Dysphagia Treatment Techniques/Strategies
Dysphagia Treatment is decided upon once a diagnosis is confirmed however many facets should be involved in that determination The clinician will choose a treatment program, based on the etiology, mental and physical capacity, and quality of life. They should discuss the treatment protocol with the patient and their family; how it will help them achieve the safest and least restrictive diet, what's happening to them anatomically, etc., and present all treatment options available for their specific swallowing problem.
It's vital to note that swallowing treatment is NOT one size fits all. Along with knowing the type and characterizations of your type of dysphagia, we also take into consideration everything that has and is going on with the patient internally and externally. Past medical history, current diagnosis, current state of health, awareness, physical and mental abilities, and much more goes into deciding ones' treatment course. Most importantly it's necessary to know beyond a reasonable doubt what is happening internally with the swallow physiology before deciding to apply any of the below strategies, otherwise one may do more damage than good as it may not be the appropriate fit for the patient. The only way to know what is going on beyond the anterior oral stage is to get an internal view via instrumentation. You can not treat what you don't see.
The best way to treat a swallowing disorder, is to swallow! By refraining from swallowing or put as NPO for an extended amount of time, the swallowing muscles can atrophy and weaken.
It's vital to note that swallowing treatment is NOT one size fits all. Along with knowing the type and characterizations of your type of dysphagia, we also take into consideration everything that has and is going on with the patient internally and externally. Past medical history, current diagnosis, current state of health, awareness, physical and mental abilities, and much more goes into deciding ones' treatment course. Most importantly it's necessary to know beyond a reasonable doubt what is happening internally with the swallow physiology before deciding to apply any of the below strategies, otherwise one may do more damage than good as it may not be the appropriate fit for the patient. The only way to know what is going on beyond the anterior oral stage is to get an internal view via instrumentation. You can not treat what you don't see.
The best way to treat a swallowing disorder, is to swallow! By refraining from swallowing or put as NPO for an extended amount of time, the swallowing muscles can atrophy and weaken.
Compensatory Strategies
Diet Modifications based on what the patient can manage safely.
- Thin/Thickened Liquids: nectar thick, honey thick, and pudding thick.
- Thin/Thick puree food
- Regular diet
- Chopped/Mechanical soft diet
- Alternative texture/temperature
- Alternate liquids and solids: to eliminate residue.
- Throat clearing: to eliminate residue.
- Tube Feedings
Parenteral & Enteral Nutrition
- Alternate tube feedings with and without PO intake
Consider environmental/stress factors.
- When/where/how the pt is eating/being fed
- Consider pt's position during meals
- Most importantly, consider pt's etiology and how it may be effecting PO intake
- Thin/Thickened Liquids: nectar thick, honey thick, and pudding thick.
- Thin/Thick puree food
- Regular diet
- Chopped/Mechanical soft diet
- Alternative texture/temperature
- Alternate liquids and solids: to eliminate residue.
- Throat clearing: to eliminate residue.
- Tube Feedings
Parenteral & Enteral Nutrition
- Alternate tube feedings with and without PO intake
Consider environmental/stress factors.
- When/where/how the pt is eating/being fed
- Consider pt's position during meals
- Most importantly, consider pt's etiology and how it may be effecting PO intake
Thickening Liquids
Thickening a patients liquids is a decision that should not be made lightly and should always be individualized per patient medical history. As we know, the thicker the viscosity, the slower it moves therefore making it easier to swallow. However, if this thicker liquid is aspirated it may take three times longer to recover if aspiration pneumonia develops (Robbins, et.al, 2008). Please read the page devoted to liquids for further information regarding this phenomenon. If it is determined via instrumentation assessment that the patient can safely swallow thickened liquids and you recommend a thickened liquid diet, it is necessary to monitor the amount of liquids the patient drinks in order to keep hydrated. Thickened liquids is not appetizing or appealing and most patients rather refuse to drink at all and dehydrate causing a decline in health. Monitor hydration by keeping eye on the patients creatine blood levels.
