Dysphagia Rehabilitation Management: Difference between revisions

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** raises the respiratory tract and lowers the oesophagus making its easier to slide the bolus down the posterior wall of the pharynx, thus minimising aspiration.
** raises the respiratory tract and lowers the oesophagus making its easier to slide the bolus down the posterior wall of the pharynx, thus minimising aspiration.
* 60 degrees or higher position is needed for independent feeding<ref name=":0" />
* 60 degrees or higher position is needed for independent feeding<ref name=":0" />
* Maintaining a seated position for 2 hours after eating may prevent gastroesophageal reflux and reduce risk for aspiration <ref>Matsui T, Yamaya M, Ohrui T, Arai H, Sasaki H. Sitting position to prevent aspiration in bed-bound patients. Gerontology. 2002 May-Jun;48(3):194-5.</ref>
* maintaining a seated position from 30 minutes<ref name=":1" /> to 2 hours<ref>Matsui T, Yamaya M, Ohrui T, Arai H, Sasaki H. Sitting position to prevent aspiration in bed-bound patients. Gerontology. 2002 May-Jun;48(3):194-5.</ref> after eating may prevent gastroesophageal reflux and reduce risk for aspiration


'''Chin tuck (chin down):'''
'''Chin tuck (chin down):'''<ref name=":0" />


* the chin down position may involve head flexion, neck flexion, or a combination of both  
* the chin down position may involve head flexion, neck flexion, or a combination of both  
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* the effectiveness of each position should be verified by a Videofluoroscopic Swallowing Study or by a  video-endoscopic examinations  
* the effectiveness of each position should be verified by a Videofluoroscopic Swallowing Study or by a  video-endoscopic examinations  


'''Chin-up:'''
'''Chin-up:'''<ref>Calvo I, Sunday KL, Macrae P, Humbert IA. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5435481/pdf/nihms856860.pdf Effects of chin-up posture on the sequence of swallowing events.] Head & neck 2017: 39(5):947. </ref>


* the chin-up posture involves the head and neck extension and lifting of the chin before initiation of the swallow.
* the chin-up posture involves the head and neck extension and lifting of the chin before initiation of the swallow.
* the head and neck extension facilitates posterior bolus transit using the force of gravity
* the head and neck extension facilitates posterior bolus transit using the force of gravity
* patient with reduction in base of tongue movements due to oral pain, mucositis, fibrosis caused by radiation, and chemoradiation and patients with prolonged oral transit time and reduced tongue strength may benefit from this posture <ref>Banerjee S. Dysphagia Rehabilitation Management. Plus Course 2024</ref>
* patient with reduction in base of tongue movements due to oral pain, mucositis, fibrosis caused by radiation, and chemoradiation and patients with prolonged oral transit time and reduced tongue strength may benefit from this posture <ref name=":1">Banerjee S. Dysphagia Rehabilitation Management. Plus Course 2024</ref>
* chin-up position is recommended only in patients with '''intact laryngeal and pharyngeal function'''
* chin-up position should be used with caution. Study by Lazarus et al.<ref name=":2" /> has found that even in healthy subject, the chin-up posture presents a challenge as it alters the normal sequence of swallowing events and it is "necessary to further investigate how the chin-up posture affects the sequence of events of impaired swallows."<ref name=":2" />
'''Head rotation:'''


helpful in patients where there is difficulty in protrusion of the tongue and this leads to an impaired pressure, known as '''the lingual pressure, created around the tongue.'''
* the effect of head rotation on swallowing involves narrowing of the piriform on the side that was turned and expanding on the opposite side. This manoeuvre makes the food bolus to travel down the non-rotated side much easier <ref name=":0" />
* head rotation technique can benefit patients with the paralysis of the pharynx (bulbar paralysis as an example). It helps guiding a food bolus to the healthy side or less paralysed side.<ref name=":0" />


'''Head tilt:'''


* head tilt towards the stronger side is going to promote the diversion of the bolus to the stronger side. The force of gravity will help to bring a food bolus downward and pass through the non-paralysed side. <ref name=":1" /><ref name=":0" />


== Exercises ==
== Exercises ==
Dysphagia can be managed by improvement in '''oro-motor function''' which includes the function created by the movements of the mouth, tongue, jaw, and lips, and by '''oral motor skills''' such as swallowing, sucking, biting, chewing, and speaking functions. <ref>Sampallo-Pedroza RM, Cardona-López LF, Ramírez-Gómez KE. [http://www.scielo.org.co/pdf/rfmun/v62n4/v62n4a12.pdf Description of oral-motor development from birth to six years of age]. Rev. Fac. Med. 2014; 62 (4): 593-604.</ref>


