1. SDDA: Dysphagia intervention - exercises
Sanna Jansson, cert SLP
Kerstin Johansson, PhD, cert SLP
March 24, 2016
SLP-course 33, T6

2. Instructions Answer the following questions for each intervention.
How do you instruct the patient? Practice on each other.
What´s the aim of the intervention?
Do you classify the intervention as an exercise, a compensatory technique or a facilitating technique?
Under what conditions is the intervention inappropriate?
Are there any risks associated with the intervention ?

3. Mendelsohn maneuver Put one hand on your larynx and swallow.
What happens?
Now, swallow again.
Feel your larynx rise but do not let it drop down.
Hold it up with your muscles for two seconds.
Release and let the larynx drop.
Repeat.
(Kahrilas et al., 1991, Neumann et al 1995, Huckabee et al 1999)

4. Effortful swallow Swallow harder!!
Some patients need extra instructions as:
Swallow hard, as if you were to swallow a large meatball/ a ball
Swallow very hard while squeezing the tongue hard against the palate.
Try this first with some water and then with water or food. Any difference?
(Bülow 1999, Huckabee et al 2005, Hind et al., 2001)

5. The head-lift exercise (Shaker)
3 long head-lifts
Lie flat on your back. Do not use a pillow under your head.
Raise your head as though you were trying to fixate your gaze on your toes. Try to press your chin against your chest. Make sure not to raise your shoulders. Hold your head sustained for one minute or as long as you can. Rest for one minute.
Repeat three times with rest in between.
30 fast head-lifts
Complete 30 fast head-lifts without sustaining in the lifted position.
Complete the program three times/day for six weeks
(Shaker et al., 2002; Easterling et al., 2005)

6. Supraglottic and Super-supraglottic swallow
Inhale
Hold your breath
Swallow
Cough
Super- supraglottic swallow
Hold your breath and bear down.
(Martin et al., 1993; Ohmae et al., 1996; Bülow et al., 2001, Boden et al 2006)

7. Neuroprep
1 2 3 Swallow!

8. Head postural adjustments
Weak side, paresis
Head postural adjustments
Chintuck ( chin down)
Head turn/rotation toward weak side
Head tilt toward strong side
Head extension ( raise chin)
How does these head postures affect swallowing?
Lean towards strong side
Turn towards weak side

9. If you have the time… Reflect on how the body position affects the swallow physiology
Swallow while being in a reclined position
Swallow while lying supine
Swallow side-lying

10. Trial meal Try the different concistencies
How does the different concistencies affect the swallow physiology?
In the oral, pharyngeal and esophageal phase?
Speed? Required force/strength? Need for oral preparation of bolus?
How does a small vs a large bolus affect the swallow physiology?
Read the litterature.

11. References
Kahrilas PJ, Logemann JA, Krugler C, Flanagan E. Volitional augmentation of upper esophageal sphinkter opening during swallowing. Am J Physiol 260(3 Pt 1): G450-G456, 1991
Hind J, Nicosia M, Roecker E, Carnes M, Robbins J. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys med Rehabil 82: , 2001
Fujiu M, Logeamann J. Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol 5:23-30, 1996
Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S et al.: Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 122(5): , 2002
Easterling C, Grande B, Kern M, Sears K, Shaker R: Attaining and maintaining isometric and isokinetic goals of the Shaker exercise. Dysphagia 20: , 2005
Martin BJW, Logemann JA, Shaker R, Dodds WJ. Normal laryngeal valving patterns during three breath hold maneuvers; a pilot investigation. Dysphagia 8:11-20
Ohmae Y, Logemann JA, Kaiser P, Hanson BG, Kahrilas PJ. Effects of two breath holding maneuvers on oropharyngeal swallow. Ann Otol Rhinol Laryngol, 105(2):
Bülow M, Olsson R, Ekberg O. Videomanometric analyses of supraglottic swallow, effortful swallow and chin tuck in patients with pharyngeal dysfunction. Dysphagia. Summer;16(3):190-5, 2001
See also Groher Crary (2016, 2010) for additional references.