That said, if a patient is willing and proves to drink the thickened liquids, there are many things they need to be aware of:
-Some food items are liquid in nature, such as soups, so you must thicken these items to the diagnosed consistency.
-Thickened liquids that are hot when you thicken them, can get thicker as they cool so you may need to change the way you thicken hot liquids.
- Thickening liquids also is dependent on the weather outside! With increased humidity or chill, thickening will have to alter.
-If you allow thickened liquids them to sit, they will thicken.
-If you notice tiny clumps/lumps in the thickened liquid, this defeats the purpose of thickening a liquid as they did not mix well with the liquid.
-Creatine/BUN blood levels to monitor for adequate hydration
Behavioral Approaches for Dysphagia
-Alternate small bites with small sips.
-Small bites/small sips -
-Liquid wash to clear oral, pharyngeal, valleculae, etc. residue.
-Dry swallow - clear residue
-Multiple swallows - to clear residue
-Small bites/small sips -
-Liquid wash to clear oral, pharyngeal, valleculae, etc. residue.
-Dry swallow - clear residue
-Multiple swallows - to clear residue
Postural Changes
Postural strategies are used to help change the way bolus flows through the swallowing mechanism.
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 VFFS/MBS; this way you can get an idea of how well or what will really work or not work for that patient.
Head Tilt
Move the head to better side, bolus is redirected through oral cavity and oral bolus transport is improved.
Head Rotation
Twist head to weaker side, so weaker side is closed off and bolus travels to stronger side. Avoids pocketing as well. When compared with a neutral head position, rotating the head to the left or right increased pharyngeal contraction pressure at the level of the valleculae and pyriform sinuses on the side of rotation, decreased UES resting pressure on the side opposite rotation, increased duration from peak pharyngeal pressure in the pyriform sinuses to the end of UES relaxation, and increased UES anterior-posterior opening diameter
Chin Tuck
Put chin down to move bolus anterior. It prevents premature spillage and widens the valleculae so spillage hesitates there giving more time for VF's to close thereby reducing the risk of aspiration.
Side Lying
The existing rational for use of the side-lying technique is that lying down will hold residual bolus material to the pharyngeal walls instead of allowing it to drop into the airway, which may more readily occur as a result of gravity in an upright position [4]. Logemann recommends the use of side lying when pharyngeal contraction is reduced such that residue is observed throughout the pharynx [4]. The side-lying posture was not included in any of the studies reviewed on LDRR on healthy swallowing; therefore, the physiological basis of this posture bears no support from exploratory research.
Head Back
Bypass oral stage by utilizing gravity to clear oral cavity
Head Tilt
Move the head to better side, bolus is redirected through oral cavity and oral bolus transport is improved.
Head Rotation
Twist head to weaker side, so weaker side is closed off and bolus travels to stronger side. Avoids pocketing as well. When compared with a neutral head position, rotating the head to the left or right increased pharyngeal contraction pressure at the level of the valleculae and pyriform sinuses on the side of rotation, decreased UES resting pressure on the side opposite rotation, increased duration from peak pharyngeal pressure in the pyriform sinuses to the end of UES relaxation, and increased UES anterior-posterior opening diameter
Chin Tuck
Put chin down to move bolus anterior. It prevents premature spillage and widens the valleculae so spillage hesitates there giving more time for VF's to close thereby reducing the risk of aspiration.
Side Lying
The existing rational for use of the side-lying technique is that lying down will hold residual bolus material to the pharyngeal walls instead of allowing it to drop into the airway, which may more readily occur as a result of gravity in an upright position [4]. Logemann recommends the use of side lying when pharyngeal contraction is reduced such that residue is observed throughout the pharynx [4]. The side-lying posture was not included in any of the studies reviewed on LDRR on healthy swallowing; therefore, the physiological basis of this posture bears no support from exploratory research.
