Treatment Terms

Delay in triggering the pharyngeal swallow

Chin tuck, Supra-glottic Swallow, Thermal-Tactile Stimulation

Unilateral laryngeal dysfunction

Chin tuck, head turn/rotation, Mendelsohn manuever, super-supraglottic swallow

Unilateral pharyngeal weakness (residue on one side of the pharynx)

Head turn/rotation, effortful swallow, head tilt

Inefficient oral tranist (reduced posterior propulsion of bolus by tongue)

Oral-motor exercises, head back, ROM, lingual strengthening

Cricopharyngeal dysfunction (residue in pyriform sinuses)

Head turn/rotation, effortful swallow, Mendelsohn Maneuver, Shaker Maneuver

Reduced laryngeal closure (aspiration during the swallow)

Super-supraglottic swallow, supraglottic swallow, chin tuck, head turn/rotation

Unilateral oral & pharyngeal weaknesses on the same side (residue in the mouth & pharynx on same side)

Head tilt, effortful swallow

Tongue dysfunction

Head back, resistance exercises, effortful swallow, tongue hold

Reduced posterior motion of tongue base (residue in valleculae)

Effortful swallow, chin tuck, tongue hold

pocketing in unilateral lateral sulcus

Effortful swallow, finger sweep, place bolus on stronger side, head tilt

Reduced pharyngeal contraction (residue spread throughout the pharynx)

Head turn/rotation, alternate liquids & solids, multiple swallows

Bilateral stasis in the valleculae/pyriform sinus

Effortful swallow, multiple swallows, alternate liquids & solids

Pt not able to rouse

NPO, feeding tube, wait until they are awake

Fatigue

Smaller more frequent meals, nutritional supplements, soft solids, purees

Chin down or Chin tuck

Increase vallecular space; narrows airway entrance
Pushes epiglottis posteriorly into more protective position over airway
Pushes tongue base backward toward pharyngeal wall

Head turn or head rotation (to weak, damaged side)

Allows bolus to pass through intact side
Pulls cricoid cartilage away from PPW, reducing resting pressure in UES; increases VF closure by applying extrinsic pressure, narrows laryngeal entrance

Head tilt (to stronger side)

Directs bolus down the most intact side

Head back/chin up

Propel bolus out of the oral cavity by taking advantage of gravity; only used for pt with adequate laryngeal closure or who can utilize the supraglottic swallow

Managing dysphagia symptoms

Postural adjustment, thicken liquids, modify texture

Postural adjustments

Lying down, side lying, upright, head extension, chin tuck, head turn/rotation, head tilt

Improving the mechansim

Oral motor exercises

Protecting the airway

Breath hold, supraglottic swallow, super-supraglottic swallow

Prolonging the swallow

Mendelsohn maneuver

Increasing the force

Effortful swallow

Add. techniques to change the swallow

Multiple swallows, tongue-hold maneuver, head-lift exercise, thermile-tactile application

Applying exercise principles

Intensity & specificity
McNeill Dysphagia Therapy Program (MDTP)

Adjunctive modalities

Surface electromyographic biofeedback, neuromuscular electrical stimulation

Subjective evidence of dysphagia

Coughing, throat clearing
Complaint of food sticking in throat or chest

Objective evidence of dysphagia

Nasal regurgitation, laryngeal penetration, aspiration, residue in valleculae/pyriform sinuses

Patient barriers to effective treatment

Depression/apathy, fatigue, expectations, poor oral hygiene

Purpose of compensatory treatment procedures

Redirect or improve flow of food through oropharynx; don't usually change physiology of swallow

Therapy procedures

Designed to change swallowing physiology

Indirect vs direct therapy

Indirect involves exercises using no food/ or liquid
Direct incorporates small amounts of food or liquid while implementing swallowing techniques

Shaker Head Lift Exercise Rationale

Improve magnitude of UES relaxation & opening
Increase laryngeal elevation
Hyolaryngeal excursion assists with CP opening

Shaker Head Lift Exercise

Lie supine & raise head to look at toes
Both isometric (holding a sustained posture) & isokinetic (repeating a movement) exercise

Compensatory Treatment Procedures

Postural, improve sensory awareness, modify diet, intraoral prosthetics, augmentative devices

Postural techniques:

Potentially change dimensions of pharynx & direction of bolus w/o increasing effort during swallowing

Postural techniques can

Eliminate or reduce aspiration; improve oral and pharyngeal transit times; improve bolus clearance

Chin Tuck

Maintain bolus in anterior oral cavity
Positions tongue base toward PPW
May improve airway protection; narrow laryngeal airway entrance & improve bolus drive; widen vallecular space in some patients

