MANAGEMENT OF SWALLOWING DISORDERS. Treatment Planning Eating involves the whole person. It is not...

Management of Swallowing Disorders

Treatment Planning

Eating involves the whole person. It is not possible or practical to separate

the person from his/her eating difficulty. One should consider the whole person—

cognitive, physical, and/or environmental barriers that may affect treatment progression.

The goal of treatment is improved nutrition and hydration status while focusing on techniques and strategies to eliminate eating difficulty and increase swallow safety.

Behavioral Therapy

Swallowing therapies fall into several categories: behavioral, medical, or surgical.

Behavioral therapies are provided by the SLP sometimes in conjunction with PT, OT, and/or nursing when:•the strength, endurance, and/or mobility of structures involved in swallowing are diminished;•diagnostic probes have indicated that swallowing may be facilitated, or made safer by bolus manipulation, postural compensations, facilitative maneuvers, or adaptive devices; or

Behavioral Therapy

•it is believed that more appropriate initiation or timing of certain swallowing events may be induced by selective stimulation of particular structures or systems.

Indications for therapy directed toward improving the strength, range of motion, endurance, and agility of gestures involved in swallowing include clear evidence of weakness or limited movement of the mandible, lips, tongue, pharynx, or larynx.

These symptoms are typical in certain patient populations (e.g., head and neck cancer, neurogenic).

Exercises should be aimed at improving the capabilities of residual, impaired swallowing gestures, and/or those with the most obvious compensatory potential.

Behavioral Therapy

Bolus manipulation of selected materials should be individually tailored to the patient.

Bolus characteristics can be manipulated to compensate for timing/coordination or construction/patency impairments of the oral, and/or pharyngeal chamber or of the lingual-palatal, velopharyngeal, laryngeal, or PE sphincter.

Characteristics of the bolus that lend themselves to manipulation include:

Behavioral Therapy

•Properties that maximize sensory feedback about the bolus and its position, e.g., temperature, taste, size, and texture; and•Properties that affect bolus deformability and/or bolus flow in response to gravity or compression, e.g., bolus viscosity, bolus size, and bolus placement.

Postural manipulation is indicated when it appears that a patient can either redirect bolus material in a manner that improves swallowing efficiency, improves protection of the airway, or both.

Changes in head/neck and upper body position can have a powerful effect on bolus flow through the oral and pharyngeal chambers.

Behavioral Therapy

Tilting the upper body or the head changes the impact of gravity on the bolus.

Capital flexion, extension, or rotation change the size and shape of the pharyngeal cavity and may impact PE opening.

Positional changes do not have to be dramatic to be effective.

Positions that exploit gravity include tilting the upper body (making sure to keep cervical spine neutral in relation to the thoracic spine), and tilting the head (flexion or extension, or extend-flex).

Behavioral Therapy

Facilitative maneuvers refer to physiologic postures or gestures that have been demonstrated to improve swallowing efficiency or safety and that a patient can learn to utilize for these purposes.

Facilitative maneuvers require sophisticated and active participation by the swallower, good muscular kinesthetic and proprioceptive sense, movement control, and ability to understand, learn, and apply the strategy during swallow.

Some maneuvers are very familiar and are applied spontaneously by patients.

Behavioral Therapy

These include effortful swallow, repetitive swallows, and expectoration of pharyngeal residue.

More difficult maneuvers to learn include altering the extent and/or timing of laryngeal behaviors for swallow, e.g., supraglottic and super supraglottic swallow, or for improving or prolonging PE opening, e.g., Mendelsohn maneuver.

Adaptive devices modify the delivery of the bolus material into the swallowing tract or change the shape of the tract in a manner that positively impacts swallowing efficiency and/or safety.

Behavioral Therapy

Examples of such devices include a syringe, a modified spoon, different nipples, different sizes and shapes of cups and bowls.

A palatal augmentation appliance or palatal prosthesis may be useful in helping reshape the oral cavity.

Finally, communication and environment must be considered in behavioral therapy.

Reduction of noise, light, and other distractions, selective positioning, and verbal cueing may enhance the patient’s level of alertness.

Behavioral Therapy

Verbal cues, such as the patient’s name, or instructions, such as “swallow,” “close your lips,” or “chew,” may be accompanied by visual cues or demonstration.

With children, prefeeding preparation may involve rituals, attendance to state, including fatigue, readiness/playtime activities, and prosthesis placement.

Sensory cues involving taste or smell can be used to heighten alertness.

During feeding, pacing of bolus delivery may help improve breath control and stamina.

