Speech Pathologist Reference Sheet on Treatment of Dysphagia

Therapy Techniques for some of the swallow dysfunctions seen on the MBSS

Improve Oral Sensory Awareness – Premature spillage can be a direct result of reduced oral sensation

1. Increase downward pressure of the spoon against the tongue when presenting food in the mouth
2. Presenting sour bolus
3. Presenting cold bolus
4. Presenting bolus requiring chewing
5. Presenting a larger volume bolus (3ml or more)
6. Allowing self-feeding so that hand-to-mouth movement provides additional sensory input
7. Thermal/tactile stimulation

Bolus control exercises are used to strengthen the muscles of the tongue and mouth and to enhance coordination.

Licorice Stick Chew

This involves tongue manipulation of a licorice stick. This must be done slowly and carefully. The SLP holds one end of the stick while the patient holds the other between the tongue and hard palate. The patient can manipulate the stick from one side of the mouth to the other and from front to back. Repeat at least 10 times. Once the patient is able to grossly manipulate the licorice stick, attach a lifesaver to a string (for smaller bolus manipulation) and do the same type of exercise.

Fruit Juice on Gauze Squeeze

This exercise will aid bolus propulsion. Soak a long, narrow roll of gauze in fruit juice. Do this only if the patient can tolerate liquid without aspirating. Place soaked gauze in the mouth and have him push upward and backward with the tongue to squeeze out the liquid. Hold the opposite end of the gauze to allow the patient to practice swallowing small amounts of liquid while manipulating solid substance.

Exercises to improve Gross Manipulation of material

1. 4×4 gauze pad or flexible licorice whip to manipulate one end while the clinician holds the other end. They should move it in a circular fashion from the middle of the mouth to the teeth on one side. This should be completed approximately 3 directions in 1 sec.
2. When they successfully complete that the same motions should be attempted with a Lifesaver candy tied to a thread held by the clinician,
3. Then be advanced to chewing gum. Without the clinicians control (Ford, Grotz, Pomerantz & Flannery, 1974)

Exercised to hold a cohesive bolus

After the patient has demonstrated the ability to manipulate the above, the patient can begin with a paste consistency, approximately 1/3 tsp. This patient is required to cup the tongue around the bolus. The bolus is placed on the tongue and he or she is asked to move the bolus around the mouth, without losing the material or allowing it to spread around the mouth.

• O-M Exercises, ROM exercises
• Tongue –tip Exercises

Bolus Propulsion Exercises

• Practice posterior propulsion.
• “gu” syllable drills

Difficulty with Lateralization

1. Exercises requiring manipulation
2. Positioning food in mouth
3. Posture

Vocal Fold Adduction Exercises – Adduction exercises are designed to increase the movement of the vocal folds (glottic level) and supraglottic contraction in order to prevent food and/or liquid from entering the airway. Most adduction exercises involve phonation, which adducts the vocal folds and extra cervical effort.

• Have patient to bear down against a chair with only one hand (rather than 2) and to produce a clear voice. After repeating this exercise 5x, the patient is asked to repeat “ah” 5 times with hard glottal attack on each vowel. These two exercises are repeated 3 times in a sequences, 5-10 times a day. It should be carefully explained that the patient can monitor improvements in laryngeal function by listening to the clarity of voice quality. It should also be explained that the exercises involving lifting, pushing, and vocalization are directly applicable to swallowing as these increase muscle activity in the larynx and are basic good laryngeal closure during swallowing. These exercises should continue for about 1 week.
• Lift and push with simultaneous voicing such as sitting and pulling up on the seat of a chair with both hands while prolonging phonation. The repeated glottal attack may be made more difficult by asking the patient to begin phonation with a hard “ah” and sustain the phonation with a clear smooth vocal quality for 5-10 sec.
• Finally ask the patient to practice a “pseudo” Supraglottic swallow – that is to take a breath, hold it, and cough as strongly as possible

In most cases, these exercises will effect improvement within 2-3 weeks. However a patient may require 6-8 months to attain adequate airway protection esp. if they have had a laryngectomy or extensive laryngeal damage.

Patients with high blood pressure should not use these exercises, as they can cause an increase in blood pressure.

