people analyze any puree for safety before assuming that all purees are easy to swallow.

If your pureed food item at your hospital, nursing facility or home is dry and sticky, you could actually choke on it. It may get more stuck in your mouth and throat than a regular food item. Make sure it is moist and cohesive.

Play with your food & Evaluate:

  • Does it mash easily with a fork, staying moist and smooth? Does the liquidized puree slip through the tines of a fork? Does the typical pureed food pass the “Spoon Tilt Test,” by sliding easily off a spoon turned sideways? –> Eat and Enjoy

OR

  • Does it stick, clump, or crumble when you mash it with a fork? –> Try adding moisture, like sauce or gravy.

OR

  • Does it pick up in one dry-sticky-hard glob? –> Avoid due to choking risk!

*******

2019 Pureed Meals Update:

For another company to try, check out HormelHealthLabs.com‘s new website for their

Thick & Easy® Pureed Meal Kits

Hormel Health Labs is trying to make being on a pureed diet easier with these complete meal kits!

 

 

 

 

 

 

Hormel Pureed Meal Kit image of a pureed breakfast with pureed forms of waffles, sausage and berries - shaped to look like the real thing.

MedBridge Education

MEDBRIDGE: Expand Your Dysphagia Education

Medbridge is currently expanding their dysphagia library of patient handouts, videos, and exercises.

In order to offer my fellow healthcare professionals the best rates on courses and annual subscriptions, I have become an affiliate member of MedBridge. I can share a big discount on an annual subscription.

Click here for $175 off your annual MedBridge subscription.

This reduces the cost of the subscription to as low as $95 per year, regularly $270.

Or enter the Coupon Code: SWALLOWstudy at checkout.

 


Click Here to get $175 off for your annual MedBridge Education subscription!

Read more about MedBridge Education.

ABILEX™ Oral Motor Exerciser

Per the company, Trudell Medical International:

“The ABILEX™ Oral Motor Exerciser device is designed to support rehabilitative oral exercise training and targeted swallowing practice.”

If you have difficulty swallowing (dysphagia), sometimes your swallowing therapy only focuses on changing your diet textures, thickening your liquids and giving your safe swallowing strategies (such as swallowing with your head turned or tucked, taking smaller bites/sips, and many more). These are called compensatory strategies, and you may need to really focus on these early on in your recovery process. You may always need to do some safe swallowing strategies. However, you should also start improving your swallow function, if you can. Based on your comprehensive dysphagia evaluation, your speech-language pathologist who specializes in swallowing will customize a therapy program based on the specific issues found in your instrumental swallowing evaluation. This is a targeted therapy approach and personalized medicine.

Click here to read our blog about the specifics of doing lingual strengthening exercises.

Read more below for one person’s story of his difficulty swallowing (dysphagia) and how the Abilex device helped him.

 


 

One Person’s Abilex™ Success Story

for Tongue Exercise

By Karen Sheffler, MS, CCC-SLP, BCS-S of SwallowStudy.com

Meet Paul (not his real name to protect identity), a 71 year-old male with a long history of chronic-multi-factoral dysphagia. In other words, he has had trouble swallowing for years. He had a major neck surgery called an anterior cervical discectomy and fusion (ACDF) with a second surgery for revision in 2011. Additionally, he has reflux that gets up high into his throat (gastroesophageal reflux disease or GERD and laryngopharyngeal reflux disease or LPR), chronic obstructive pulmonary disease (COPD), sleep apnea, and severe dry mouth (xerostomia). An otolaryngologist noted in December 2018 that his GERD/LPR symptoms were resolved (as these were addressed in a first round of therapy).

Summary of 1st Round of Dysphagia Evaluation & Dysphagia Treatment:

That first round of therapy started with a videofluoroscopic swallow study (VFSS) followed by dysphagia therapy from October 2017 to January 2018. In addition to slight diet modifications, he needed many compensatory swallowing strategies. Therapy also targeted rehabilitation, and Paul used the EMST device (expiratory muscle strength trainer). This was chosen due to his known risk for aspiration (material getting into the top of the airway/larynx and dropping below the vocal cords into the trachea and lungs) and his poor sensation of aspiration. We hoped the EMST would strengthen his cough and ability to eject any material that got down the wrong way. He also worked on effortful swallows and several non-device assisted lingual exercises (for examples, pushing his tongue into a tongue depressor and the Masako Tongue Hold, which has people swallow while their tongue is sticking out. He really had trouble with that Masako and usually skipped that exercise).