=== Guidelines for Exercises in Dysphagia ===
=== Guidelines for Exercises in Dysphagia ===
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* poor compliance with swallow exercises reported with patients  treated for head and neck cancer
* poor compliance with swallow exercises reported with patients  treated for head and neck cancer
* pre-treatment depression correlates with poor compliance with exercises  
* pre-treatment depression correlates with poor compliance with exercises  
* timing and type of exercises. Lazarus et al.<ref>Lazarus CL, Husaini H, Falciglia D, DeLacure M, Branski RC, Kraus D, Lee N, Ho M, Ganz C, Smith B, Sanfilippo N. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9548242/pdf/nihms-549913.pdf Effects of exercise on swallowing and tongue strength in patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy.] Int J Oral Maxillofac Surg. 2014 May;43(5):523-30. </ref> found that one month post-radiotherapy for patients treated for head and neck cancer may be too soon to initiate a swallow therapy programme.
* timing and type of exercises. Lazarus et al.<ref name=":2">Lazarus CL, Husaini H, Falciglia D, DeLacure M, Branski RC, Kraus D, Lee N, Ho M, Ganz C, Smith B, Sanfilippo N. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9548242/pdf/nihms-549913.pdf Effects of exercise on swallowing and tongue strength in patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy.] Int J Oral Maxillofac Surg. 2014 May;43(5):523-30. </ref> found that one month post-radiotherapy for patients treated for head and neck cancer may be too soon to initiate a swallow therapy programme.
 
=== Outcome Measures ===
Outcome measures for each type of exercises are highly variable. When combination exercises are used the following outcome measures are recommended:<ref>Krekeler BN,  Rowe LM, Connor NP.  Dose in Exercise-Based Dysphagia Therapies: A Scoping Review. Dysphagia 2021; 36(1): 1.</ref>
 
* [http://media.ciaoseminars.com/pdfs/cms/113.pdf Functional Oral Intake Scale (FOIS)]
* [https://userweb.ucs.louisiana.edu/~ncr3025/roussel/codi531/8pointscale.html Penetration Aspiration Scale] (PAS - measures changes  on videofluoroscopy)
* Percutaneous endoscopic gastrostomy (PEG) tube dependence <ref>Pohar S, Demarcantonio M, Whiting P, Crandley E, Wadsworth J, Karakla D. Percutaneous endoscopic gastrostomy tube dependence following chemoradiation in head and neck cancer patients. Laryngoscope. 2015 Jun;125(6):1366-71. </ref>
* [https://iopimedical.com/medical-professionals/#tongue Lingual pressure measurements] <ref>Shieh WY, Wang CM, Cheng HK, Imbang TI. Noninvasive Measurement of Tongue Pressure and Its Correlation with Swallowing and Respiration. Sensors (Basel). 2021 Apr 7;21(8):2603.</ref>
* [https://med.stanford.edu/content/dam/sm/ohns/documents/voicecenter/visit/DysphagiaInventory.pdf MD Anderson Dysphagia Inventory]
 
==== Oro-Motor Exercises ====


== Sub Heading 3 ==


== Resources  ==
== Resources  ==

Revision as of 19:12, 4 July 2024

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Introduction[edit | edit source]

Positioning[edit | edit source]

Position during eating and drinking[edit | edit source]

Body position:

  • 30 degrees reclining position:[1]
    • raises the front of the oral cavity and lowers the back
    • facilitates bringing a food bolus from the oral cavity to the throat for patients with difficulties sending a food bolus into the pharynx
    • raises the respiratory tract and lowers the oesophagus making its easier to slide the bolus down the posterior wall of the pharynx, thus minimising aspiration.
  • 60 degrees or higher position is needed for independent feeding[1]
  • maintaining a seated position from 30 minutes[2] to 2 hours[3] after eating may prevent gastroesophageal reflux and reduce risk for aspiration

Chin tuck (chin down):[1]

  • the chin down position may involve head flexion, neck flexion, or a combination of both
  • the head flexion involving the upper cervical spine is effective when food residue is stuck in the epiglottic vallecula
  • the neck flexion involving the middle and lower cervical spine is effective the initiation of swallowing reflex is poor.
  • the effectiveness of each position should be verified by a Videofluoroscopic Swallowing Study or by a video-endoscopic examinations

Chin-up:[4]

