1. TREATMENT

2. 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

3. 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

4. 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.

5. 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.

6. 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…

7. 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.

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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.

14. Oral-Pharyngeal Sensation
Deep Pharyngeal Thermal Stimulation:
Indication: decreased oral-pharyngeal stimulation?
Rationale: Maximal sensory input to elicit pharyngeal swallow trigger?

15. 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.

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

17. 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

18. 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

19. 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.

20. Therapeutic Strategies for Specific Disorders

21. 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

22. 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

23. 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

24. 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

25. Esophageal Disorders
May be suspected by SLP; typically diagnosed by GI physician
Typically treated medically

26. 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

27. Dietary: Hydration Management
Manipulating consistencies to alleviate symptoms
Oral phase
Liquids/solids
Thinner
Thicker
Pharyngeal Phase
Esophageal Phase

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

29. 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

30. 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