56 terms

Swallow Tx

focus of swallow tx depends on which aspects of swallow are disordered, including:
1. muscle strength and ROM
2. timing
3. coordination of oropharyngeal movements
should tx objectives be specific to the physiologic cause of the s/s?
why use compensatory techniques
-to compensate for lost function/timing
-to control flow of food to help eliminate s/s w/o changing physiology of the swallow
-most oft used by pt during meals
some compensatory techniques
changes in:
1. posture
2. increase sensory input
3. timing and coordination
4. food placement
5. food presentation
6. food consistency
why use the chin down/chin tuck postural adjustment?
-for use w/decreased oral or back of tongue control

-pt gets more volitional control of bolus for propulsion
-widens valleculae in many pts
-pushes epiglottis posteriorly, increasing airway protection
-narrows distance from epiglottis to pharyngeal wall and laryngeal entrance
chin down vs. chin tuck
chin down=looking down

chin tuck=retraction of mandible
-increases airway protection more than chin down
is more complete chin tuck better?
negatives of chin tuck
-increased risk of aspiration in those w/dementia, OD and even healthy individuals
-MUST be tested with VFSS prior to use
who to use head rotation with?
-those with unilateral pharyngeal paresis or paralysis

-pt. should rotate head all the way to damaged side () degrees if able

-this narrows the pyriform sinus on that side
-it increases VF closure
-reduces resting tone in cricopharyngeal muscle (so can be used to assist in cricopharyngeal opening
in chin tuck, there is a delayed UES opening, resulting in increased residue (t or f)
lateral head tilt
used with hemiparesis of tongue and pharynx
(tilt head to intact side for directing bolus)
posterior head tilt
-rarely recommended
-may help those with decreased ability to propel bolus posteriorly to initiate swallow (lets gravity assist)
-maybe for oral cancer pts
external pressure to cheek
-compensates for decreased muscle tone
-decreases material falling into weaker lateral sulcus
-the tactile cue helps remind pt to check lateral sulcus for material
labial and chin support
place finger under chin or lower lip to help maintain closure of mouth, give jaw stability
use of sour bolus
-can improve onset of oral and/or pharyngeal stage swallows
-increases spontaneous swallows per minute compared to water
-best for pts w/o dementia
cold bolus
-increased speed of swallow initiation, timing and coordination
-can use ice and ice water, finger of glove, etc.
another sensory compensation
-causes increased hyoid movement (but this decreased over time)
-laryngeal penetration and oral-pharyngeal residue and time to laryngeal closure were all reduced
antoehr sensory compensation
-reduces laryngeal penetration and asp in some people
-may be equivalent to nectar thick liq
ideas to improve timing and coordination
1. 3 second prep (1, 2, 3, swallow!)
2. metronome
3. suck-swallow (have them suck and then swallow)
4. anterior bolus hold (if they are afraid to swallow-to not let spillage occur)
food placement options
1. on stronger side
2. in middle of tongue
3. as far back on tongue as possible
4. only use spoon wiht liquids
5. no straws
food presentation ideas
-different presentations
-alernate liq and solids
-multiple swallows per bolus
what are facilitation techniques
*designed to improve function--to change swallow physiology
* may or may not be used during meals
* some techniques are both comp and facilitation
-oral motor exercises
-laryngeal exercises
-exercises for increasing laryngeal closure
some goals of exercise;
-speed of movement
-bolus clearance
-some combo of the above
oral motor exercises
1. bolus maintenance (in oral cavity)
2. bolus preparation/manipulation
3. bolus propulsion and clearance
ho to work on bolus maintenance
1. labial control exercises
2. lingual control exercises
bolus preparation/manipulation exercises
1. chewing exercises to control and manipulate bolus
boluls propulsion and clearance exercises
1. isometric lingual exercises (increase tongue strength and bulk)
-can use IOPI or MOST for this
-set target swallow strength at 60% of max
-begin w/series of 5t rials w/rests btwn
-increase training load by no more than 10% per week
-6-8 weeks for results
-IOPI for 8 wks increases oral pressure during swallow and safety of swallow
-MOST is still in development, but similar
-use tongue depressor in lieu of those