Medical Therapy

Medical therapy targets the underlying medical condition that results in dysphagia.

When a neuromuscular disease is the etiology of the dysphagia, medications prescribed for the patient must be reviewed to determine if any contribute to dysphagia (e.g., cholinergic drugs).

GER may contribute to swallowing difficulties and may require an antireflux regimen and well behavioral modifications.

Xerostomia impedes bolus lubrication and bolus flow and is deleterious to oral mucosal and dental health and esophageal GER defense.

Medical Therapy

Treatment of xerostomia includes maximizing hydration, limiting mouth-breathing, minimizing use of products that contribute to xerostomia (e.g., medications, mouthwashes, toothpastes) or favor bacterial growth.

Surgical Therapy

Selective condition may benefit from surgical therapy.

Some structures which may be repaired or altered surgically with skin flaps include the soft palate and the tongue .

Surgical procedures are available to correct some vocal fold paralyses and other causes of glottic incompetence.

Problems with cricopharyngeal relaxation due to neuromuscular disease and/or GERD may necessitate a myotomy.

Esophageal achalasia and strictures are often treated with esophageal dilations.

Surgical Therapy

Dysphagia is often multifactorial. Surgical therapy may be able to correct part of

the problem but often other difficulties will persist.

Patients need to be counseled about the limitations of surgery so that their expectations will be realistic.

Progress after surgery is more likely to be gradual, and a period of post-operative swallow therapy may be required to realize the fullest benefit from surgery.

Nutrition & Hydration

Patients who are experiencing dysphagia are at risk for malnutrition and dehydration.

Physical signs of malnutrition include: dry, flaky skin; spoon-shaped nails; small yellowish lumps around the eyes; dull, dry hair; night blindness; gums that bleed easily; red, swollen lips; slow-healing wounds;


5% weight loss in 1 month; 10% weight loss of total body weight; and weight below 90% of the ideal.

Factors which can lead to malnutrition include: NPO status or significantly reduced dietary

intake for more than 3 days; burns, trauma, infection, disease processes, or

surgery increasing nutritional needs; anorexia from illness or drug use; alcoholism or substance abuse;


depression; dysphagia; chemotherapy and radiation; and intestinal malabsorption disorders.

Factors which can lead to dehydration include: decreased water access due to immobility, poor

visual ability, and/or altered mental status; presence and severity of dysphagia, leading to

fear of oral intake; fear of urinary incontinence, leading to

diminished food intake;


administration of diuretics; anorexia; acute illness imposed on chronic disability; feeding dependency; impaired communication skills; impaired cognitive skills; low frequency of medications; low frequency of meal consumption; poor fluid intake of both beverages and solid foods; and administration of either IV radiographic contrast agents

or high protein enteral feeding, causing an osmotic diuresis.


Physical signs of dehydration include: dry tongue, mouth, and great thirst; less urination and dark urine; sunken eyes; wrinkled skin; dizziness and confusion; and rapid heartbeat and breathing.


In infants, dehydration may be evidenced by dry mouth or thick saliva, and small amounts of dark urine in diaper.

The fontanel on the head sinks in when the baby is held upright or in sitting position.

Skin forms a "tent" when pinched and stays pinched up.

Dark circles appear around eyes. The baby may be fussy, sleepy, not hungry, or

difficult to wake up.

Special Treatment Protocols: DPNS

Deep Pharyngeal Neuromuscular Stimulation (DPNS) is a therapeutic technique for adults developed during a two-year period by Karlene Stefanakos (1993).

Stefanakos claims that “traditional compensatory techniques have as their focus minimizing the function/effect of pharyngeal musculature” when decreased muscle strength, endurance, absent or diminished reflex responses and discoordination between pharyngeal reflexes disrupt swallow function.

Special Treatment Protocols: DPNS

“DPNS is a systematized therapeutic method for pharyngeal dysphagia which utilizes 11 specific stimulation techniques within the oral/pharyngeal areas.” http://www.speechteam.com/workshops.htm

To date, no published results of her ongoing study, or specific stimulation techniques are available except by attendance at her workshop.

Frazier Water Protocol

The Frazier Water Protocol (Panther, 2005) was implemented in 1984 at the Frazier Rehabilitation Institute in Louisville, KY.

The Frazier Water Protocol was developed in response to patients who were non-compliant with recommendations for no thin liquids or refusing to drink thickened liquids.

Despite videofluoroscopic evidence of aspiration, non-compliant patients at the Frazier Rehabilitation Institute were not developing pneumonia.


