Dysphagia Treatment

compensatory treatment

designed to affect the mechanical movement of the bolus immediately without change to the physiology of the patient’s anatomy

• altering in the movement

rehabilitative

goal of improving physiological functioning through exercise programs, neuromuscular stimulation, and/or repeated practice

• alter structures in the long run

prevention

avoiding or minimizing negative outcomes: food/liquid restriction, nutrition/hydration deficits, infections, and more

• preventing or minimizing dysphagia in high-risk population

compensatory treatment strategies

• head posture adjustments

• body posture adjustments

• thickening liquids

• texture-modified diets

• sensory enhancement

neck extension

rationale: impaired oral bolus propulsion

instructions: tilt head after placing bolus in mouth when posterior movement is needed

how it works: harnesses gravity for oral transport to pharynx

syringe feeding

rationale: impaired oral bolus propulsion

instructions: place syringe in buccal cavity and slowly administer bolus

how it works: bypasses much of the oral phase by placing bolus posteriorly in oral cavity

chin tuck

rationale: reduced oral bolus control with aspiration before/during the swallow

instructions: head and neck flexed forward with chin as close to chest as possible prior to swallowing

how it works:

• keeps bolus in anterior oral cavity preventing premature spillage

• widens calleculae to accommodate bolus prior to swallow response

• flexes epiglottis into more protective position over laryngeal vestibule

• reduced tongue base to posterior pharyngeal wall distance

head turn to weak side

rationale:

• unilateral pharyngeal paralysis or paresis

• unilateral vocal fold paralysis or paresis

instructions: head turned parallel to shoulder on weaker side prior to swallow

how it works:

• channels bolus down stronger side by closing off weaker side pyriform sinus

• increases vocal fold closure through external pressure on thyroid cartilage

• increases UES opening duration and reduces UES resting pressure thereby decreasing pyriform sinus residue post-swallow

head tilt to strong side

rationale: unilateral oropharyngeal weakness

supraglottic swallow

rationale: inadequate or delayed laryngeal closure

instructions: prior to swallow, hold breath and don’t release until after swallow

how it works: conscious closure of vocal folds to improve airway protections

throat clear/re-swallow

rationale: penetrated material that remains in laryngeal vestibule after the swalloe

instructions: after swallowing, cough/clear throat and swallow again

how it works: ejects penetrated material from laryngeal vestibule to minimize risk of aspiration after the swallow

effort swallow

rationale: poor tongue base retraction with post-swallow residue

instructions: swallow hard

how it works:

• increased pressures in the tongue-to palate, pharynx, UES, and esophagus to aid in bolus propulsion

liquid wash

rationale: post-swallow residue

instructions: after swallowing a bite of food, take a sip of liquid to wash it down

how it works: extra swallows or liquid wash can reduce or eliminate residue

postural strategies

• head back

• chin tuck

• head rotation

• head tilt

• side lying

redirect bolus flow and change pharyngeal dimensions in systematic ways in order to facilitate safe passage of the bolus through a less functional physiology

what do postural strategies do?

head extension

• assists in bolus flow to the posterior of the oral cavity

• helpful for individuals with anatomical deficits in the oral cavity but intact pharyngeal swallow

Anatomic effects:

• widens oropharynx

• may help move bolus posteriorly from OC to pharynx when lingual deficits are present

Physiologic effects:

• may impair laryngeal closure

• ay affect UES and coordination between pharyngeal and UES activity

head flexion/chin tuck

• different combinations can have different effects on position of the oral and pharyngeal structures

• different structural positions can make a difference on where and how the bolus travels through the oropharynx

• can cause silent aspiration, can only test using imaging

anatomic effects

• improved laryngeal vestibule closure

• narrows the oropharynx

• reduces distance between hyoid bone and larynx

physiologic effects:

• may result in weak pharyngeal contractions

• may alter coordination of swallowing and respiration

• degree of flexion can impact swallow function

head rotation/head turn

• increased pharyngeal contraction pressure of the side of head rotation

• increased UES opening diameter and duration

• effectively closes off pharyngeal recesses on the side of rotation, sending the bolus down the opposite side

• increase the likelihood of a bolus making it into the esophagus when the system is compromised by unilateral weakness

anatomic effects

• narrowing or closing of the swallowing tract on the side toward which the head is turned

• closure may not extend throughout the hypopharynx

physiologic effects

• drop in contralateral UES pressure and corresponding increase in UES opening

• increased pharyngeal manometric swallow pressures on the side of the pharynx toward head turn

• drop in UES resting pressure opposite head turn

• delay in UES closure

side-lying

• strategy for individuals who have weak pharyngeal muscle function resulting in residue throughout the pharynx after the swallow