-can also use expiratory muscle strength trainer (EMST) as progressive, load-bearing strength training device; is a 1-way, spring loaded pressure release valve that pt blows into; release set at 60-80% of max expiratory pressure;
-will improve expiratory breathing muscles
-increases activity of suprahyoids
-improved expiratory driving forces for cough
-also used as IMST (inspiratory muscle strength trainer)
-contra-indiations=pregnancy, untreated HTN, recent stroke, cardiac abnormalities, asthma, hx of collapsed lung, head/neck surgery, untreated GERD, s/s of heartburn..consult MD
EMST Method=
a. have pt take very deep breath
b. position device in mouth, pinch off nose
c. pt forcibly blows into device until valve pops
d. after every trial, ask about comfort, and light-headedness
e. establish proper resistance, then begin training
f. check for lip seal, expect inconsistency in training
g. min. 25 reps/day; 6 days/wk; 6+ wks

2. BOT exercises=
a. lingual isometrics are best
b. yawn: "pull tongue back during yawn and hold for a second" (yawn makes you want to swallow)
c. gargle "pull tongue back during a gargle and hold for a sec

3. PPW exercises=Masuko Maneuver (tongue hold)
-to increase forward movement of posterior pharyngeal wall
-ask pt to protrude tongue and hold it btwn teeth while swallowing
-done w/saliva swallows, NOT food (b/c it increases pharyngeal residue, shortens duration of airway closure and increases pharyngeal delay time)

4. laryngeal elevation exercises=
a. high-ptiched "ee" will see pharyngeal wall movement
b. pitch glides
c. Mendelsohn Maneuver (squeeze at height of swallow to keep larynx up high in neck)(to keep larynx at highest point during the swallow)
-use with those with reduced laryngeal movement or discoordinated swallow
-also opens the UES, and prolongs laryngeal elevation and UES opening
-normalizes timing of pharyngeal swallow events
a. swallow with your fingers lightly on your larynx
b. when larynx is at highest, hold it up by pushing your tongue hard against roof of mouth and keeping it there.
c. Hold the larynx lift for _____seconds

5. exercises to increase laryngeal closure (laryngeal adduction)
-same techniques used in voice tx (pushing, pulling, hard glottal attack)

a. Valsalva Maneuver (breath hold or effortful breath hold==>hold it like you're picking up a box on the floor)

b. supraglottic swallow (reduces laryngeal aspiration)
-closes at level of TVCs=used w/reduced or delayed VF closure or pharyngeal swallow
-take a breath
-let a little out
-hold your breath tightly
-swallow again

c. super-supraglottic swallow (reduces laryngeal penetration, for reduced closure of airway entrance; it tilts arytenoids forward)
-take a breath
-let it out
-hold breath as tightly as possible
-swallow, squeezing as tightly as possible
-swallow again
***supraglottic and supersupraglottic techniques were found to be contraindicated in stroke or CVD pts due to 86% having abnormal cardiac findings

6. effortful swallow-to get more movement of the base of tongue and help push food through pharynx
-also helps peristalsis of esophagus
-put tongue against roof of mouth, squeeze all of mouth and throat muscles as hard as possible as you swallow (swallow like you're swallowing a golf ball)

b. Showa Maneuver "take deep breath, hold it tightly, keep tongue contacting the roof of your mouth as tightly as you can and keep squeezing your throat"
-helps narrow orifeces at level of laryngeal entrance and VFs

7. LSVT (improve oral transit time and % of pharyngeal residue; reduce delay, improved tongue-base retraction w/reduction in amount of residue spilling from valleculae)
swallowing is a ____muscular activity
what is the Shaker exercise for?
-is an isotonic/isometric neck exercise
-is an augmentation method
Goal=increase deglutive UES opening
-strengthen UES opening muscles
-increase anterior excursion of larynx
-decrease hypopharyngeal intrabolus pressure
-decrease pharyngeal outflow resistance

how to do it:
1. do sustained head lifts followed by repetitive lifts. Do this 5x per day for 6 wks

*Sustained Head Lift
-lay in supine position, no pillow
-lift head and look at toes
-shoulders remain flat
-hold for 1 min, with 1 min rest
-do 3 x

*Repetitive head lift
-lay supine, no pillow under head
-pt is instructed to lift head up to look at toes, then back down (keep shoulders flat)
-30 consecutive reps, then rest 1 min
-do 3 x (90 situps total)

-neck pain (usually resolved w/in 1 wk)
-do NOT put chin to chest
if strength and endurance is the goal, how many reps and sets should we do?
*8-12 reps per set
*6-8 sets
if someone has fatigue toward end of meal, what to do?
-the prob is endurance
-strength train w/8-12 rep sets
what to do if someone has a weak swallow?
try 6-8 reps with a high-load demand
participating in strength training exercises may;
1. build foundation of force producing capacity
2. increase functional reserves
3. prime neuromuscular system for activity