  • the chin-up posture involves the head and neck extension and lifting of the chin before initiation of the swallow.
  • the head and neck extension facilitates posterior bolus transit using the force of gravity
  • patient with reduction in base of tongue movements due to oral pain, mucositis, fibrosis caused by radiation, and chemoradiation and patients with prolonged oral transit time and reduced tongue strength may benefit from this posture [2]
  • chin-up position is recommended only in patients with intact laryngeal and pharyngeal function
  • chin-up position should be used with caution. Study by Lazarus et al.[5] has found that even in healthy subject, the chin-up posture presents a challenge as it alters the normal sequence of swallowing events and it is "necessary to further investigate how the chin-up posture affects the sequence of events of impaired swallows."[5]

Head rotation:

  • the effect of head rotation on swallowing involves narrowing of the piriform on the side that was turned and expanding on the opposite side. This manoeuvre makes the food bolus to travel down the non-rotated side much easier [1]
  • head rotation technique can benefit patients with the paralysis of the pharynx (bulbar paralysis as an example). It helps guiding a food bolus to the healthy side or less paralysed side.[1]

Head tilt:

  • head tilt towards the stronger side is going to promote the diversion of the bolus to the stronger side. The force of gravity will help to bring a food bolus downward and pass through the non-paralysed side. [2][1]

Exercises[edit | edit source]

Dysphagia can be managed by improvement in oro-motor function which includes the function created by the movements of the mouth, tongue, jaw, and lips, and by oral motor skills such as swallowing, sucking, biting, chewing, and speaking functions. [6]

Guidelines for Exercises in Dysphagia[edit | edit source]

Determinants of dose for exercise prescriptions dysphagia should include: (1) duration or length of the programme, (2)intensity (% of max), (3)repetitions (number of actions per set), and (4) frequency (number of sets/day, number of days/week).

Factors Affecting Outcomes[edit | edit source]

  • poor compliance with swallow exercises reported with patients treated for head and neck cancer
  • pre-treatment depression correlates with poor compliance with exercises
  • timing and type of exercises. Lazarus et al.[5] found that one month post-radiotherapy for patients treated for head and neck cancer may be too soon to initiate a swallow therapy programme.

Outcome Measures[edit | edit source]

Outcome measures for each type of exercises are highly variable. When combination exercises are used the following outcome measures are recommended:[7]

Oro-Motor Exercises[edit | edit source]

Resources[edit | edit source]

  • bulleted list
  • x

or

  1. numbered list
  2. x

References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Hitoshi Kagaya H, Inamoto Y, Okada S, Saitoh E. Body Positions and Functional Training to Reduce Aspiration in Patients with Dysphagia. JMAJ 2011; 54(1): 35–38.
  2. ↑ 2.0 2.1 2.2 Banerjee S. Dysphagia Rehabilitation Management. Plus Course 2024
  3. ↑ Matsui T, Yamaya M, Ohrui T, Arai H, Sasaki H. Sitting position to prevent aspiration in bed-bound patients. Gerontology. 2002 May-Jun;48(3):194-5.
  4. ↑ Calvo I, Sunday KL, Macrae P, Humbert IA. Effects of chin-up posture on the sequence of swallowing events. Head & neck 2017: 39(5):947.
  5. ↑ 5.0 5.1 5.2 Lazarus CL, Husaini H, Falciglia D, DeLacure M, Branski RC, Kraus D, Lee N, Ho M, Ganz C, Smith B, Sanfilippo N. Effects of exercise on swallowing and tongue strength in patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy. Int J Oral Maxillofac Surg. 2014 May;43(5):523-30.
  6. ↑ Sampallo-Pedroza RM, Cardona-López LF, Ramírez-Gómez KE. Description of oral-motor development from birth to six years of age. Rev. Fac. Med. 2014; 62 (4): 593-604.
  7. ↑ Krekeler BN, Rowe LM, Connor NP. Dose in Exercise-Based Dysphagia Therapies: A Scoping Review. Dysphagia 2021; 36(1): 1.
  8. ↑ Pohar S, Demarcantonio M, Whiting P, Crandley E, Wadsworth J, Karakla D. Percutaneous endoscopic gastrostomy tube dependence following chemoradiation in head and neck cancer patients. Laryngoscope. 2015 Jun;125(6):1366-71.
  9. ↑ Shieh WY, Wang CM, Cheng HK, Imbang TI. Noninvasive Measurement of Tongue Pressure and Its Correlation with Swallowing and Respiration. Sensors (Basel). 2021 Apr 7;21(8):2603.

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