The guidelines that were developed through the multidisciplinary cooperation of physicians, SLPs, and a dietician at Frazier were tailored to the patients seen in this acute rehabilitation environment.

The acute rehabilitation population can generally tolerate three hours of therapy/day, are upright, mobile, and relearning to manage functional activities.

A doctor’s order is not required to implement a free water protocol.

Any patient receiving tube feedings or on thickened liquids may have water.


For patients who are eating orally, water is allowed between meals only.

Clinicians who decide to pursue allowing patients who aspirate thin liquids to drink water should be sure that the water source is safe.

Make sure that the facility’s internal water test meets, or exceeds, the strict requirements enacted by the EPA.

At your initial bedside visit, screen the patient with water to determine if the patient is demonstrating signs and symptoms of dysphagia.


Check for level of alertness and presence of impulsivity.

Decide if further dysphagic instrumental evaluation is warranted.

Patients exhibiting impulsivity or excessive coughing and discomfort should be restricted to water taken under supervision.

Patients with extreme choking may not be permitted oral intake of water due to the physical discomfort of coughing, although this is a rare occurrence.

Occasionally, a physician may order strict NPO for a patient and water or ice chips will not be permitted.

For patient on oral diets, water is permitted between meals.


Water intake is unrestricted prior to a meal and allowed 30 minutes after a meal.

The period of time following the meal allows spontaneous swallows and gravity to clear pooled solid or thickened liquid residues.

NPO patients are permitted water any time. Patients who are thin liquid restricted wear

yellow bands to communicate the liquid restrictions to all staff.

The band may also include wording to individualize specific compensations, such as “no thin liquids except water between meals;” or “no thin liquids except water by teaspoon between meals.”


Water is freely offered to patients throughout the day according to the guidelines documented on the yellow arm band.

Patients for whom compensations, e.g., chin tuck, head turn, etc., have proven successful are encouraged to use compensations while drinking water.

Aggressive oral care should be provided to those patients who are unable to clean their own teeth and mouth so that pathogenic bacteria are less likely to contaminate secretions.

Medications are never given with water.


Pills are given in a spoonful of applesauce, pudding, yogurt, or thickened liquid.

Family education includes emphasis on the rationale for allowing water intake.

Written material is provided as well. Education is documented in the medical record. To date, the only published research related to

the consumption of water by patients with dysphagia was conducted by Garon, Engle, and Ormiston (1997).

20 patients with hx of stroke and aspiration of thin liquids during a VFSS were randomly assigned to two groups.


The control group received thickened liquids while the experimental group received thickened liquid and water between meals only upon request.

Prior to drinking water, patients were required to pre-rinse in an effort to reduce the volume of bacteria in the oral cavity.

No patients in either group developed pneumonia or dehydration during the conduction of the study or during a 30-day follow-up period.

A significant difference in thickened liquid intake per day was found between the groups.


The control group took more thickened liquids, although the experimental group drank more fluids overall.

Mean days from onset of stroke to end point of no thin liquid aspiration was 39 days for the control group and 33 days for the experimental group.

Patients allowed water reported a high degree of satisfaction and reported that thickened liquids did not quench thirst.

None of the patients in the control group reported satisfaction with thickened liquids and all reported a desire for ice chips or water to quench thirst.

E-Stim

Functional Electrical Stimulation (FES) or E-stim, is the artificial elicitation of a muscle action potential to generate useful body functions.

Electrical stimulator devices, called neuroprostheses, provide short bursts of electrical impulses to the nervous system to produce sensory and/or motor functions.

Over the past 40 years, neuroprostheses have been developed for a wide variety of applications.

Cochlear implants are one type of neuroprosthesis that has achieved great success.

E-Stim

Other neuroprostheses, such as those for upper limb and lower limb function have not yet matured to a level that creates a significant consumer demand.

Attempts to develop electrical stimulation devices for assisted swallowing have been few, but researchers have begun building a foundation for future developments.

Some preliminary studies have been carried out to assess the feasibility of electrical stimulation in the treatment of chronic dysphagia.

E-Stim

Another study by Freed, Freed, Chatburn, and Christian (2001) examined the effects of continuous electrical pulse delivery by a pair of surface electrodes located on the neck in reducing severity of aspiration and subsequent need for gastrostomy in a group of 110 patients with a history of swallowing disorders caused by stroke.

Specifically, a pair of electrodes was placed in one of two configurations: one electrode above the lesser horns of the hyoid bone and the other roughly 4 cm below it; or both electrodes above the lesser hyoid bones bilaterally.

E-Stim

The digastric and thyrohyoid muscles likely received direct stimulation from this electrode placement.

