Compensatory Strategies for Swallowing Difficulties

Purpose of Compensatory Strategies

  • Two approaches to managing dysphagia:
    • Swallow rehabilitation: Aims to permanently change swallowing physiology.
    • Compensation: Works around the damaged mechanism to:
      • Increase sensory information.
      • Change bolus flow to avoid aspiration.
      • Enhance comfort and intake.
  • Addressing dysphagia:
    • Compensate.
    • Rehabilitate.
    • Educate and counsel.
  • Compensatory approaches:
    • Provide immediate but transient effect on swallow efficiency/safety.
    • Do not provide long-term change to swallow physiology.
    • Facilitate oral intake through feeding assistance.
    • Facilitate a positive mealtime experience.

General Considerations

  • Swallowing with a compensatory technique or texture is better than not swallowing at all.
  • Swallowing thin fluids with a compensatory technique is better than drinking thickened fluid.
  • Prioritize rehabilitation if possible.
  • Maintain current skills if rehabilitation isn't fully achievable.
  • Compensate to maximize:
    • Swallow safety and efficiency.
    • Adequate nutrition.
    • A positive and engaging mealtime experience.

Compensatory Approaches to Intervention

  • Changes to posture
  • Rate of intake
  • Texture and consistency of foods and fluids
  • Taste or temperature
  • Type of intake (oral versus non-oral)
  • Feeding strategies
  • Changes to the physical or social mealtime environment
  • Alterations to medication presentation
  • Strategies to increase positive feeding support and prompts
  • AAC and general strategies to aid successful communication and reduce communication breakdown

Changes to Posture

  • Adjusting posture facilitates safe and efficient swallow.
  • Assessing posture during eating and drinking should be routine.
  • Altering posture can assist in:
    • Providing adequate trunk support.
    • Redirecting the bolus.
    • Changing bolus speed.
    • Making the most of gravity.
  • May be used as short- or long-term management strategies.
  • Encourage an upright posture (at least 45 degrees) with adequate support at the pelvis and anchored feet.
  • Prioritize stability, even if it means sacrificing uprightness.
  • In general, the person's head should be straight and the chin down slightly down.
  • Ideally, the person should remain upright for 30 minutes after eating or drinking.
  • Speech pathologists often recommend more specific postural changes after trialing them under instrumental assessment.
  • Consider whether posture will work in the "real world".
    • Clients must be able to achieve and maintain the desired posture.
    • Consider attention, memory, awareness, cognitive skills, physical strengths, flexibility, and limitations.
  • Work with physiotherapists and occupational therapists to assist clients in achieving compensatory postures during mealtimes.
  • Specific postural changes:
    • Chin down: for delayed onset, reduced oral control, approximation PPW
    • Head rotation (to the weaker side): for unilateral pharyngeal residue
    • Head tilt (to the stronger side)

Diet Modification (Liquid and/or Fluid Modification)

  • Altering texture/viscosity alters the physiology and function of a swallow; no change to swallow long term.
  • Change the speed, how well it sticks together, or how much sensory input it gives.
  • Changes can:
    • Make it easier to swallow without food/fluid entering the airway.
    • Make it more likely that all of the bolus is cleared successfully past the cricopharyngeus/UES.
  • Steele et al. (2015) provides a discussion of the influence of food texture and fluid viscosity on the physiology and function of the swallow.

Cons of Modified Fluids and Diets

  • Many clients dislike them, impacting nutritional status.
  • Implications for participation and quality of life (e.g., withdrawing from social events).
  • Changes to nutritional value.
  • Limited choice.
  • Potential for over-compensation.
  • Leder et al. (2013) study (n=84): Puree swallowed without aspiration, but thin liquid aspirated; nectar thickness was sufficient, negating the need for honey-thick liquids.

