Mealtime Partners, Inc.

Specializing in Assistive Dining and Drinking Equipment

April 2015 Independent Eating and Drinking Newsletter

Independent Eating...   is a Wonderful Thing

April Topics:

  • The Effect of Feeding Method on Swallowing

  • Penetration or Aspiration?

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The Effect of Feeding Method on Swallowing

Last month’s Newsletter discussed some of the causal factors that contribute to the occurrence of aspiration pneumonia and identified causes including being fed by another person. This article will describe some of the findings from an unpublished research project that investigated the impact of feeding methods upon the coordination of the suck, swallow, breath pattern that occurs during eating in an upright position (sitting). The preliminary findings from the study provide some insight into the significance of feeding method on swallowing. The study examined both eating and drinking, but for brevity this article will only address eating.

The Normal Variance of the Coordination of Respiration and Swallowing during Eating and Drinking study was conducted at Texas Women’s University, School of Occupational Therapy, Denton, Texas, campus, and was approved by the University’s Institutional Review Board. Written informed consent was obtained from each study participant. The purpose of the research was to gather data on the coordination patterns of oral manipulation of food, respiration, and deglutination in people with no known swallowing difficulties, using a non-invasive, economical, method of data collection. It was hoped that the data could provide a baseline for comparison with data from individuals with known swallowing difficulties. Data was collected using a Kay Elemetrics Digital Swallowing Workstation from KayPENTAX (DSW).

Additionally, an audio/video recording of each participant was made simultaneously with data collection sessions. The video captured a profile of the left side of the participant’s head, neck and shoulders.

Swallowing tasks involved eating three bites of three different textures of food (9 bites of food per method of food presentation): soft food (pudding); mixed textured food (fruit cocktail); and, crunchy dry food (crackers). Food was delivered using three different methodologies (not in any particular order): the participants fed themselves, eating the various foods using a spoon and scooping the food from a bowl and putting it into their mouth They were also fed by a research team member using a spoon to scoop the food from a bowl and placing it in the participant’s mouth. And, they fed themselves using an electromechanical feeding device that was controlled by the participant that delivered a spoonful of food to the participant’s mouth when the participant pressed an adaptive switch. Data was collected for a total of 27 bites of food for each participant. The order in which trials were conducted was randomized.

Surface electrodes provided electromyographic (EMG) data from muscle activity of both the masseter and hyoid muscles. A nasal cannula allowed the concurrent collection of respiratory data. Using this data allowed a detailed description of the chew, breathe, and swallow patterns of the participants in the study to be graphically depicted. Data analysis identified the beginning of the first swallow in each eating sequence. The onset of the apneic event (the cessation of breathing) was defined for the purpose of this study as the beginning of the first swallow. Video recording review verified the beginning of the swallow. The chew and swallow sequence of each bite of food was compared for each participant across the types of food, within the sequence of food type (1, 2, or 3), and the series was evaluated. The same data was compared across participants.

Data showed that when eating pudding, regardless of the method of food presentation, the chew and swallow sequence for bite one was well organized. The pudding was moved around the mouth to form a bolus and the bolus was swallowed. However, bites two and three became less organized with more than one swallow occurring for a single bite, especially on the third bite. When eating fruit cocktail, participants chewing varied significantly, but within each participant, the three bites of fruit were processed in a similar manner. Eating crackers provided the greatest variation among participants as to the chew and swallow sequence. The time spent chewing bite one of crackers varied significantly among participants with a variation of several seconds from the crackers being put in the mouth to the first swallow. The chewing and bolus forming time extended for each consecutive bite of cracker (participants could take a drink of water between bites if they chose). Regardless of what was being eaten, sequential bites of food became less structured in how they were chewed and swallowed.

Information gained from the analysis of data relating to the method of food presentation was very informative. All participants displayed good control of food chewing and swallowing when they fed themselves. Even though the level of organization of their chew and swallow reduced as consecutive bites were taken, nevertheless, self-feeding was shown to produce the most consistent chewing and swallowing patterns.   The data collected from participants eating when they were fed by a researcher revealed that chewing and swallowing was not systematic with inconsistent chewing times prior to swallowing and additional swallows occurring after the initial swallow. It should be noted that the researchers used the best known practices for feeding the participants throughout the study. Consistently, participants displayed chewing and swallowing patterns that were less structured and uniform than those shown when they fed themselves.

The third method of presenting food was using an assistive dining device. For this study a Mealtime Partner Dining System was used. Participants served themselves food using the device. They activated the spoon using an adaptive switch that they pressed with their hand, which presented a bite of food very near their mouth. Data showed that participant chewing and swallowing patterns were less uniform than when they fed themselves, however, compared with when they were fed by a research team member, their chew and swallow patterns were significantly better organized regardless of the type of food they were eating.

Further study is necessary to evaluate whether the initial findings of this study regarding feeding methods would carry over to someone who is a dependent eater. Yet, it does indicate that even though self-feeding is the most desired way of consuming food when someone is unable to feed themselves, a dining system such as the Mealtime Partner is probably a better option than being fed by another person.

Acknowledgement: We would like to extend our thanks to Dr. Rebecca Estes, and Dr. Johnnie Aven who were the Principal Investigators for this study. 

The Mealtime Partner Dining System empowers those who use it to greater independence and greater control over their lives.
At mealtimes:
  • They are able to pace when they will take each bite of food. They can eat as quickly or as slowly as they wish, taking each spoonful of food into their mouth when they choose.
  • They can decide what they will eat, or won’t eat, from the foods that are served. They are even able to change their minds; once a spoonful of food is served, they can return it to the bowl from which it came if they decide not to eat it.
  • They are able to pause to listen to and/or participate in mealtime conversation if they want.
Child Using the Mealtime Partner Dining System
The very versatile Mealtime Partner Dining System can accommodate the diverse needs of individuals who have spinal cord injuries (SCI), Parkinson’s disease, arthrogryposis, cerebral palsy (CP), amyotrophic lateral sclerosis (ALS), and many other disabilities and disorders.