Head Back
Bypass oral stage by utilizing gravity to clear oral cavity
| pttypepostural.png |
Therapeutic Dysphagia Strategies
Sensory Strategies
Sensory strategies include changing volume, texture, temperature, or taste therefore changing the sensory feedback provided by the bolus (Logemann, 1989, '97).
For patients with apraxia of the swallow, it may be best to let them feed themselves allowing the swallow to be more automatic.
Thermal Stimulation
Used if there is a delayed swallow to increase sensitivity.
How to do Thermal Stimulation
Laryngeal Mirror must be very cold, (sitting in ice for a long time before seeing pt). Put laryngeal mirror in the ice, Stroke the area around pt's faucial pillars /arches, base of tongue, and margin of velum. Strokes should be quick, back and forth motions. When finished with each rep, pt should swallow some bolus/liquid. Eventually this will wear off, and it doesn't work for every pt. Usually lasts for 4 - 5 swallows. Adjustments to consider while doing thermal stim, is adding "sour" into the mix. Remembering sensory stimulation as well. Adding sensory stim to the thermal stim in one. This can be done in several ways. I've done it via adding lemon aide powder directly to the ice, mixing it in the apple-sauce used as the bolus. I've also used "sweet" as a sensory stim, adding sugar to the apple sauce. The components here are "cold" and "sensory"
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.
Sensory strategies include changing volume, texture, temperature, or taste therefore changing the sensory feedback provided by the bolus (Logemann, 1989, '97).
For patients with apraxia of the swallow, it may be best to let them feed themselves allowing the swallow to be more automatic.
Thermal Stimulation
Used if there is a delayed swallow to increase sensitivity.
How to do Thermal Stimulation
Laryngeal Mirror must be very cold, (sitting in ice for a long time before seeing pt). Put laryngeal mirror in the ice, Stroke the area around pt's faucial pillars /arches, base of tongue, and margin of velum. Strokes should be quick, back and forth motions. When finished with each rep, pt should swallow some bolus/liquid. Eventually this will wear off, and it doesn't work for every pt. Usually lasts for 4 - 5 swallows. Adjustments to consider while doing thermal stim, is adding "sour" into the mix. Remembering sensory stimulation as well. Adding sensory stim to the thermal stim in one. This can be done in several ways. I've done it via adding lemon aide powder directly to the ice, mixing it in the apple-sauce used as the bolus. I've also used "sweet" as a sensory stim, adding sugar to the apple sauce. The components here are "cold" and "sensory"
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.
Motoric & Coordination
Various exercises can be done to improve the range of motion (ROM) of the lips, tongue, and jaw, to improve coordination, to improve vocal fold adduction, laryngeal elevation, or tongue base retraction.
Range of Motion exercises
assist with structural/tissue damage
Resistance exercises
strengthen muscles
Resistance Exercises
involve pushing against tongue depressor or spoon to create "resistance"
Falsetto Exercises
used to increase laryngeal elevation. Involve repetitive /i/ or /ng/.
Range of Motion exercises
assist with structural/tissue damage
Resistance exercises
strengthen muscles
Resistance Exercises
involve pushing against tongue depressor or spoon to create "resistance"
Falsetto Exercises
used to increase laryngeal elevation. Involve repetitive /i/ or /ng/.
Swallowing Maneuvers
Various swallowing maneuvers are used to change the swallow physiology. Each swallow maneuver is utilized for very specific diagnoses and should only be used after discussing with your Speech Language Pathologist.
Supraglottic Swallow
Voluntary breath hold closes VF’s before and during swallow thus protecting the airway. Before pt resumes breathing, pt will clear throat. Patient will expectorate the residual material left above Pharynx after the swallow.