*hope for transference
following cessation of exercise, elders have been shown to maintain performance above baseline for_____________
5-31 weeks
*if they continue exercise 1 x per week, they can maintain both strength and muscle size
why do thermal-tactile application?
-is compensatory and facilitating
-improves oral sensory awareness prior to swallow
-it alerts CNS, which lowers threshold of swallow centers
who are candidates for thermal-tactile application?
-should show radiographically defined delay on at least 2 consecutive swallows
how to measure effectiveness of thermal-tactile stim
1. oral-stage initiation time
2. oral transit time
3. pharyngeal delay time
4. reduction in stage transition duration
what is DPNS? which 3 reflex sites does it focus on?
-uses frozen probes to stimulate afferent sensory tracts
-deep pharyngeal neuromuscular stimulation; directly stimulates the pharyngeal musculature

focus on:
1. tongue base and bitter taste buds for improving tongue-base retraction reflex
2. soft palate muscles for improving palatal reflex and VP closure
3. superior and medial pharyngeal constrictor muscles to improve pharyngeal constrictor reflex

*activating these reflexes activates muscle group contractions which then strengthens the pharyngeal and lingual musculature
immediate benefits of DPNS
1. redirective/reflexive cough
2. improved saliva/phlegm mgmt
3. vocal quality
4. generalized sensation that pharyngeal muscles are "stronger" or "feel better"
sEMG (Surface electromyography)
-a record of electrical activity from muscle or group of muscles
-gives biofeedback
which muscle activity is picked up by the laryngeal elevators
(laryngeal elevators)
anterior belly of digastric
who to use the sEMG with?
1. cortical CVA
2. disuse atrophy
3. oral/pharyngeal CA
4. neurodegenerative disorders
5. pts with good cognition
tx with the biofeed may focus on
-muscle relaxation and inhibition
-coordination and patterning of muscle response (Mendelsohn, Masako, Effortful swallow)
how to measure tx progress with sEMG
1. change in peak amplitude during swallow
2. # times pt exceeds threshold
3. ability to sustain contraction for period or maintain relaxation for a period
coordination and patterning of muscle responses can be worked on with
-mendelsohn, masako, effortful swallow
NMES types
vitalstim and biber approach
FDA approved uses of NMES
-muscle re-eduation
-prevent/ retard disuse atrophy
-relax muscle spasm
-increase circulation
-prevent DVT (deep vein thrombosis)
-maintain, increase ROM
use of NMES for swallow
1. standard muscle re-education for small muscle groups
2. to prevent/retard disuse atrophy of suprahyoid musculature due to inactive periods (NPO)
clinical implications of vital stim
-sensory stim may aid all pts by giving extra input to CNS

-motor stim may serve as resistive tx in pts who can already raise the hyo-laryngeal complex by making them augment volitional elevation (add resistance to elevation)

***hyoid depression may put people at further risk as it opens the vestibule in those who don't have hyoid elevation
**high levels of stim that produce hyoid depression should only be used in pts with hyo-laryngeal elevation

***consider this early in recovery for less severe pts (greater change has been seen in less severe pts--those who could consume some food safely)

what is the McNeill Dysphagia Tx Program (MDTP)
-systematic, exercise-based tx framework for tx
-organizes simple exercises into progressive hierarchy (11 steps)
-15 sessions
-can terminate once reach FOIS (functional oral intake scale) level 6
-includes HW based on pt progress
-has specific criteria
-daily performance index (# swallows=amount of practice=intensity)
-80-100 swallows per session
-based on principles of exercise physiology and rehab:
(frequency, intensity, speech and coordination, varying planes of movement)
-may use compensatory maneuvers, which are faded as progression occurs; removes all crutches (spitting in cups ,liquid washes)
complete session=1 hr
*can be paired w/ NMES (good results)

-to challenge and normalize the swallow
does muscle stretch induce fiber growth?
and immobility causes atrophy
how to monitor outcome
FOIS (functional oral intake scale)
tx programs that meet exercise principles
lingual resistance
FITT principle
general guidelines
-approp seating
-small amounts
-no straws
-upright during and for 30 min after meal)
-head slightly flexed
-intact cognition
-good environ
criteria for dysphagia tx
1. must be alert and cooperative enough for 15 min of structured tx
2. for mass practice, need 45-60 min
3. be able to learn, memorize exercise program, or read written instructions or have helping family member available multiple times of day
4. must be able to demonstrate progress during the program