Ch. 6

* What type of nutritional management is necessary? * Should therapy be initiated and what type? * What specific therapy strategies should be utilized?

* The continuous goal of any treatment program is the reestablishment of oral feeding while constantly maintaining adequate hydration and nutrition and safe swallowing.

* What is the Diagnosis? * What is the prognosis? * What is the patient’s reaction to Compensatory strategies? * What is the severity of the patient’s dysphagia? * Can they follow directions? * What is their respiratory function? * Do they have supportive caregivers and family? * What is the patient’s motivation and interest?

* Factors to consider * Time taken to swallow a single bolus of a particular consistency of food * Aspiration- more than 10% of every bolus, regardless of consistency of food- should not be eating orally

* Control the flow of food * Eliminate the patient’s symptoms * Do not necessarily change the physiology of the patient’s swallow. * Can be used with patient’s of all ages and cognitive levels * Postural changes * Increasing sensory input * Modifying volume and speed of food presentation * Changing food consistency

* Chin-Down * Pushes anterior wall posteriorly * Tongue base and epiglottis are pushed closer to pharyngeal wall * Airway entrance is narrowed * Vallecular space is also widenced * Helps with delay in triggering the pharyngeal swallow * Helps with reduced tongue base retraction * Helps with reduced airway closure

* Chin-Up * Uses gravity to drain food from oral cavity * Helpful with reduced tongue control * Head Rotation * Rotate to damaged side * Allows food to flow down normal side * Helpful when there is unilateral pharyngeal wall impairment * Helpful with unilateral vocal fold weakness or paralysis * Chin Down with Head Rotation * Head Tilt

* Chin Down with Head Rotation * Helpful for airway protection * Head Tilt * Helpful when a patient has both a unilateral oral impairment and a unilateral pharyngeal impairment on the same side * Tilt to the better/stronger side

* Utilized for the following * Swallow apraxia * Tactile agnosia for food * Delayed onset of the oral swallow * Reduced oral sensation * Delayed triggering of the pharyngeal swallow

* Increase downward pressure of spoon against the tongue when presenting the food to the patient * Presenting a sour bolus * Presenting a cold bolus * Presenting a bolus requiring chewing * Presenting a larger volume bolus * Thermal-tactile stimulation

* Help to improve the trigger of the pharyngeal swallow * Rubbing anterior faucial arch firmly * 4-5 times on each side * Use a laryngeal mirror that has been held in crushed ice for several minutes * Alerts sensory stimulus to cortex and brainstem

* Determining the volume of food per swallow that will elicit the fastest pharyngeal swalllow * A larger bolus may facilitate triggering of the swallow * Taking too much food too rapidly can result in a severe residue in pharynx and possible aspiration

* Thin liquids * Oral tongue dysfunction * Reduced tongue base retraction * Reduced pharyngeal wall contraction * Reduced laryngeal elevation * Reduced Upper Esophageal Sphincter opening

* Thickened liquids * Oral tongue dysfunction * Delayed pharyngeal swallow * Puree and thick foods * Delayed pharyngeal swallow * Reduced laryngeal closure

* Direct Therapy- work directly on the swallow- introduce food into the mouth and attempt to reinforce behaviors and motor control during the swallow * Indirect Therapy-exercise programs or swallows of saliva, but no food or liquid is given

* Supraglottic swallow * Super-supraglottic swallow * Effortful swallow * Mendelsohn Maneuver

* See Handout

* Sustain Phonation * Cough/Glottal Attack * Pitch scales * Push/Pull with voicing

* Inpatienets- Acute Care * Bedside Swallow Evaluation and/or Videoswallow Study * Awake and alert * Seen daily for therapy * Outpatients * Videoswallow study results preferred prior to first visit * Clinical Swallow Evaluation in the office * Twice weekly