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) Resistance 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: Deep pharyngeal muscular Nero stimulation.

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 Falseto voice elavates layrengo the same as swallow.

Direct Treatment/Intervention Involves administration of a bolus and incorporating instructions/compensations Small bolus sizes/volumes should be initiated

Swallowing Maneuvers Supraglottic swallow: Super-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: Mendolsohn maneuver: 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: Shaker 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 Manipulate bolus placement Posture Reduced oral Sensitivity

Oral Transit Phase of the Swallow Tongue thrust Bolus positioning Reduced tongue movement Exercises Postural changes 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 Delayed cricopharyngeal opening

Pharyngeal Phase Posture Supraglottic swallow Adduction exercises 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 Esophageal Phase

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

Adaptive Equipment Glossectomy Cut-out cups Food processors 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 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