Dysphagia Rehabilitation Management

Original Editor - Ewa Jaraczewska based on the course by Srishti Banerjee

Top Contributors - Ewa Jaraczewska, Jess Bell, Tony Lowe and Kim Jackson  

Introduction

Many individuals experience dysphagia, or difficulty swallowing. In the United States alone, an estimated one million people are diagnosed with dysphagia each year. However, only around half of all people with dysphagia seek medical attention. Many people try to manage their symptoms by altering their eating patterns. Yet optimal dysphagia management requires input from qualified healthcare professionals. This article discusses key rehabilitation management strategies, including swallowing rehabilitation and reeducation, nutrition and dietary modifications, and alternative nutritional support.

Please note that the techniques discussed in this page should be used with caution and by trained professionals after consultation with the multidisciplinary team. Each treatment plan must be individualised and specifically tailored for a patient based on their specific impairment. Treatments will require regular reassessment and adjustment. Please make sure you always work within your scope of practice.

Positioning

Posture can affect swallowing and, in turn, can be affected by swallowing. A good understanding of the relationship between swallowing and posture is essential when managing patients with dysphagia. If you would like to learn more about this relationship, please see: The Relationship Between Posture and Swallowing.

Position During Eating and Drinking

Body position:

• reclining position with the head raised 30 degrees:
  • this position is often selected for individuals with severe dysphagia
  • raises the front of the oral cavity and lowers the back
  • can be useful for individuals who have difficulty transferring food boluses to the pharynx, as gravity facilitates movement of the bolus from the oral cavity to the throat
  • raises the respiratory tract and lowers the oesophagus, making it easier for the bolus to slide down the posterior wall of the pharynx, thus minimising the risk of aspiration
• a tilt of 60 degrees or higher is needed for independent feeding
• maintaining a seated position for 30 minutes to 2 hours after eating may prevent gastroesophageal reflux and reduce the risk for aspiration

Chin-down or chin-tuck:

• there are three types of chin-down:
  • head flexion = upper cervical spine flexion
    • helps when food residue remains in the epiglottic vallecula
  • neck flexion = middle / lower cervical spine flexion
    • useful when there is a poor initiation of the swallowing reflex
  • combination of head and neck flexion
• please note that a chin tuck can make a swallow worse depending on the impairment. Therefore, the effectiveness of each position should be assessed by a Videofluoroscopic Swallowing Study or by a video-endoscopic examination

Chin-up:

• in chin-up posture, the individual extends their head and neck and lifts their chin before initiating a swallow
• this position uses gravity to enhance posterior bolus transit
• it might be useful for individuals with reduced base of tongue movement due to oral pain, mucositis, fibrosis caused by radiation, and chemoradiation and those with prolonged oral transit time and reduced tongue strength
• it is only recommended in patients with intact laryngeal and pharyngeal function and it should be used with caution:
  • a study by Lazarus et al. found that even in healthy subjects, the chin-up posture presents a challenge as it alters the typical sequence of swallowing events, and it is "necessary to further investigate how the chin-up posture affects the sequence of events of impaired swallows"

Head rotation:

• rotating the head towards the affected side will direct the bolus to the unaffected side
• it narrows the piriform fossa (also known as pyriform sinus) on the rotated side, which expands the opposite side. This helps the food bolus move down the opposite side (i.e. the side that is not rotated) more easily
• this technique can be useful for individuals with paralysis of the pharynx (e.g. bulbar paralysis)

Head tilt:

• tilting the head towards the stronger side promotes the flow of the bolus to the stronger side
• the force of gravity helps move a food bolus down and pass through the non-affected side

Oral Hygiene

Oral hygiene is essential for individuals with dysphagia. It helps to prevent aspiration pneumonia caused by the introduction of microbes into the lungs during aspiration.