The neuroprosthesis was applied as an intervention for 60 minutes per day and was tested against another intervention, thermal stimulation.

While the authors reported overwhelming success, their methodology was judged to be flawed.

Subsequent studies, with more rigorous methodology, are being undertaken.

E-Stim

A 2-channel version of the neuroprosthesis described by Freed et al. has been commercialized as the VitalStimTM and has received FDA approval.

A more recent study has looked at different muscle recruitment strategies for augmenting laryngeal elevation via e-stim (Burnett, Mann, Cornell, & Ludlow, 2003).

Many suprahyoid and infrahyoid muscles are simultaneously active early in the pharyngeal phase of swallowing, when laryngeal elevation begins.

E-Stim

Geniohyoid, mylohyoid, and digastric muscles are used selectively by different individuals, with some individuals using all three muscles at the onset of swallowing and other using different pairs (Spiro, Rendell, & Gay, 1994).

In their study, Burnett et al. utilized hooked-wire monopolar electrodes inserted into mylohyoid, thyrohyoid, and geniohyoid muscle regions in 15 healthy men selected for having a highly visible thyroid prominence for videotaping.

E-Stim

During trials of single, bilateral, and combined muscle stimulations, thyroid prominence movements were video recorded, digitized, and normalized relative to elevation during a 2-ml water swallow.

When an individual muscle was stimulated, it induced approximately 30% of the elevation observed during a swallow and about 50% of swallow velocity.

When paired muscles (bilateral mylohyoid, bilateral thyrohyoid, or ipsilateral mylohyoid and thyrohyoid) were stimulated, there was approximately 50% of the elevation and about 80% of the velocity produced during a swallow.

E-Stim

Paired muscle stimulation produced significantly greater elevation than single muscle stimulation.

The authors felt that their findings suggested a possible role for paired muscle stimulation as a means for augmenting laryngeal elevation and improving airway protection in patients with dysphagia.

Be on the look out for more studies by these folks!

Muscle Interventions

Strength training is a common strategy approach in dysphagia management for muscle weakness from either acute insult or atrophy.

If your aim is to increase the strength of a muscle, you should have the patient participate in short repetitions of the movement under heavy load/resistance.

If you work the muscle in lengthy repetitions under light load/resistance, you are going to increase muscle endurance not strength.

Stretching is another active exercise sometimes used in dysphagia management.


Stretching can be passive or active. It can increase or decrease tone. If you stretch a muscle quickly, you increase its tone. If you stretch a muscle slowly, you decrease its tone. Decreased tone can improve range of motion. Active range of motion can reduce tissue adhesions,

scars, and contractures. Passive range of motion does not increase strength or

endurance nor prevent atrophy. Passive warming before stretch can increase range of

motion. Warming without stretch does not change range of

motion.


Warming elevates threshold for pain so one is able to stretch further without pain.

Warming reduces muscle spasm and improves blood flow which may facilitate muscle strength.

Icing temporarily reduces nerve conduction and may be effective for increasing range of motion at the early stages of the stretch.

There is limited data on range of motion exercises for swallowing.

Range of motion exercises without resistance may not act against atrophy.


Let’s look at some traditional swallow treatments and the focus of the exercise and the outcome.

Lip pucker—an endurance exercise; maintains muscle.

Tongue protrusion/retraction—an endurance exercise; maintains muscle.

Sucking/blowing—an endurance exercise; maintains muscle.

Hard swallow—an endurance exercise; slow to fatigue.

Pushing tongue against tongue bulb—a strength exercise; increases tongue strength but faster to fatigue.


Mendelsohn’s maneuver—a strength exercise; increases strength but faster to fatigue.

Falsetto maneuver (lateral movement of the pharyngeal walls)—an endurance exercise; maintains muscles.

Pushing—a strength exercise; increases strength but faster to fatigue.

Supraglottic swallow—a strength exercise; increases strength but faster to fatigue.

Shaker—a strength exercise; increases strength, but faster to fatigue.


Many of our exercises are aimed at the right goal but how they are delivered does not achieve the level required to change muscle function.

Force level and duration are important issues in retraining the muscular system of swallowing.

Short periods of activity under loaded conditions have significant impact.

Many treatments do not have appropriate intensity nor repetitions to make impact.

After stroke, one should wait about 2 weeks before beginning strength and endurance training.


Muscle atrophy is an important factor in swallowing impairment.

Atrophy happens rapidly. Atrophy is greater in regularly used muscles

and in power muscles. Retraining is beneficial However, exercising atrophic muscles in the

malnourished individual can cause damage.

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