INSTRUCTIONS
1. Take a breath in.
2. Hold your breath after you inhale (lightly cover your tracheostomy tube, if present).
3. Keep holding your breath while you swallow.
4. Clear your throat immediately after swallow before breathing.
5. Swallow again.
Perform each food/liquid swallow.
Perform ___ times throughout the day.
Hold your breath tightly. Now, swallow twice, release your breath with a sharp cough, and swallow again.
␣ Repeat this exercise five times.
References
Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424.
Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993). Normal laryngeal valving patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20.
McConnel, F.M., Mendelsohn, M.S., & Logemann, J.A. (1987). Manofluorography of deglutition after supraglottic laryngectomy. Head and Neck Surgery, 5, 142-150
INSTRUCTIONS
1. Take a breath in.
2. Hold your breath after you inhale (lightly cover your tracheostomy tube, if present).
3. Keep holding your breath while you swallow.
4. Clear your throat immediately after swallow before breathing.
5. Swallow again.
Perform each food/liquid swallow.
Perform ___ times throughout the day.
Hold your breath tightly. Now, swallow twice, release your breath with a sharp cough, and swallow again.
␣ Repeat this exercise five times.
References
Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424.
Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993). Normal laryngeal valving patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20.
McConnel, F.M., Mendelsohn, M.S., & Logemann, J.A. (1987). Manofluorography of deglutition after supraglottic laryngectomy. Head and Neck Surgery, 5, 142-150
Super-Supraglottic Swallow
The Super - Supraglottic Swallow is the Supraglottic swallow with Effortful swallow
Effortful breath hold tilts arytenoids forward closing the airway entrance before and during the swallow
Used to reduce hyolaryngeal excursion (reduced airway closure)
INSTRUCTIONS
Ask pt to inhale and hold their breath very tightly, bearing down. Instruct pt to continue to hold breath lightly while swallowing. (immediately after the swallow the pt should cough to clear any residue)
WARNING: Pt's with high blood pressure should not do this maneuver as bearing down may raise blood pressure.
References
Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993). Normal laryngeal valving patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20.
Ohmae, Y., Logemann, J.A., Kaiser, P., Hanson, D.G., & Kahrillas, P.J. (1996). Effects of two breath-holding maneuvers on oropharyngeal swallow. Annals of Otology, Rhinology, and Laryngology, 105, 123-131.
Effortful breath hold tilts arytenoids forward closing the airway entrance before and during the swallow
Used to reduce hyolaryngeal excursion (reduced airway closure)
INSTRUCTIONS
Ask pt to inhale and hold their breath very tightly, bearing down. Instruct pt to continue to hold breath lightly while swallowing. (immediately after the swallow the pt should cough to clear any residue)
WARNING: Pt's with high blood pressure should not do this maneuver as bearing down may raise blood pressure.
References
Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993). Normal laryngeal valving patterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20.
Ohmae, Y., Logemann, J.A., Kaiser, P., Hanson, D.G., & Kahrillas, P.J. (1996). Effects of two breath-holding maneuvers on oropharyngeal swallow. Annals of Otology, Rhinology, and Laryngology, 105, 123-131.
Shaker Manuever
Used to increase laryngeal excursion and width and duration of UES opening, Can be used on patients who exhibit reduced upper esophageal sphincter opening and who demonstrate food residue in the pyriform sinuses.
INSTRUCTIONS
Lie flat on your back with no pillow under your head. Lift your head to look at your toes, while keeping your shoulders. Hold the position for 30 seconds and then release.
Do this 3 times
Lift your head and look at your toes and let your head go back down as if doing sit-ups for your neck.
Repeat this 30 times
Rest for one minute
Repeat this for two more sets of 30 for a total of 90 repetitions
Do the whole regimen at least 5 times per day.
Intensity is important in achieving improvement.
WARNING: MD clearance needed for patients with HTN, Cardiac problems or Cervical spine problems Patients with neck problems (e.g.- arthritis) may not be able to perform this exercise.
