TX OF DYSPHAGIA MSSLP 507

Fundamental Considerations in Dysphagia Treatment

  • When determining the appropriate treatment (TX) for dysphagia, clinicians must conduct a comprehensive assessment of various factors related to the patient's condition and life context:     - Etiology of the underlying disease or disorder: Understanding the cause of the dysphagia is critical for selecting the right intervention.     - Severity: The extent of the swallowing impairment dictates the intensity and type of therapy required.     - Prior eating history: Investigating the patient’s dietary habits and preferences before the onset of dysphagia.     - Psychosocial factors: Considering the emotional, social, and psychological impact of the disorder on the patient.     - Anticipated medical course: Projecting whether the condition is expected to improve, stabilize, or degenerate.     - Caregivers: Evaluating the support system available to assist the patient with treatment adherence and feeding.     - Cognitive Status: Determining the patient's ability to follow directions, learn maneuvers, and safely manage oral intake.

Evidence-Based Practice (EBP)

  • The selection of any treatment for the patient with dysphagia must adhere to the principles of Evidence-Based Practice (EBP).

  • Verbatim Definition (Groher, 2016): ‐‐ ‘The selection of any treatment for the patient with dysphagia should be based on the best available evidence from the published literature, the patient’s wishes, and the clinician’s experience with similar problems. The combination of these three variables in preparing a treatment plan is referred to as evidence-based practice (EBP).’

Therapy Risks and Aspiration Pneumonia (PNA)

  • Risk Engagement: During active therapy, there is an inherent risk that the patient will aspirate.

  • Aspiration vs. Pneumonia: Research indicates that the number of individuals who aspirate is significantly greater than those who actually develop pneumonia (PNA).

  • Contributing Factors for PNA: Whether aspiration leads to pneumonia depends on several extraneous variables:     - Age: Older patients may be at higher risk.     - Mobility: Physical movement levels and bed-bound status.     - Medical status: Overall health and immune system strength.

Food and Liquid Modifications

  • Texture and Viscosity: Altering the physical properties of intake to ensure safety.

  • Volume and Bolus Size: Controlling the amount of food or liquid presented at one time.

  • Temperature: Adjusting the heat or coldness of the bolus to trigger a better swallow.

  • Carbonation: Evaluating if carbonated beverages assist in the swallow reflex.

  • Taste and Smell: Enhancing sensory input to improve the oral phase of swallowing.

  • Transitional Foods: Utilizing foods that start as one texture and change to another (e.g., melting) as a bridge in therapy.

The IDDSI Framework (International Dysphagia Diet Standardisation Initiative)

  • The IDDSI provides a global standard for descriptive terms and levels for food and liquid thickness (www.iddsi.org):     - Level 7: Regular     - Level 6: Soft & Bite-Sized     - Level 5: Minced & Moist     - Level 4: Pureed (Food) / Extremely Thick (Drink)     - Level 3: Liquidised (Food) / Moderately Thick (Drink)     - Level 2: Mildly Thick     - Level 1: Slightly Thick     - Level 0: Thin

Prosthetic Interventions

  • Dental Prosthetics: Aimed at improving dentition to enhance mastication (chewing).     - Dentures: Full sets of artificial teeth.     - Partials: Removable appliances replacing specific missing teeth.

  • Palatal Reshaping Prosthetic: Specifically designed to modify the shape of the hard palate to assist in bolus transport.

  • Lingual Prosthetics: Devices designed to assist with tongue function or replace lost lingual volume.

Exercises and Specific Swallowing Maneuvers

  • Oral Motor Exercises: Targeted movements to strengthen and coordinate the lips, tongue, and cheeks.

  • Vocal Fold Closure Exercises: Designed to improve the protective mechanism of the airway.

  • Effortful Swallow: A specific technique to increase the force of the swallow.

  • Masako Maneuver: An exercise involving the protrusion of the tongue held between the teeth while swallowing to improve pharyngeal wall movement.

  • Shakir Exercise: A head-lift exercise performed while lying flat to improve the opening of the upper esophageal sphincter.

Specialized Dysphagia Therapy Programs

  • McNeill Dysphagia Therapy Program (MDTP):     - A program based strictly on the principles of exercise science.     - Requires clinicians to attend a specific certification course for implementation.

  • LSVT (Lee Silverman Voice Treatment): Often used for Parkinson’s patients; has downstream effects on swallowing function.

