Dysphagia Rehabilitation Management

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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 improving oro-motor function which includes the function created by the movements of the mouth, tongue, jaw, and lips, oral motor skills such as swallowing, sucking, biting, chewing, and speaking functions, and the respiratory muscles strength training. [6][7]

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).[7]

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]

  1. Mandible Exercises:[7]
    • include jaw opening, jaw closing, and chin tuck against resistance (CTAR)[7]
    • a systematic review of CTAR exercises by Park JS et al.[10] indicated, that CTAR exercise can selectively activate the suprahyoid muscle. Authors suggested that CTAR exercises are effective in improving swallowing function in patients with dysphagia [10]
    • outcome measures consist of chin tuck strength, jaw opening strength, tongue strength, muscle volume, changes in videofluoroscopy parameters, body weight gain, Penetration Aspiration Scale (PAS) ratings laryngeal elevation and epiglottic closure
    • recommended frequency: 3 times per day, 7 days per week [11]
  2. Lip muscle training:[2]
    • protruding the lips while biting an ice cream stick to prevent jaw and teeth from moving
    • lip rounding, such as if you are blowing a whistle or blowing on something hot
    • treatment duration may range from 4 weeks to 6 months[7]
  3. Cheeks exercises:[2]
    • puffing the cheeks
  4. Tongue exercises:[5]
    • lingual range of motion, protrusion, lateralisation, elevation, and retraction towards the posterior pharyngeal wall
    • isometric tongue exercises against resistance. Individuals press against a tongue depressor with their tongue in four directions: left, right, on protrusion, and on elevation, while resisting with the tongue depressor. Each press should be hold for 2 seconds
    • a protocol by Lazarus et al.[5]indicates that isometric tongue exercises should be performed 5 days a week for 6 weeks, practicing five times per day with 10 repetitions per practice session

Oral-Motor Skills[edit | edit source]

  1. Vocalisation exercises
    • vocalisation exercises involving pronouncing letters of the alphabet can activate labial consonants (letters P and B), alveolar consonants (letters T and D), and palatal consonants (letters K and G)
  2. Mendelsohn maneuver
    • The patient swallows the air which raises the larynx to the highest position. Next the patient holds this position for several seconds. The goal is to enlarge the entrance of the oesophagus through a prolonged elevation of the larynx.
  3. Vocal fold adduction exercises
  4. Shaker's exercise
  5. Supraglottic swallow:[1]
    • this training method can benefit patients who aspirate during swallowing
    • the patient takes a deep breath, holds it, swallows a food bolus, and immediately clears the throat
    • the effect of this exercise is based on the mechanism of holding one’s breath closes the glottis which prevents aspiration. Additionally coughing after swallowing removes any food from the respiratory tract.
  6. Super-supraglottic swallow
  7. Effortful swallow

Modalities and Devices[edit | edit source]

  1. Ice massage with a cold cotton bud targeting trigger point of swallowing reflexes, such as your soft palate, dorsum of the tongue. [2]
  2. Thermal tactile stimulation using a cold laryngeal mirror applied to the base of the arches. The mirror is rubbed up and down five times. Special training to perform this stimulation is required.[2]
  3. Passy Muir® Valve improves cough, decrease secretions, and reduce aspiration. [12] It can be used by clinicians other than speech therapists after passing a competency training.

Respiratory Muscles Strength Training[edit | edit source]

  • The goal is to increase respiratory muscle strength as respiration and swallowing actions are highly coordinated. [7]
  • The choice between inspiratory vs expiratory muscle strength training depends on the outcome desired.[13] Example: A patient with Parkinson's disease presenting with difficulty with breathing, swallowing, and cough production will benefit from increasing expiratory muscle force generation. [13]
  • Outcome measures include the Penetration Aspiration Scale (PAS), Modified Barium Swallow Impairment Profile, Swallowing Quality of Life questionnaire (SWAL-QOL). [7]
  • The recommended exercise frequency is 5 time a day for 5 days per week. [7]

The Respiratory Muscle Training article discusses different methods of respiratory muscle training.

Diet[edit | edit source]

Resources[edit | edit source]

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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 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 2.3 2.4 2.5 2.6 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 5.3 5.4 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. ↑ 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8 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.
  10. ↑ 10.0 10.1 Park JS, Hwang NK. Chin tuck against resistance exercise for dysphagia rehabilitation: A systematic review. J Oral Rehabil. 2021 Aug;48(8):968-977.
  11. ↑ Kraaijenga SA, van der Molen L, Stuiver MM, Teertstra HJ, Hilgers FJ, van den Brekel MW. Effects of Strengthening Exercises on Swallowing Musculature and Function in Senior Healthy Subjects: a Prospective Effectiveness and Feasibility Study. Dysphagia. 2015 Aug;30(4):392-403.
  12. ↑ Han X, Ye Q, Meng Z, Pan D, Wei X, Wen H, Dou Z. Biomechanical mechanism of reduced aspiration by the Passy-Muir valve in tracheostomized patients following acquired brain injury: Evidences from subglottic pressure. Front Neurosci. 2022 Oct 31;16:1004013.
  13. ↑ 13.0 13.1 Sapienza C, Troche M, Pitts T, Davenport P. Respiratory strength training: concept and intervention outcomes. Semin Speech Lang. 2011 Feb;32(1):21-30.

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