Head Back

Gravity assists with bolus transfer; improve oral transit
But, can reduce laryngeal closure

Head Turn/Rotation to weaker side

Narrow pharyngeal recesses on weak side; Redirects bolus to stronger side; May be used in combination with chin tuck

Head Tilt to Stronger Side

Gravity direct bolus to stronger side
Used when both unilateral oral & unilateral pharyngeal weakness is present on same side

Compensatory Procedures:
Improving Sensory Awareness

Prior to swallow - prime oropharynx before swallow´┐Ż
Alert CNS; increase sensory awareness
Can result in improved oral & pharyngeal transit times
Increased downward pressure of spoon against the tongue when presenting food in the mouth

Bolus characteristics that may improve timing & coordination of oral & pharyngeal swallow phases

Sour/cold/carbonated bolus
Bolus requiring chewing
Large volume bolus

Compensatory Procedures:
Diet Modification

Affects patient's desire to eat, quality of life, potentially hydration/nutrition levels
Modify volume; alternate liquid & solid; temperature; taste/spices/smells; multiple swallows

Diet Modification Chart

Compensatory Procedures:
Bolus Control Maneuvers

Multiple Swallows - reduce residue
Alternate solids w/ liquids - liquid wash, clear reside
Small bites/sips - control bolus flow, reduce residue
Periodic throat clears - eject penetrated material

Compensatory Procedures:
Intraoral Prosthetics

Augment the configuration of palate to improve oral transit
Palatal obturator; palatal reshaping device; Palatal lift;

Compensatory Procedures:
Augmentive Devices

Syringe; syringe w/ extension; nosey cup; straw

Therapy techniques designed to

Change or improve swallowing physiology

Therapy Techniques - Exercises

Resistance, ROM, sensory-motor integration, swallow maneuvers, biofeedback

Therapeutic Procedures:
Lingual Resistance Exercises

Pressing specific portions of tongue against hard palate; lingual/labial/buccal strength

Resistance Exercises: Tongue Hold Maneuver

Improve tongue base to PW contact & pharyngeal clearance of bolus
Causes tongue base to be positioned anteriorly; encourages increase in PW contraction & bulging to achieve contact with anteriorly displaced tongue base

Shaker Head Lift Exercise Contraindications

Cardiac conditions or hypertension need doctor approval; only appropriate for medically stable patients

Range of Motion Exercises

Improve extent of movement of lips, jaw, tongue, pharynx, larynx, & vocal folds

Improving Sensory Awareness
Thermal-tactile application

Difficulty triggering swallow response, delay or absent pharyngeal swallow
Temperature & tactile sensation to prime oropharynx
Cold touch to anterior faucial pillars before swallow

Goal of thermal-tactile application

Increase sensory input to brainstem (via CN IX, X, etc.) may help trigger swallow response

Neuromuscular Electrical Stimulation (NMES)

VitalStim - Stimulates skin & underlying muscle; cannot activate specific muscles; better if used with therapy
Intramuscular stimulation - stimulate nerve & nerve endings; augment hyolaryngeal movement

Other Sensory-Motor Integration Procedures

Deep pharyngeal neuromuscular stimulation - sensory stimulation to various points in oral cavity; may improve swallow initiation

Super-Supraglottic/ Supraglottic Swallow Rationale

Protects airway before/during the swallow & clears the laryngeal vestibule of penetrated material after the swallow

Effects of Super-Supraglottic/Supraglottic

Close airway entrance (vestibule) before/during swallow by narrowing airway opening; Close airway at true VF before/during swallow; Increase anterior laryngeal motion & tongue-base movement; Assist in upper esophageal sphincter opening

Super-Supraglottic Swallow

Super" means a follow-up cough associated
Hold breath tightly, bear down, swallow while continue holding breath, cough immediately after

Effortful Swallow

Hard/forceful swallow
Increase lingual driving force; Improve BOT to PW contact; Increase pharyngeal constriction; Laryngeal elevation; Reduce residue & protect airway

Mendelsohn Maneuver

Swallow & hold at the height of laryngeal elevation
Increase extent & duration of laryngeal elevation to increase UES opening

BioFeedback

Videofluoroscopy; EMG biofeedback; Ultrasound; Videoendoscopy

Causes of xerostomia

Medication, autoimmune disorders, radiation

Xerostomia treatment

Artificial saliva; Stimulate salivary secretions by mechanical or systemic therapy; lozenges; gum chewing; sugarless candies

Xerostomia

Dry mouth; reduced salivation, makes transit of the bolus more difficult

General Treatment Considerations

May need more than one treatment;
Impacted by physical barriers, cognitive status, level of independence, and other factors