References
Easterling, C., Kern, M., Nitschke, T., Grande, B., Kazandjian, M., Dikeman, K., Massey, B.T., & Shaker, R. Restoration of oral feeding in 17 tube fed patients by the Shaker Exercise. Dysphagia, 15: 105, 2000.
Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E., Hoffmann, R.G., Arndorfer, R.C., Hoffmann, C., & Bonnevier, J.
Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. AJR, 272: G1518-1522, 1997.
INSTRUCTIONS
Lie flat on your back with no pillow under your head. Lift your head to look at your toes, while keeping your shoulders. Hold the position for 30 seconds and then release.
Do this 3 times
Lift your head and look at your toes and let your head go back down as if doing sit-ups for your neck.
Repeat this 30 times
Rest for one minute
Repeat this for two more sets of 30 for a total of 90 repetitions
Do the whole regimen at least 5 times per day.
Intensity is important in achieving improvement.
WARNING: MD clearance needed for patients with HTN, Cardiac problems or Cervical spine problems Patients with neck problems (e.g.- arthritis) may not be able to perform this exercise.
References
Easterling, C., Kern, M., Nitschke, T., Grande, B., Kazandjian, M., Dikeman, K., Massey, B.T., & Shaker, R. Restoration of oral feeding in 17 tube fed patients by the Shaker Exercise. Dysphagia, 15: 105, 2000.
Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E., Hoffmann, R.G., Arndorfer, R.C., Hoffmann, C., & Bonnevier, J.
Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. AJR, 272: G1518-1522, 1997.
Masako
Used to improve posterior pharyngeal constriction wall by making contact with the BOT. Tongue is placed b/w teeth.
INSTRUCTIONS
Tongue hold between teeth while swallowing.
The below 2 published studies examine the effectiveness of the Masako, however neither study supports the theory of improving TBR:
References
Fujiu M, Logemann J: E?ect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol 5:23-30, 1996: Authors concluded that the Masako improved posterior pharyngeal wall bulging which could improve pharyngeal pressure generation by making contact with the BOT.
Doeltgen, S. H., Witte, U., Gumbley, F., & Huckabee, M. (2009). Evaluation of manometric measures during tongue-hold swallows. American Journal of Speech-Language Pathology, 18, 65-73: Examined manometric measures during the Masako and concluded that while the technique should not be done during PO trials as it reduces oropharyngeal pressure generation, there may be increased pharyngeal constrictor strength after regular training.
INSTRUCTIONS
Tongue hold between teeth while swallowing.
The below 2 published studies examine the effectiveness of the Masako, however neither study supports the theory of improving TBR:
References
Fujiu M, Logemann J: E?ect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. Am J Speech Lang Pathol 5:23-30, 1996: Authors concluded that the Masako improved posterior pharyngeal wall bulging which could improve pharyngeal pressure generation by making contact with the BOT.
Doeltgen, S. H., Witte, U., Gumbley, F., & Huckabee, M. (2009). Evaluation of manometric measures during tongue-hold swallows. American Journal of Speech-Language Pathology, 18, 65-73: Examined manometric measures during the Masako and concluded that while the technique should not be done during PO trials as it reduces oropharyngeal pressure generation, there may be increased pharyngeal constrictor strength after regular training.
Effortful Swallow
Used to increase BOT retraction and pressure during the pharyngeal phase of the swallow and reduce the amount of food residue in the valleculae of the throat & thereby possibly aspiration/penetration. Tell patient to swallow hard. Effort increases posterior tongue movement thus improving bolus clearance from the valleculae
INSTRUCTIONS
Swallow as hard as you can with food or saliva. Push as hard as you can with the tongue against the roof of your mouth while you swallow.
Perform with each food/liquid swallow.
Perform ___ times throughout the day.
References
Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424.
Shanahan, T.K., Logemann, J.A., Rademeker, A.W., Pauloski, B.R., & Kahrillas, P.J. (1993). Chin down posture effects on aspiration in dysphagic patients. Archives of Physical Medicine and Rehabilitation, 74, 736-739.