• working hypothesis is that this position will lessen gravity and decrease the chance of aspiration after the swallow

• primarily used with infants; current evidence base for adult population is slim

breath holding

• provides additional airway protection with vocal fold closure by conscious breath-holding immediately before and during the swallow

• increases true and false vocal fold closure with command for a hard/forceful breath-hold

• need instrumental to recommend

thickening liquids

• studies suggest thickening liquids reduced aspiration rates

• immediate effect of reducing aspiration during fluoroscopy

• overall clinical benefit, especially long-term benefit is unclear

• proven to not cause silent aspiration

texture-modified diets

• foods may be modified to accommodate perceived limitations in swallowing function

• patients tend to self-modify diet items that are difficult to swallow

• concerns regarding nutritional adequacy of modified diets

• important to frequently reassess patients for ability to advance textures

feeding strategies

• alternate bites/sips

• small bites/sips

• slow rate of intake

• present bolus to stronger side

• light external pressure to weaker side

• double swallow

sensory enhancement

• sensory heightening by controlling or manipulating tastes, temperature, or mouthfeel of foods

• goal: increased sensory information to assist those who have difficulty recognizing the bolus in the oral cavity and reduce swallow response delays

physiologic etiology: decreased labial seal

clinical sign: anterior spillage of food from mouth

physiologic etiology: decreased lingual control of bolus

clinical sign: premature spillage of bolus into pharynx

physiologic etiology: decreased oral bolus manipulation

clinical sign: poor ability to develop a cohesive bolus

physiologic etiology: impaired mastication

clinical sign: prolonged mastication

physiologic etiology: poor A → transport

clinical sign: oral residue and inability to move bolus to pharynx

physiologic etiology: reduced lingual strength

clinical sign: diffuse oral residue/stasis

physiologic etiology: decreased soft palate elevation

clinical sign: nasopharyngeal regurgitation

physiologic symptom: reduced laryngeal elevation

clinical sign: residue in pyriform sinuses

physiologic etiology: decreased anterior movement of the hyoid

clinical sign: reduced epiglottic inversion; valecullar residue

physiologic symptoms: decreased laryngeal closure

clinical sign: laryngeal penetration or aspiration

physiologic etiology: reduced pharyngeal contraction

clinical sign: residuals along pharyngeal wall

physiologic etiology: decreased UES opening

clinical sign: pooling in the pyriform sinuses

iowa oral pressure instrument (IOPI)

• bulb sensory that measure pressure generated by the tongue as it squeezes the bulb to the hard palate

• increased tone strength during volitional tongue spush activity and swallowing

• increased lingual muscle size

therabite

• hand operated device designed to stretch jaw to treat trismus (reduced jaw opening)

• uses passive motion for stretching

• especially effective for post-radiation trismus

pharyngeal strengthening exercises

• effortful swallow

• tongue-hold maneuver (masako)

• mendelson maneuver

• shaker exercise

• supraglottic swallow

effortful swallow

• volitional attempt by pt. to increase force applied to the bolus from structures within the swallowing mechanism

• presume physiologic change: increased lingual-palatal and pharyngeal pressures during swallow

tongue-hold maneuver (masako)

• presumed physiologic change: increased duration and pressure of tongue base pharyngeal wall contact

• some evidence suggesting decreased post-swallow residue

mendelson maneuver

• voluntary increase in contraction of tongue muscles at the height of a swallow with prolonged contraction of the suprahyoid muscles, targeting increased force and endurance after swallow

• presumed physiologic change: increased hyolaryngeal excursion and UES opening

shaker exercise

• goal: improve opening of the UES by increasing the strength of muscle groupd that contribute to UES opening

• increase the load condition by holding or repetitively lifting the head from a supine position with the goal of strengthening the muscles responsible for UES opening

• mixed results, hard to implement in hospital

LSVT-loud

• non-swallow program developed to improve vocal intensity for PD patients

• some improvements to swallowing but research is limited

respiratory muscle strength training

• inspiratory/expiratory exercises utilizing spring-loaded trainer device that offers resistance

• goal: increasing force-generating capability of expiratory muscles

• increased expiratory msucle strength hypothesize to support productive cough

bolus driven therapy (MDTP)

• incorporates exercise principles of specificity and intensity with frequent therapy sessions and variety to facilitate enhanced coordination during swallowing

• patients receive daily therapy sessions are structured to evoke mass practice of swallowing

• improved functional oral intake and positive changes in swallowing effort and timing

• can be effective for chronic dysphagia who haven’t had success with other therapy

• produces clinical results superior to more traditional swallowing maneuvers