Increased Sensory Input

  • Impact on physiology
    • Carbonated Liquids
      • Reduce risk of aspiration by prompting a faster pharyngeal transit and leaving less residue.
    • Sour Bolus
      • Increased sensory input increases oral and pharyngeal stage efficiency, faster swallow initiation and pharyngeal transit, and reduced likelihood of aspiration.
    • Altered Temperature
      • Reduce the temperature increase sensory input

Bolus Positioning, Control and Transition

  • 3-second prep (automatic → volitional onset)
  • Lingual sweep (with finger)
  • Fluid washdown (cyclical intake)
  • Dry swallows
  • Thermal stimulation
  • Bolus placement (to "good" side)
  • Modifying rate of intake
  • Increasing bolus size (sensory input)
  • Decreasing bolus size (oral control)

Facilitating Airway Protection

  • Supraglottic swallow
    • Hold breath, swallow during breath-holding, and cough immediately after the swallow but before inhalation.
  • Super-supraglottic swallow
    • Hold breath, bear down (provides closure of the laryngeal vestibule), swallow while breath-holding and bearing down, and cough immediately after the swallow.
  • Mendelsohn Maneuver
    • Peak of hyolaryngeal excursion → pharyngeal residue, UES opening difficult to teach without biofeedback such as sEMG; increased cessation of breathing

Feeding and Mealtimes

  • Compensatory strategies for feeding difficulties
    • Bolus size (cut up meal)
    • Temperature (altering sensory input and taste)
    • Meal placement (within reach, on stronger side)
    • Specialized crockery and cutlery (consult OT colleagues)

Feeding Assistance

  • How much assistance is needed with the meal?
    • Full feeding assistance
    • Partial assistance (due to fatigue or specific needs)
    • Hand-over-hand assistance
    • Verbal prompts or physical cues
    • Assistance to engage socially or minimize disruptive behaviors
  • Educate and provide explicit training to feeding assistants.

Mealtimes

  • Observing the mealtime (typical or one-off)
  • Physical environment, culturally appropriate food/fluids, interactions are more than just about the process
  • The context of the meal and the mealtime environment impacts ALL clients and can alter the flow and success of oral intake significantly.
  • Don’t forget about feeding and mealtimes!

Oral Hygiene

  • Ensuring good oral hygiene should be an integral part of care for ALL clients.
  • There is significant evidence to support that improving and maintaining good oral hygiene IS an effective treatment of dysphagia. Dependence for oral care and the severity of tooth decay correlation with the development of aspiration.
  • Oral hygiene should be a ROUTINE part of management of mealtime and swallowing difficulties!
  • Oral hygiene is a TEAM effort. As speech pathologists we are an INTEGRAL part of the TEAM!
  • Poor oral hygiene leads to problematic flora in the mouth, which can be carried down in aspirate to the chest, increasing the risk for aspiration pneumonia.

Free Water Protocols

  • Allow clients access to water ONLY, even with aspiration risk of thin fluids.
  • Often attributed to the Frazier Free Water Protocol.
  • NOT a "FREE for ALL" and NOT suitable for all clients
  • Implemented to reduce dehydration and increase QoL.
  • The body is made up of 60% water/water is PH neutral/water is the safest fluid for our body to manage if we do aspirate it.
  • Water intake discontinued during and for 30 minutes after a meal to allow clearing of post swallow residue
  • Aggressive oral care
  • Exclusion criteria:
    • Poor cognition/impulsive behavior
    • Severe coughing with aspiration
    • Aspiration of thickened liquids or food
    • Inability to rinse and expectorate
    • Inability to hold a cup and/or self-feed

Take Home Messages

  • Diet modification should never be used as a blanket solution!
  • Studies suggest a vast majority of people in residential aged care facilities are on a diet that is more restrictive than required.
  • ALL clients that have been placed on a modified diet SHOULD be regularly reviewed by a speech pathologist and dietitian!
  • Ideally - the need and benefit of compensation techniques should be confirmed with instrumental assessment.