  • DPNS (Deep Pharyngeal Neuromuscular Stimulation): A specialized sensory stimulation technique.

Myofascial Release in Dysphagia

  • Development: Adapted from physical therapy methods originally used to treat fibrosis (scarring/stiffening) in the fascia.

  • Primary Application: Used mostly with head and neck cancer patients following radiation therapy.

  • Technique: Employs specialized stretching to mobilize stiffened tissue.

  • Requirement: Clinicians must attend a certification course to practice this technique.

Body Positioning and Posture

  • There is no single universal position that improves swallowing for all individuals; it must be tailored to the specific deficit.

  • Options include:     - Upright     - Reclined     - Side lying

  • Head Positions:     - Head extension: Tilting the head back.     - Head flexion (Chin tuck/down): Moving the chin toward the chest to protect the airway.     - Head rotation: Turning the head to the Right (R) or Left (L) to redirect the bolus through a stronger side of the pharynx.

Advanced Swallowing Maneuvers: Procedural Steps

  • Supraglottic Swallow: A 4-step process intended to close the vocal folds before the swallow and clear residue after.     1. Inhale and hold your breath.     2. Place the bolus in the swallow position.     3. Swallow while continuing to hold the breath.     4. Cough immediately after the swallow before inhaling again.

  • Super-supraglottic Swallow: Identical to the supraglottic swallow but with an added effort component.     - The Additional Step: Bear down (Valvsalva-like maneuver) once the breath is being held.     - Purpose: Intended to increase the degree of vocal fold closure.

  • Mendelsohn Maneuver:     - Technique: The patient is instructed to initiate dry swallows while palpating the neck for laryngeal elevation.     - Procedure: The patient swallows and maintains the larynx at its highest point of elevation for several seconds.     - Objective: Holding the larynx up allows food to pass more easily into the esophagus by prolonging UES opening.

  • Effortful Swallow:     - Instruction: The patient is told to ‘squeeze as hard as they can’ when they swallow.     - Objective: Intended to increase the overall efficiency and pressure of the swallow.     - Clinical Advantage: High utility for patients who struggle with following complex, multi-step directions.

Compensatory Strategies

  • Multiple Swallows: Instructing the patient to swallow two or more times per bolus to clear pharyngeal residue.

  • Alternating Liquids/Solids (Liquid Wash): Alternating a bite of food with a sip of liquid to help clear the oral cavity or pharynx of food particles.

Neuromuscular Electrical Stimulation (NMES)

  • Objective: Intended to facilitate better contraction of weakened muscles through electric pulses.

  • Common Brand: VitalStim.

Biofeedback in Dysphagia Treatment

  • Verbatim Definition (Steele, 2004): ‐‐ ‘Biofeedback refers to the use of equipment to measure body functions that are not monitored consciously. These measurements are displayed as a signal that clients can learn to manipulate, allowing them to develop control over the corresponding body functions.’

  • Clinical Application: Devices provide visual feedback to the patient regarding the effectiveness of an intervention or effort level.

  • Devices and Technologies:     - sEMG (Surface Electromyography): Measures muscle activity.     - Swallow Strong     - Synchrony     - Vital Stim Plus

Surgical Interventions for Dysphagia

  • Medialization Laryngoplasty: Placing an implant between the thyroid cartilage and the vocal fold.

  • Vocal Fold Injections: Specifically used for patients with unilateral vocal fold paralysis to bring the damaged fold to the midline, allowing the functional fold to approximate/close against it.

  • Upper Esophageal Sphincter (UES) Interventions:     - Dilatation: Stretching the UES.     - Myotomy: Surgically cutting the muscle of the UES.     - Botox injections: Used to paralyze/relax the UES to facilitate bolus passage.

Respiratory Muscle Strength Training (RMST)

  • Treatment focusing on the muscles used for breathing to indirectly support swallowing safety and airway protection.

Evaluating Evidence Maps

  • Clinicians should utilize evidence maps to evaluate treatment approaches based on three criteria:     1. Review: Analyze the evidence map for a specific area of treatment.     2. Rating: Rate the treatment approach on a scale of 1 (weak) to 10 (strong) based on the evidentiary strength.     3. Summary: Formulate a paragraph-length statement summarizing the current state of available evidence for that approach.

Questions & Discussion

  • References for further study include articles on Canvas regarding Respiratory Muscle Strength Training.