INSTRUCTIONS
Swallow as hard as you can with food or saliva. Push as hard as you can with the tongue against the roof of your mouth while you swallow.
Perform with each food/liquid swallow.
Perform ___ times throughout the day.
References
Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424.
Shanahan, T.K., Logemann, J.A., Rademeker, A.W., Pauloski, B.R., & Kahrillas, P.J. (1993). Chin down posture effects on aspiration in dysphagic patients. Archives of Physical Medicine and Rehabilitation, 74, 736-739.
| effortfulsw_forpt.pdf |
Mendelsohn Maneuver
Used to Increase laryngeal elevation and thereby increase the extent and duration of cricopharyngeal opening. Patients who exhibit reduced laryngeal movement and consequent reduced cricopharyngeal opening. Keeps larynx elevated longer prolonging the opening of upper esophageal sphincter. The Mendelsohn Maneuver helps to normalize the timing of the pharyngeal swallow and improve the coordination of the swallow.
INSTRUCTIONS
1. Swallow normally. Feel the larynx (voice box) lift during the swallow.
2. On the next swallow, feel your larynx (voice box) elevating and hold it up with your neck muscles. Do not try to lift the larynx early. Let the larynx lift normally and then hold it up so that it does not drop for ___ seconds. Complete the swallow.
Perform with each food/liquid swallow.
Perform ___ times throughout the day.
References
Kahrilas, P.J., Logemann, J.A., Krugler, C., & Flanagan, E. (1991). Volitional augmentation of upper esophageal sphincter opening during swallowing. American Journal of Physiology, 260, G450-456.
Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424.
Logemann, J.A., & Kahrilas, P.J. (1990). Relearning to swallow post CVA: Application of maneuvers and indirect feedback: A case study. Neurology, 40, 1136-1138.
INSTRUCTIONS
1. Swallow normally. Feel the larynx (voice box) lift during the swallow.
2. On the next swallow, feel your larynx (voice box) elevating and hold it up with your neck muscles. Do not try to lift the larynx early. Let the larynx lift normally and then hold it up so that it does not drop for ___ seconds. Complete the swallow.
Perform with each food/liquid swallow.
Perform ___ times throughout the day.
References
Kahrilas, P.J., Logemann, J.A., Krugler, C., & Flanagan, E. (1991). Volitional augmentation of upper esophageal sphincter opening during swallowing. American Journal of Physiology, 260, G450-456.
Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424.
Logemann, J.A., & Kahrilas, P.J. (1990). Relearning to swallow post CVA: Application of maneuvers and indirect feedback: A case study. Neurology, 40, 1136-1138.
| mendelsohnman_forpt.pdf |
Jaw Opening Exercise
Used to improve upper esophageal sphincter (UES) opening during the swallow. Patients that have poor hyoid elevation and/or poor UES opening due to decreased hyoid elevation.
INSTRUCTIONS
1. Hold the jaw in the maximally opened position for 10 seconds.
2. Rest for 10 seconds.
3. Repeat 5 times.
4. Do two sets a day.
WARNING: “When the jaw is closed, the superior head of the lateral pterygoid muscle maintains contraction in order to properly position the articular disk. When the jaw is fully open, however, the superior head is controlled in a relaxed position. Thus, this exercise is probably safer when patients open their jaw to the fullest extent. However, dislocation of the mandibular joint could occur if aging has caused some wear of the articular fossa or condyle, or degeneration of the articular disk. Accordingly, patients with a history of mandibular joint dislocation should not perform this exercise” (Wada, et al 2012).
Click here to read blog post & get handout.
References
Satoko Wada, Haruka Tohara, Takatoshi Iida, Motoharu Inoue, Mitsuyasu Sato, Koichiro Ueda, Jaw-Opening Exercise for Insufficient Opening of Upper Esophageal Sphincter, Archives of Physical Medicine and Rehabilitation, Available online 10 May 2012, ISSN 0003-9993, 10.1016/j.apmr.2012.04.025.
