These
techniques are designed to actually change the physiology of
the swallow.
Icing (simulation)
This is a
technique developed by occupational therapists. It may or
may not be effective but is currently in use. The external
surface of the lower cheeks and the mouth are typically iced
and the velum and uvula may also be treated.
Icing some areas
could possibly have dangerous consequences for the elderly,
the frail, or those with heart problems. (Icing these areas
would not affect a young healthy person.)
Icing above the
mouth can cause a sympathetic nervous system response which
increases heart rate. This might cause plaque to break lose
from a thrombus and lead to another stroke or to a heart
attack.
Icing behind the
ear can lower blood pressure to dangerous levels in some
patients.
Icing near the
pinna can cause irregular heart beat and respiratory
problems.
Thermal Stimulation (simulation)
Evidence regarding
the efficacy of this procedure is mixed, but it is commonly
used. Logemann (1989) has promoted the use of this
technique.
Thermal
stimulation involves tapping or rubbing the patient's
anterior faucial pillar with an iced dental mirror. In each
treatment "set" the tapping/rubbing is done about five
times. As immediately as possible after a set is completed
the patient is instructed to swallow and may be given a
small amount of liquid through a straw, even carbonated. The
extra stimulation provided by the iced mirror is supposed to
somehow alert the nervous system, allowing the swallow
response to occur more rapidly.
Logemann (1989)
recommends doing thermal stimulation three times per day.
She suggests stimulating only the anterior faucial pillar on
the patient's good side. I like to do both sides and only
when the patient is taking a break in between doing
oral-motor exercises. I have grave doubts about the efficacy
of thermal stimulation. The research is quite conflicting
and from my own experience after working with swallowing
patients for many years I am quite unconvinced as to its
efficacy.
Sensory stimulation
(for apraxia of swallowing or reduced sensation) (simulation)
(Logemann, 1989, '97)
It may involve
presenting a warm or cold bolus, presenting foods with
strong tastes or textures, or pressing the spoon on the
tongue when food is presented.
For patients with
apraxia of the swallow, it may be best to let them feed
themselves, allowing the swallow to be more
automatic.
Suck-swallow
technique (simulation)
The patient
produces an exaggerated suck with the lips closed followed
by an exaggerated vertical back-tongue motion prior to
swallowing attempts. (Have the patient suck on a popsicle
stick.)
The sucking action pulls saliva to the back of the mouth,
and this seems to help trigger the swallow more rapidly. So,
this technique is also based on the idea that increased oral
sensation will help to trigger the swallow.
Chewing
For some patients,
this provides the extra oral sensation necessary to trigger
the swallow. If this technique is used, the patient must
also chew liquids prior to swallowing them.
Motor
exercises(simulation)
Exercises can be
done to improve the range of motion of the lips, tongue, and
jaw, to improve coordination, to improve vocal fold
adduction, laryngeal elevation, or tongue base
retraction.
Range of motion
exercises involve moving target structures as far as
possible from rest position, holding them at the most distal
point for a few seconds and then relaxing.
Resistance
exercises involve moving against pressure. For the tongue,
use a tongue blade. Falsetto exercises will improve
laryngeal elevation.
Posture to facilitate
the swallow (simulation)
(Logemann, 1989. '97)
Specific postures
are used to compensate for particular types of dysphagia by
changing the way that the food moves through the pharynx. It
is a good idea to have the patient try using these postures
during the radiographic study; this way you can get an idea
of how well they will really work.
If the patient's
problem is delayed initiation of the
swallow, have them tuck their chin while
they eat. This head-down posture moves the tongue
forward, enlarging the vallecula. The vallecula can then
contain the bolus a little longer than usual, allowing more
time for the larynx to elevate and the vocal folds to
adduct. It also narrows the airway and puts the epiglottis
in a more over-hanging position.
If the patient has
poor
tongue control, have him/her swallow in a
head-back position, allowing for
more drainage. When a patient swallows in this position, it
may be dangerous to give him/her thin liquids. Also, if the
patient has both poor tongue control and problems with
airway closure, he/she could swallow in this position using
the supraglottic
swallow. (Remember that only patients with
fairly intact cognition can effectively use the supraglottic
swallow.)
In the case of
unilateral paralysis of the pharynx, the patient should
turn his head toward the paralyzed
side
before swallowing. This closes the pyriform sinus on the bad
side and keeps food on the functioning side of the
pharynx.
If there is a
unilateral
paralysis of both the oral cavity and the
pharynx, the patient should swallow while
tilting the head
toward
the better side. This technique prevents pocketing
and also sends the bolus down the functioning side of the
pharynx.
Note that the head should only be turned toward the bad side
in the case of unilateral paralysis of the pharynx alone. If
the oral cavity is also affected, use the tilting technique.
(Tilting could be used for pharyngeal problems alone if
turning is too difficult for the patient.)
If the patient is
pocketing food in the oral cavity, it may be necessary to
teach him/her to sweep the buccal cavity with a
finger.
Food consistencies to
increase safety while swallowing (simulation)
(Logemann, 1989)
Again, there is no
"typical" dysphagia diet. The consistency of food should be
chosen based on the specific nature of the problem.
In the case of
reduced stripping
action, patients will do better with
liquids rather than with thicker foods. Liquid will move
more easily through the pharynx.
If the problem is
reduced tongue
control, use thickened liquids. They should
be sufficiently viscous to prevent splashing.
If the patient has
problems with airway closure, use thickened liquids
(you may use carbonated beverages during trial feedings
only). They will travel more slowly, allowing more time for
laryngeal elevation and closure.
In the case of
problems with the cricopharyngus, thinner consistencies are
better. Thin liquids can drain into the esophagus through
even a small opening in the p.e. segment.
In cases of
reduced laryngeal
elevation, use thin liquids because of crico
pharyngeal problems. Remember, laryngeal elevation stretches
the cricopharyngeous resulting in relaxation of the
muscle.
In addition to
changing the type of food that the patient eats, you can
also ask them to regulate the size of the bolus that they
try to swallow. Have them take small bites.
Techniques for
protecting the airway (Logemann, 1989, 1997) (simulation)
The
supraglottic swallow
The
patient is told to take a breath and hold it while
swallowing and then coughs after the swallow. This results
in the voluntary closure of the vocal folds before, during
and after the swallow.
From my experience
with swallowing patients this technique is rarely effective.
In the first place, it is seldom necessary as only 5% of
dysphagia patients have problems with airway closure. Of
this group, many will have cognitive impairments that
prevent them from using this strategy. In addition, many
elderly patients are unable to hold their breath and open
their mouths at the same time. (It is a better strategy to
have put food in their mouths first and have them start
holding their breath only when they are ready to
swallow).
The supra
supra-glottic swallow
This
technique closes the entrance to the airway at the level of
the arytenoid cartilages. The patient follows the same
procedure as with the supra-glottic swallow, but "bears down
while holding his breath."
The
Mendelsohn Maneuver
This
technique helps the patient gain some voluntary control over
the opening and closing of the p.e. segment.
The patient is
told to pay attention to the way the thyroid cartilage
(Adam's apple) goes up and down during swallowing. Then he
learns to use muscles to keep the larynx elevated for
several seconds after the swallow. This should facilitate
the opening of the cricopharyngus muscle.
The
Effortful Swallow
This
increases the tongue driving force by causing exaggerated
retraction of the tongue. This helps to get food past the
valleculae.
The patient is directed to squeeze hard with his throat and
neck muscles during the swallow.
*** The above
techniques are most often used with patients who have had
brain stem lesions and so have severe dysphagia, but still
have good cognitive ability.