Tongue Base Exercises

Impairment in tongue base retraction creates decreased pressure in the pharynx. Adequate pressure is needed to drive the bolus from the valleculae through the pharynx and into the esophagus. Reduction in tongue base retraction may cause unilateral or bilateral vallecular retention following the pharyngeal swallow. Also pharyngeal wall residue may occur because of impaired tongue base retraction and insufficient pressure in the pharynx.

• Pull the tongue straight back in the mouth as far as possible and hold it for 1 second
• Pretend to gargle, which pulls the tongue back
• Pretending to yawn, this also pulls the tongue back.
• Sustain a long /i/ sound, high pitch
• Effortful swallow also improves tongue base retraction
• g/ and /k/ sounds

Reduced labial closure

• Stretching lips in the /i/ position as far as possible and holding in extreme extension for 1 sec
• Pucker lips as tightly as possible and hold for 1 sec
• Close lips against a tongue blade or spoon and try to hold on to it while the clinicians try to remove it.

You should increase time to 2 seconds repeating 10 times a day

Reduced Buccal tension

Often noted with lateral sulcus residue and biting cheek walls

• Facial exercises
• External pressure on the affected cheek

Also see oral motor exercises in this booklet

Reduced mandibular movement

• Opening the jaw widely as possible and holding for 5 seconds
• Moving to jaw from side to side
• Moving the jaw around in a circle

Delayed or absent Triggering of the pharyngeal swallow

There are no standards to date that tell us what is considered to be mild, moderate, or a severe delay; however Perlman et al. 1994 suggest that a delay of less than 2 sec is mild and a delay greater than 5 sec is severe.

• Thermal stim – 3-4x a day for 5-10 minutes
• Tactile stim
• Suck-swallow
• Bolus with sensory characteristic such as sour or cold or volume

Pharyngeal Contraction

Pressure is created when the base of the tongue retracts towards the pharyngeal wall and the pharyngeal wall contracts toward the base of the tongue. The decreased pressure can cause material to collect on pharyngeal wall and in the pyriform sinuses.

No direct therapy improves laryngeal contraction at all levels. Compensatory techniques:

• Alternating liquid and semisolid or solid swallows so liquid washes the material of thicker consistency
• Limiting diet to liquids or thin pastes/puree (this is one reason why you always assess thin and thick puree)
• Following each swallow with several repetitive dry swallows
• Expectoration
• Tongue hold

Pharyngeal Paralysis – usually results in asymmetrical residue in the valleculae and pyriforms

• No exercise improves pharyngeal paralysis, however compensatory strategies techniques can be used
• Turn head to affected side
• Tilting head toward stronger side
• Supraglottic swallow to expectorate residue

Cervical Osteophyte

Foods of thicker consistency will be more difficult, changing head position; particularly rotating to one side or the other may be helpful.

Cricopharyngeal Dysfunction – depends on why it is occurring and/or what it is resulting in

• Mendelsohn maneuver
• Tongue base exercises
• Head rotation to the weaker side
• Hyolaryngeal exercises

Vallecular and Pyriform Retention due to reduced laryngeal elevation

1. Hard swallows
2. Mendelsohn Maneuver
3. Alternate solids and liquids

Pyriform Retention due to cricopharyngeal dysfunction or poor laryngeal elevation

1. dry swallows, hard swallow
2. alternate liquid and solids
3. Mendelsohn maneuver
4. head rotation
5. last resort: myotomy

Reduced Laryngeal elevation –

Elevation prevents material from entering the airway and also opens the PES. Penetration may occur before, during, or after the swallow

• Mendelsohn Maneuver
• Supraglottic swallow may be helpful as it speeds the onset of laryngeal elevation
• Falsetto exercise may be used as a ROM
• Light pressure on the thyroid cartilage to assist in laryngeal elevation when assisting with falsetto ex.
• Hyolaryngeal exercises

Unilateral Pharyngeal Retention

1. Turn head to damaged side
2. Turn head to r/l shoulder during dry swallow
3. Pharyngeal resistance
4. Push on side of face and pt, push opposite

Reduced Velopharyngeal function

May result in possible speech distortions. May expel leakage into nasal passage. Reduce velar function may also allow for premature spillage