INSTRUCTIONS
1. Hold the jaw in the maximally opened position for 10 seconds.
2. Rest for 10 seconds.
3. Repeat 5 times.
4. Do two sets a day.
WARNING: “When the jaw is closed, the superior head of the lateral pterygoid muscle maintains contraction in order to properly position the articular disk. When the jaw is fully open, however, the superior head is controlled in a relaxed position. Thus, this exercise is probably safer when patients open their jaw to the fullest extent. However, dislocation of the mandibular joint could occur if aging has caused some wear of the articular fossa or condyle, or degeneration of the articular disk. Accordingly, patients with a history of mandibular joint dislocation should not perform this exercise” (Wada, et al 2012).
Click here to read blog post & get handout.
References
Satoko Wada, Haruka Tohara, Takatoshi Iida, Motoharu Inoue, Mitsuyasu Sato, Koichiro Ueda, Jaw-Opening Exercise for Insufficient Opening of Upper Esophageal Sphincter, Archives of Physical Medicine and Rehabilitation, Available online 10 May 2012, ISSN 0003-9993, 10.1016/j.apmr.2012.04.025.
Instrumental
As discussed earlier in the Dysphagia section, imaging is used to evaluate, and can also be used to find strategies that may work to help with the Dysphagia. Then there are other types of instruments to provide immediate feedback such as Surface Electromyography (SEMG), tongue bulbs and/or Vital Stimulation or EStim. Most of the time Instrumental treatment is done in tandem with a Compensatory Strategy, Postural Change, or some sort of Stimulation therapy.
BioFeedback
SEMG - electrodes placed on thyroid lamina while pt swallows and can visually see how strong/weak their swallow may be.
Videofluoroscopy
Muscle Stimulation
Newer techniques such as NMES and Vitalstim have been introduced and are more widely being used. See My Blog for recent studies. Though controversial, many clinicians feel they have seen change in their pt's with use of these types of protocols. They require training and certification. Recent studies suggest that NMES is most efficient when utilized in conjunction with therapeutic dysphagia strategies.
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3. Updated Dysphagia Treatment
4. Dysphagia Patient Handout Bundle
5. Videoflouroscopy Evaluation Form
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The difference between this document and the Dysphagia Treatment by Rationale is that the Dysphagia Treatment with Rationale is meant as a simple treatment cheat sheet so the clinician can carry it around the hospital or SNF for reference or guided treatment.
The Updated Dysphagia Treatment II doc includes all of the same information as the original document, Dysphagia Treatment by Rationale, plus clinical observations for each swallowing symptom/diagnosis as well as motoric and sensory innervations all placed in an easy to read six page chart.
The Updated Dysphagia Treatment II doc includes all of the same information as the original document, Dysphagia Treatment by Rationale, plus clinical observations for each swallowing symptom/diagnosis as well as motoric and sensory innervations all placed in an easy to read six page chart.
Bedside Swallow Examination
The Adult Bedside Swallow Examination is a two sided evaluation page which includes: a full Oral Peripheral Examination, a brief Cognitive - Linguistic Examination adapted from the Boston Diagnostic Exam and a full bedside Swallow Exam. The bedside swallow covers all possible boluses and physiological observations. The bedside swallow can easily be used and transferred as an official consult and is worth discussing with your apartment heads as it is a BIG time saver!
Videofluoroscopy (VFFS)/Modified Barium Swallow Study (MBSS) Examination Report
This easy to read, easy to fill in VFFS form is structured to include all consistencies and all of the main physiologic components involved in a VFFS/MBSS Exam. There is also plenty of room for comments when there are unique findings. This two (2) page form is also a good study guide for students just starting out and wanting to learn about VFFS/MBSS.