Second Round of Dysphagia Evaluation & Dysphagia Treatment with Abilex:

He returned in December 2018 for a repeat VFSS and another round of treatment due to his report of a worsening of his dysphagia, especially after a motor vehicle accident in September 2018 where he was struck from behind (without head strike). The study described a moderate oropharyngeal dysphagia, similar to that in 2017. Briefly, his specific swallowing problems were as follows:

Key safety issues were: Decreased bolus control (a bolus is the ball of liquid or food) with thin liquids with loss of the bolus to the pharynx and larynx, causing penetration before the swallow. Before the swallow started, his boluses dropped down to the pyriforms (pockets in your throat way down by the opening to the airway or larynx) or were already into the laryngeal vestibule (top of the airway). He was then slow in moving his structures to reach the height of his swallow or the height of when the airway/larynx are closed (for therapists: this is a delayed laryngeal vestibule closure reaction time). This slow closure contributed to penetration and aspiration just before and during the swallow. He had no response to the aspirations and had an ineffective cough when told to cough. He aspirated on thin liquid by cup, thin liquid in mixed consistencies, and thin liquid when taking a barium pill (even when using a chin tuck – or tucking the chin down while swallowing).

Main efficiency issues were: He used many piecemeal swallows to clear residue off tongue. Then a significant amount of residue built up in the valleculae (pockets behind the tongue). He had a full valleculae space after the swallow with solids. This was suspected to be due to decreased tongue strength and base of tongue propulsion. His tongue base retraction was reduced with decreased contact of the back of the tongue to posterior pharyngeal wall, whereas his pharyngeal constriction (squeeze of pharyngeal or throat muscles) appeared functional. He needed 5 swallows to clear boluses of cracker and bread. After just two swallows, a significant collection of residue was present on his oral tongue and tongue base and his valleculae was still full bilaterally with residue. Even with performing an effortful swallow with biofeedback (watching video screen during swallow), he still needed 3-4 swallows to clear barium pudding out of the valleculae.  

In addition to further teaching about some slight diet modifications (i.e., adding moisture) and safe swallow strategies (i.e., multiple effortful swallows and taking pills in applesauce), a device-assisted therapy was performed this time. He expressed his past difficulty with some of the standard tongue exercises given in 2017 (he really disliked that Masako, as noted above). We continued the EMST for its potential benefit to help with strengthening his cough response as he was still a known aspirator, and thin liquid was still risky even with the strategies of: small sip, chin tuck, and cough/reswallow.

Device-Assisted Dysphagia Treatment:

Therapy newly and aggressively targeted tongue strengthening with the Abilex device. He performed daily anterior and posterior lingual presses against the Abilex bulb (See exercises #3 and 4 that come with the device instructions. His modification to #4 was to hold the posterior tongue press).

This picture shows the use of the Abilex device by pushing the tongue up. Press the Abilex bulb into the roof of the mouth.

This is tongue exercise #3 per Abilex: He used the Abilex for pushing up in this anterior position.

This is a picture of using the Abilex to push the bulb up against the roof of your mouth and then creating a suction, pressing the tongue backwards along the roof of the mouth.

This is tongue exercise #4 per Abilex. He modified this by pushing up in the back (posteriorly) as far back as he could tolerate before causing a gag.


He started training with the Abilex with 5 per set and 5 sets a day, for at least 4 days a week. He was holding the tongue presses for about 3 seconds. After 3-4 weeks, he ramped up his exercise to 10 repetitions per set and 5 sets a day, over at least 5 days a week. After 8 weeks, he reported switching to a maintenance level of 3-5 times a week.

Then, during each outpatient clinic session, we took his IOPI pressure measurements.

Note: The IOPI is the Iowa Oral Performance Instrument that can give you a digital display of a person’s maximum isometric pressures/MIPs while pushing on a small bulb. It can also be used for skill-based training and provides biofeedback with numbers and lights. However, it is quite expensive – over $1,000 expensive — and the small bulb size is not for everyone.

Paul would push into the IOPI bulb over 8-10 repetitions on both the anterior and posterior positions, as indicated by the IOPI. His maximum isometric pressures are listed in the chart below. We recorded his range of pressures, as well as his average anterior and posterior pressure for that day.