Oral care after every meal and before bed is recommended and should include the following steps:

• brushing the teeth/oral mucosa
• keeping the mouth (lips and mucous membranes) hydrated / protected
• rinsing the oral cavity with an antiseptic mouthwash twice a day (for individuals with severe dysphagia)

Please see the following resources for more information:

• Oral Care Tips for People with Swallowing Issues
• Basic Oral Care for Patients with Dysphagia - A Special Needs Dentistry Perspective

Please also see the following resources for information on free water protocols. Free water protocols are not appropriate for everyone, and each patient must be assessed by a speech and language therapist. However, a free water protocol can be beneficial for some patients who have known aspiration but would like to drink for pleasure and comfort.

• The Frazier Free Water Protocol
• What is Free Water Protocol?

Exercise Rehabilitation

Dysphagia can be managed by improving:

• oromotor function, including movements of the mouth, tongue, jaw, and lips
• oral-motor skills, such as swallowing, sucking, biting, chewing, and speaking
• respiratory muscle strength training

Exercises for dysphagia aim to improve swallowing mechanics and impact bolus flow via compensatory strategies and rehabilitative exercises (e.g. effortful swallow, supraglottic swallow, super-supraglottic swallow, and the Mendelsohn manoeuvre, or by improving swallowing physiology (e.g. Shaker exercise).

Guidelines for Dysphagia Exercises

When determining the appropriate dosage for dysphagia exercises, consider the following: (1) duration or length of the programme, (2) intensity (% of maximum), (3) repetitions (number of actions per set), and (4) frequency (number of sets per day, number of days per week).

Factors Affecting Outcomes in Dysphagia Rehabilitation

• Patient motivation: in adults aged over 65 years with dysphagia, motivation has been found to affect outcomes during the maintenance stage of rehabilitation
• Optimal dosing for swallowing exercises: swallowing exercises performed at an intensity that is less than the level of activity to "which the system is accustomed will not result in adaptation." It is recommended that the "swallowing exercise task must exceed usual levels of activity and be performed for an adequate duration."
• Specificity of interventions: interventions "that are nonspecific to impairments in swallow physiology could result in lack of treatment response"
• Individuals treated for oral and oropharyngeal cancer:
  • generally have poor compliance with swallow exercises
  • pre-treatment depression is associated with reduced compliance with swallow exercises
  • the timing and type of exercises is significant: Lazarus et al. found that initiating a swallow therapy programme at one-month post-radiotherapy may be too soon for individuals treated for oral and oropharyngeal cancer

Outcome Measures

Different outcome measures can be used depending on the type of exercise used in a dysphagia exercise programme. When combination exercises are used, the following outcome measures can be useful:

• Functional Oral Intake Scale (FOIS)
• Penetration Aspiration Scale (PAS - measures changes on videofluoroscopy)
• Percutaneous endoscopic gastrostomy (PEG) tube dependence
• Lingual pressure measurements
• MD Anderson Dysphagia Inventory

Oromotor Exercises

1. Mandible exercises:
   • exercises include jaw opening, jaw closing, and chin tuck against resistance (CTAR)
   • a systematic review by Park et al. indicated that CTAR exercises can selectively activate the suprahyoid muscle and that they are effective in improving swallowing function in patients with dysphagia
   • outcome measures include: 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: three times per day, seven days per week
2. Lip muscle training:
   • exercises include:
     • protruding the lips while biting an ice cream stick to prevent the jaw and teeth from moving
     • lip rounding, like blowing a whistle or blowing on something hot
   • treatment duration may range from 4 weeks to 6 months
3. Cheek exercises:
   • puffing the cheeks
4. Tongue exercises:
   • exercises include:
     • 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 elevation, while resisting the tongue depressor; each press should be held for two seconds
   • a protocol by Lazarus et al. provides guidance for isometric tongue exercises: they can be performed five days per week for six weeks, five times per day with ten repetitions per practice session

