Speech Pathologist Reference Sheet on Treatment of Dysphagia

Oral Motor Function 

The following exercises should be performed 10 times each 2-3 times a day.

Lips – reduced lip sensation, strength, and ROM may result in drooling, lip biting and pocketing, as well as anterior loss.

1. Assess labial musculature by pressing lips tightly around a tongue depressor as the SLP tries to remove it
2. Have patient close eyes. Lightly touch each of the 4 quadrants of the upper and lower lips with a tongue depressor or cotton swab. This will assess lip sensitivity.
3. Smile. If patient can produce a smile, have them say “ee”
4. Pucker. If patient is unable to pucker, have them say “oo”
5. Alternate between “ee” and “oo”
6. Say the syllable “puh” as quickly as possible to determine ability to obtain closure of lips. If patient can do this, have them say, “Bill met Barbie at the beach”.
7. Open mouth but try to hold a pucker
8. Close lips around the tongue blade
9. Press lips together “MMMMMMM”

Cheeks –reduced cheek sensation, strength, and range of motion may result in pocketing of food or biting cheek.

Before beginning exercises, observe patients facial asymmetry. Check buccal musculature by:

1. Have them puff their cheeks up with air. Be sure to check velum function prior to this exercise because reduced velopharyngeal seal can result in decreased oral pressure and may contribute to patient’s inability to puff cheeks.
2. Assess sensitivity of cheeks by touching random locations with a cotton swab
3. Pretend to “swish mouth wash around in the mouth”
4. Push cheeks out with tongue blade
5. Suck cheeks in

Tongue – reduced tongue sensation, strength, and ROM can result in the inability to manipulate bolus in oral cavity, it can also result in residue on hard palate and pocketing.

1. Assess sensitivity by touching various areas of the tongue
2. Stick out tongue – check for deviation, fatigue, and fasciculation’s
3. Move tongue from left to right – check for ROM, speed, and coordination
4. Elevate tip of tongue – maintain for 3 seconds. Can also elevate tip to alveolar ridge and move it anteriorly to posteriorly along palate.
5. Stick out tongue and point down to chin – maintain for 3 seconds
6. Move tongue tip into right and left cheek – patient must bulge buccal musculature
7. Tongue retraction – humping it posteriorly and hold for 3 sec
8. Lingual resistance – Extend tongue forward and push against tongue depressor, lollipop, or finger. Hold for 1 sec then relax, repeat 5-10 times. This can also be done for tongue push up, push from side to side.
9. Mid tongue – suck in cheeks while lifting tongue up and back
10. Mid tongue – 3 sec prep set
11. Back tongue – chin tuck for posterior leakage
12. Diadochokenetic rate

Soft Palate – reduced sensation, strength, and ROM can result in reduced gag reflex, hypernasal speech, nasal reflux, and premature spillage

1. Phonate “ah” in isolation and repetitive pattern – observe elevation
2. Assess for hypernasality
3. Assess gag reflex

Velar Exercises

1. Thermal Stim
2. Suck/swallow
3. Effortful “guh”
4. High pitch ‘eeee
5. Snore

Jaw strength and ROM – Necessary for rotary movements involved in mastication. Can be used with patients exhibiting reduced oral ROM or masseter weakness.

Mandible – mastication/ side-to-side and rotary action is required for cohesive boluses

1. Open mouth wide, hold for 3 seconds
2. Open and close 5 times quickly
3. Move jaw from left to right
4. Move jaw in a circular motion as though rotary chewing. Repeat 5-10 times

Patients who have Parkinson’s disease or ALS often have reduced Mandibular ROM due to general muscle weakness.

Pharyngeal Exercises and Strategies

Valleculae/Tongue Base

1. Yawn
2. Prolong /i/ or “eeeee” with a high pitch quality
3. Pretend to gargle
4. /k/ and /g/ words/sounds. Say “guh”
5. Pull/hump tongue base posteriorly
6. Head tilt or turn as appropriate
7. Chin tuck if appropriate

PES/UES/Cricopharyngeal sphincter if related to laryngeal elevation!

1. Effortful/dry/hard swallow
2. Alternate solids and liquids if appropriate
3. Head turn or tilt if appropriate
4. Chin thrust (not chin tuck!)
5. Hyolaryngeal exercises if it is a neurological involvement (see below)
6. Mendelsohn Maneuver or E-Stim
7. Myotomy as a least resort

Pharyngeal Posterior wall

1. Masaka (protrude tongue between teeth – hold – swallow hard
2. Repeat and increase rate of swallow
3. Thermal Stim
4. Alternate solids and liquids if appropriate
5. Expectoration

Pharyngeal Pyriform

1. Head turn to damaged side if appropriate
2. Tilt head to stronger side if appropriate
3. Alternate solid and liquids if appropriate
4. Push against mandible while swallowing
5. Successive swallow

Laryngeal or Hyolaryngeal exercises

1. Lie flat – raise head – look at toes/feet – hold
2. Mendelsohn Maneuver or E-Stim
3. Falsetto exercises
4. Adduction ex while lifting or pushing
5. Supraglottic swallow if appropriate
6. Effortful swallows
7. Mandibular protrusion – hold
8. Posterior lingual elevation
9. Valsalva maneuver (breath hold)
10. Resistive jaw opening and closing exercises

Esophagus

Esophageal Phase training

1. Bend forward and initiate an effortful swallow
2. Food/ liquid textures as well as PO timing.