His results are in the following chart:

Changes with Abilex Treatment December 21, 2018

Initial Eval

Jan 4, 2019

After starting

Abilex

Jan 11, 2019

After continuing

Abilex

Jan 28, 2019

After Abilex

For 1 month

Feb 8, 2019

After continuing Abilex

Feb 28, 2019

After continuing

Abilex

IOPI Anterior

(Range)

26 – 42 43-56 41-56 39-65 43-64 56-59
IOPI Anterior

(Average)

32.8 48 46.5 52 53 57
IOPI Posterior

(Range)

21-35 29-46 37-44 37-44 39-46 43-54
IOPI Posterior

(Average)

29 33 40.1 40.6 44 50

Note: IOPIMedical’s reported norm for “older” adults >60 years old is a mean of 56 kPa for anterior position, which is close to his mean on Jan 28 and Feb 8, 2019, and he reached that on the day of the repeat videofluoroscopic swallow study (VFSS).

 

Therapy Success After Tongue Exercise with Abilex:

Within the first few weeks, Paul said he could feel the effort in his tongue and in the muscles under his chin.

“I can feel my tongue is far stronger.”

He liked the convenience of the Abilex, as he exercised while watching TV. His wife and grandson call it his lollipop! He commented that the Abilex air pocket is easier to push on than the IOPI. He noted that it could be positioned exactly where he wanted it and it gave more feedback to push harder. Whereas, the smaller IOPI bulb caused his tongue to “swing all over it and slip to the side.” Even when his tongue was cracked from being so dried out by his CPAP machine and due to side-effects of medications, he reported no pain when pushing into the broader cushion.

His repeat VFSS was in the end of February 2019. Briefly, he had minimal oropharyngeal dysphagia, and here is a summary of safety and efficiency improvements:

  • Improved bolus control with no loss of thin liquid bolus, even with mixed consistencies (e.g., a solid plus a liquid in one bite, like cold cereal).
  • Improved swallow initiation with bolus head at ramus of mandible (higher up at the jaw line), rather than in pyriforms or airway, like in December 2018. Therefore, he had no aspiration before the swallow.
  • Quicker and a greater extent of movement to reach the height of the larynx or airway closure (for therapists: he had better hyolaryngeal excursion and laryngeal vestibule closure with improved laryngeal vestibule closure reaction time). This eliminated penetrations just before the height of the swallow (as was seen on the prior study). Note: we tried to train “volitional laryngeal vestibule closure” (vLVC) on the first round of therapy, but this device may also have allowed for this improved speed of movement, as the vLVC skill was not trained during this second round of therapy. Due to these physiological improvements, he had NO penetrations during rapid drinking of thin liquid by cup. He only had penetration on the 4th sip of thin liquid by straw, and that was above the level of the vocal cords and ejected (Penetration/Aspiration Scale Score of 2). This is within functional limits, and he even detected this and responded with a cough.
  • Improved oral and pharyngeal clearance with improved lingual/tongue stripping motion to clear bolus more efficiently off the tongue. No piecemeal swallows were needed to get the bolus out of the mouth. We suspected improved tongue base strength and propulsion as he no longer had a wide column of contrast between tongue base and posterior pharyngeal wall. This shows improved tongue base to pharyngeal wall contact to initiate a good driving force on the bolus.
  • He only had trace lingual and valleculae residue after 2 swallows. He could clear a cracker or bread bolus with 2 swallows rather than 5.

Now Paul can continue to do all the terrific traveling that he loves to do, as he does not need weekly outpatient swallowing therapy anymore. He will continue his maintenance program with his Abilex device to hopefully prevent the dysphagia exacerbation that he had last fall of 2018.

*******

Disclosures:

This patient was given this device by the company, and the patient was motivated to give feedback.

Karen received small stipends for writing articles for this company, but Karen does not make money on individual sales of the product.

*******

Bottom-Line on ABILEX™ Oral Motor Exerciser:

I really do think it is a great device with key points being:

  • inexpensive,
  • motivating to help you complete your rehabilitation program,
  • easy to use,
  • durable to carry it with you anywhere and can withstand even the strongest of bite-reflexes,
  • comfortable air-filled bulb especially for people with irregular palates, high palates or sore mouths, and
  • potential for a preventative exercise program for people who are at risk, frail and have sarcopenia (loss of skeletal muscle mass with aging).

A preventative exercise program can be done along with other health-maintenance exercise programs provided by physical therapists, occupational therapists and the medical team. Can we prevent an acute onset of dysphagia in an older at-risk individual who ends up hospitalized, critically ill and weak? If that person had built up a “functional reserve” of a stronger tongue prior to the prolonged hospitalization, would their swallow safety and function stay more preserved? We don’t know, but it would make sense.

*******

Again, please see the prior blog on SwallowStudy.com about Tongue Exercise and Lingual Strengthening.

Check it out on YouTube:

Here is a pdf of the Abilex Oral Motor Exerciser Brochure

Please comment below if you have had experiences with an exercise program to improve your swallowing.

 

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