The Mealtime Partner Dining System can be positioned to meet the specific needs of each user. The user does not have to adjust their position to eat using the device because the Partner’s flexible mounting systems permit positioning to fit the user's needs, making mealtimes a comfortable, relaxed experience, with the user positioned safely for eating.

The Mealtime Partner empowers its user to eat what they want, when they want it.

The Mealtime Partner Dining System is quick and easy to learn and has no complicated programming requirements. Each Dining System comes with a complete training video on DVD so new users and caregivers can learn to use it in just a few minutes. Click here to select some of the instructional videos to view.

For more information about the Mealtime Partner Dining System, please visit Mealtime Partners website. There is no other assistive dining system that meets the needs of the users, like the Mealtime Partner.

Penetration or Aspiration?

Because Mealtime Partners works exclusively with products that relate to eating and drinking, it is important that the products are safe to use and help people eat and drink without choking or aspirating (i.e., drawing a foreign substance, like food or drink, into the respiratory tract). However, even though choking and aspiration have been referred to and discussed in many articles, the actual process of choking or aspirating has not been precisely defined. This article offers information about A Penetration-Aspiration Scale that was developed by Rosenbek, et al,* and first published in 1996. Rosenbek defined an eight-point scale that identified the various levels that material can travel into the airway when being swallowed. They range from a normal swallow to material entering the lungs.

The scale is as follows:

1. Material does not enter airway

2. Material enters the airway, remains above the vocal folds (voice box), and is ejected from the airway.

3. Material enters the airway, remains above the vocal folds, and is not ejected from the airway.

4. Material enters the airway, contacts the vocal folds, and is ejected from the airway.

5. Material enters the airway, contacts the vocal folds, and is not ejected from the airway.

6. Material enters the airway, passes below the vocal folds, and is ejected into the larynx or out of the airway.

7. Material enters the airway, passes below the vocal folds, and is not ejected from the trachea despite effort.

8. Material enters the airway, passes below the vocal folds, and no effort is made to eject.

When normal eating is undertaken, the food enters the mouth and is chewed and formed into a bolus. The tongue pushes the bolus backward into the pharynx and it moves downward into the esophagus during the swallow process. This scenario describes number 1 on the Penetration-Aspiration Scale. The swallow is within normal parameters and does not have a risk of aspiration.

In the event the bolus takes a detour when it is swallowed and it enters the glottis (the opening to the airway or trachea), but does not travel beyond the true vocal folds, and, it is ejected from the airway almost immediately, it is described as penetration. When this occurs, coughing typically triggers the ejection of the material from the airway. Because the material that penetrates the airway is rapidly ejected, this level of aspiration risk is considered mild. This level is described by number 2 on the Penetration-Aspiration Scale.

When material enters the airway but remains above the vocal folds, and is not ejected from the airway during or after the swallow, the material remains in the valleculae and pyriform sinuses and creates a moderate risk of aspiration. (Number 3 on the Penetration-Aspiration Scale.) The material can be potentially aspirated after the swallow is complete.

Number 4 on the Penetration-Aspiration Scale describes material entering the airway, contacting the vocal folds, and being ejected from the airway, typically by coughing. There is a moderate risk of aspiration attached to this level of penetration even though the material is ejected from the airway, residue may remain.

Number 5 on the Scale describes material entering the airway, contacting the vocal folds, and not being ejected from the airway by coughing. Compared with Number 3 on the Scale, the material descends until it contacts the vocal folds. The risk of aspirating the material that has entered the airway is moderate according to the Scale.

For number 6 on the Scale, material enters the airway. However, at this level the material passes below the vocal folds, but once it has passed below them, the material is ejected from the airway. The risk of aspiration is classified as severe at this level of penetration.

For level 7, as with level 6, material enters the airway and passes below the vocal folds. For level 7, however, the material is not ejected from the trachea despite effort. For level 7, the material has a severe risk of being aspirated.

The final level (8) on the Penetration-Aspiration Scale describes material entering the airway, passing below the vocal folds, and no effort being made to eject it. There is a severe risk of aspiration at this level.

Number 1 on the Penetration-Aspiration Scale indicates no risk of material penetration, or aspiration; numbers 2 through 5 indicate that material has penetrated into the larynx; 6 to 8 indicate aspiration of material.

* John C Rosenbek PhD, Jo Anne Robbins PhD, Ellen B. Roecker PhD, Jame L. Coyle MA, & Jennifer L. Woods MS,  A Penetration-Aspiration Scale.  Dysphagia  11:93-98, 1996 .

Did You Know? Did you know that shingles is caused by the same virus as causes chicken pox? Shingles causes a very painful rash that can occur anywhere on the body. However, the blisters almost always occur either on the right or left side of the body and wrap around the side of the body that is affected. Shingles is caused by the varicella-zoster virus. For people who have had chicken pox the virus lies dormant in the nerves near the spinal cord or brain and can become active again after many years. The reactivation is known as shingles. There is a vaccine available that can significantly reduce the impact of shingles. Additionally there are medications that can lessen the seriousness of the occurrence. The older a person is, the more likely they are to have shingles and to have complications relating to shingles. Postherpetic neuralgia occurs when the virus damages nerve fibers. The damaged nerves send confused and exaggerated messages of pain from your skin to your brain that cause significant pain which can be permanent, or last for months or years after the shingles blisters have healed.

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