TREATMENT

Treatment Modalities Compensatory Strategies

Postural changes Diet modification

Direct Treatment/intervention Working directly on swallow using food and liquid

Indirect treatment/intervention Manipulation of structures involved with swallowing

Education Patient Medical staff Family/visitors

Compensatory Strategies

Chin down/tuck: Indications: pharyngeal swallow delay;

reduced tongue base retraction; laryngeal dysfunction

Rationale: widens valleculae; narrows airway; pushes epiglottis and tongue base posteriorly

Compensatory Strategies Chin-up/head back:

Indications: reduced A-P bolus transit Rationale: uses gravity to help move bolus

posteriorly.

Head rotation/turn: Indications: unilateral laryngeal and pharyngeal

dysfunction; cricopharyngeal dysfunction Rationale: closes off weak side; airway

protection; reduces cricopharyngeal tension.

Compensatory Strategies

Head tilt: Indications: unilateral oral and pharyngeal

dysfunction Rationale: direct bolus to stronger side

Lying down: Indications: reduced pharyngeal

contraction or reduced laryngeal elevation Rationale: keeps residue on pharyngeal

wall.

Diet Modification Liquids:

Thin: Water, apple juice, Kool-Aid, etc…

Nectar thick: Eggnog, V8, etc…

Honey thick: Artificial maple syrup, honey, molasses, etc…

Frozen or congealed liquids should still be considered thin. Example: ice cream, jello, popsicles, etc…

Diet Modification Solids

Regular: Steak, boiled potatoes, chicken, cereal, etc…

Mechanical Soft: Well-done vegetables, chopped meat with gravy, etc…

Pureed: Applesauce, mashed potatoes, blenderized meats, etc…

Some facilities will provide a mixed consistency diet. Need to talk with dietician/food service coordinator to

determine appropriate consistency meals.

Indirect Treatment

Typically involves exercises with three primary purposes: Increase oral motor control of the

bolus/voluntary stage of the swallow Stimulation of the swallowing reflex Increase airway protection through

adduction exercises

Oral Motor Exercises

Necessary tongue movements Lateralization Elevation to the hard palate Creating a single, cohesive bolus Elevation to hold the bolus Range of anterior to posterior propulsion Organized anterior to posterior

propulsion

Oral Motor Exercises Range of Motion (ROM)

Protrusion Elevation Lateralization

Resistance Isometric exercise

Pushing against a tongue blade, sucker, spoon, etc.

Difficult to measure, only through behavioral means

Quantitative measures available IOPI

Oral Motor Exercises Bolus Manipulation

Gross manipulation Large manipulable

Clinician controlled Licorice whip Sucker

Consider excess saliva Hold a cohesive bolus

Hold a bolus, manipulate, expectorate Examine for signs of poor containment

Propulsion Gauze soaked in juice

Stimulate the Swallow Reflex

Thermal Stimulation Laryngeal mirror

#00 or #0 Ice water Stimulation to the base of the anterior

faucial arches 5-10x Pipette ice water

If tolerated Can be carbonated

Oral-Pharyngeal Sensation Thermal-tactile stimulation:

Indication: Reduced oral-pharyngeal sensation; delayed pharyngeal swallow trigger

Rationale: To increase sensation and swallow trigger

Electrical stimulation: Indication: Reduced oral-pharyngeal sensation;

delayed pharyngeal swallow trigger Rationale: To increase sensation and swallow

trigger

Oral-Pharyngeal Sensation

Deep Pharyngeal Thermal Stimulation: Indication: decreased oral-pharyngeal

stimulation? Rationale: Maximal sensory input to elicit

pharyngeal swallow trigger?

Adduction Exercises

Hold breath Pushing or pulling on a chair

Both hands, 5 seconds

Pushing or pulling One hand while producing clear voice

Following 5 rep of the sequence “AH” with hard glottal attack. Supraglottic swallow

Direct Treatment/Intervention

Involves administration of a bolus and incorporating instructions/compensations

Small bolus sizes/volumes should be initiated

Swallowing Maneuvers

Supraglottic swallow: Indication: reduced vocal fold closure;

delayed pharyngeal swallow Rationale: closes vocal folds before and

during swallow

Super-supraglottic swallow: Indication: decreased airway closure Rationale: tilts arytenoids and closes

laryngeal vestibule

Swallowing Maneuvers

Effortful swallow: Indication: reduced tongue base retraction Rationale: increase tongue base retraction

Mendolsohn maneuver: Indication: reduced laryngeal elevation;

uncoordinated swallow; delayed cricopharyngeal relaxation

Rationale: opens UES and prolongs opening

Swallowing Maneuvers

Masako maneuver: Indication: reduced tongue base

retraction Rationale: increase anterior movement

of post. pharyngeal wall.

Shaker maneuver: Indication: cricopharyngeal dysfunction Rationale: Increase laryngeal elevation

and increase opening of UES.

Therapeutic Strategies for Specific Disorders

Oral Preparatory Phase of the Swallow Reduced lip seal

Lip exercises Pocketing/buccal

Posture change External pressure Exercises

Reduced tongue movement Exercises Manipulate bolus placement Posture

Reduced oral Sensitivity

Oral Transit Phase of the Swallow Tongue thrust

Bolus positioning Reduced tongue movement

Exercises Postural changes Bolus positioning

Delayed Reflex Thermal stimulation Posture

Tilt head forward Diet/hydration manipulation

Pharyngeal Phase Reduced pharyngeal peristalsis

Alternate solid-liquid swallows Chin press Mendelsohn maneuver Effortful swallow Shaker exercises Electrical neuromuscular stimulation

Reduced laryngeal elevation Supraglottic swallow Super supraglottic swallow Electrical neuromuscular stimulation

Delayed cricopharyngeal opening

Pharyngeal Phase Pharyngeal hemiparesis

Posture Tilt toward stronger side Turn toward weaker side

Reduced laryngeal closure/elevation Supraglottic swallow Adduction exercises Electrical stimulation

Cricopharyngeal dysfunction Hypertonicity

Myotomy Mendelsohn maneuver Dilatation Shaker maneuver

Esophageal Disorders

May be suspected by SLP; typically diagnosed by GI physician

Typically treated medically

Medical Management of Dysphagia Tongue scarring

Surgical release Positioning of food

Cervical osteophyte Surgical removal Diet modification

Scar tissue Removal Posture

T-E fistula Surgical closure

Diverticulum Surgical repair

Dietary: Hydration Management Manipulating consistencies to alleviate

symptoms Oral phase

Liquids/solids Thinner Thicker

Pharyngeal Phase Liquids/solids

Thinner Thicker

Esophageal Phase Liquids/solids

Specific Diagnoses

Mysasthenia gravis Amyotrophic lateral sclerosis (ALS) Huntington’s Chorea Parkinson’s Disease Cognitive impairment

Alzheimer’s dementia

Adaptive Equipment Glossectomy

Spoons Syringes

Cut-out cups Assures chin tuck position

Food processors Manipulate food consistency

Non-slip surface disks Plate guards, lipped dish Built up utensils

Splints Arm rests

Oral vs. Non-oral Feedings Oral Feedings:

Risk of aspiration Rate of deglutition Weight considerations Body requirements

Meeting requirements? Calorie counts Full time dietary staff support

Non-oral feedings NG tube (small-bore; Dobbhoff): nasogastric G-tube (PEG): gastric J-tube (PEJ): intestinal Orogastric