The Neuroscience on the Web Series:
CMSD 642 Neuropathologies of Swallowing and Speech

CSU, Chico, Patrick McCaffrey, Ph. D


Chapter 7. The Remediation of Dysphagia


Therapy Strategies

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, 1997)

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, 1997)

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, 1997)

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.

NG tubes and swallowing

According to Logemann (1989), its not necessary to wait until tubes are removed to begin therapy. Others, including the instructor believe that NG tubes can affect swallowing. It may be difficult for the patient to realize that food is stuck in the pharynx as an NG tube touches the pharynx all the way down through the esophagus.

Other Personnel Involved in the Treatment of Dysphagia

Primary Care Physician

Radiologist

Physical Therapist

Occupational Therapist

Dietician

Gastroenterologist

Patient/family counseling and followup

Assessment may involve the SLP, the gastroenterologist (manometry), the otolaryngologist (endoscopy), and the radiologist (videofluoroscopy). Non oral feeding may be necessary. Rehabilitation may be required to bring the patient back to full oral intake, and nutritional support should be provided to facilitate recovery. Physical and occupational therapy will provide assistive devices for feeding, as well as for seating and positioning.

Patient and family counseling and follow-up will inform the family about the details of the problem. Family members and the patient, if feasible, will be taught how to do thermal stimulation, oral motor exercises, etc.


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Other courses in the Neuroscience on the Web series:
CMSD 620 Neuroanatomy | CMSD 636, Neuropathologies of Language and Cognition

Copyright, 1998-2013. Patrick McCaffrey, Ph.D..