Oral-Motor Skills

1. Vocalisation exercises
   • voice training or vocal exercises that focus on improving voice function have been found to have a positive impact on swallowing function
   • the patient is asked to pronounce certain letter sounds, such as labial consonants (letters P and B), alveolar consonants (letters T and D), and palatal consonants (letters K and G)
   • outcome measures include: Videofluoroscopic Dysphagia Scale (VDS), Speech Handicap Index-15 (SHI-15), Eating Assessment Tool-10 (EAT-10), Functional Oral Intake Scale (FOIS), and Quality of Life in Swallowing Disorders Questionnaire (SWAL-QOL)
   • a systematic review by Liu et al. found a positive short-term effect of voice training on swallowing in patients with neurological dysphagia (stroke) and non-neurological dysphagia (head and neck cancer), but they note that the long-term effects are unknown
   • Park et al. note that voice training can improve tongue strength leading to better control of the bolus and decreasing bolus loss prematurely
2. Mendelsohn manoeuvre
   • in this exercise, the patient swallows air, raising their larynx to its highest position. They then hold this position for several seconds
   • the goal of this manoeuvre is to enlarge the entrance of the oesophagus through prolonged elevation of the larynx
3. Vocal fold adduction exercises
   • the goal of these exercises is to improve swallowing and reduce the risk of aspiration
   • a patient is asked to clasp the palms of their hands together and press them against each other. While pressing the palms, they say "ee" five times in a clear voice
   • next, the patient is asked to repeat "ah" five times while maintaining the pressure on their palms
   • recommended repetitions and frequency: perform this exercise five times per day, with five to ten repetitions in each session
4. Shaker exercise
   • the goal of this exercise is to enlarge the entrance of the oesophagus and strengthen the suprahyoid muscles
   • to perform this exercise, the patient lies supine. They are then asked to lift their head and hold it up for one minute. This is followed by a one-minute rest. This sequence is repeated three times
   • they then raise their head up and down thirty times
   • recommended frequency: perform this exercise three times per day for six weeks
5. Supraglottic swallow
   • this training method can benefit patients who aspirate during swallowing
   • to perform this exercise, the patient takes a deep breath, holds it, swallows a food bolus, and immediately coughs out
   • by holding their breath, the patient's glottis closes, which prevents aspiration - coughing after swallowing also removes any food from the respiratory tract
6. Super-supraglottic swallow
   • the following instructions are given to the patient: "take a breath and hold it tightly while bearing down, continue to hold your breath and bear down as you swallow, immediately after your swallow (before you inhale) cough then immediately swallow hard again (before you inhale)"
7. Effortful swallow
   • this exercise aims to improve the posterior movement of the tongue
   • the patient is asked to swallow by squeezing their neck and throat muscles as hard as possible

Modalities and Devices

1. Ice massage with a cold cotton bud can be used to target trigger points of swallowing reflexes, such as the soft palate and dorsum of the tongue
2. Thermal tactile stimulation using a cold laryngeal mirror. The mirror is placed on the base of the anterior faucial arches and rubbed up and down five times. Special training is required to perform this technique.
3. Passy Muir® Valve improves cough, decreases secretions, and reduces aspiration. It can be used by clinicians other than speech therapists after passing competency training.

Respiratory Training

Respiratory muscle strength training:

• aims to improve swallowing by increasing respiratory muscle strength (as respiration and swallowing are closely coordinated processes)
• the choice between inspiratory vs expiratory muscle strength training depends on the desired outcome:
  • a patient with Parkinson's who has difficulty breathing, swallowing, and producing an effective cough will benefit from increasing expiratory muscle force generation
  • a patient with paradoxical vocal fold motion will benefit from inspiratory muscle strength training to improve the strength and endurance of the diaphragm, external intercostal, and parasternal intercostal muscles
• outcome measures include the Penetration Aspiration Scale (PAS), Modified Barium Swallow Impairment Profile, and Swallowing Quality of Life Questionnaire (SWAL-QOL)
• recommended frequency: perform this exercise five times per day, five days per week

Please see Respiratory Muscle Training for a discussion of different methods of respiratory muscle training.

Sputum discharge manoeuvres

• commonly used in respiratory physiotherapy to assist with the removal of secretions trapped in the central respiratory tract
  • huffing (a quick, strong exhalation while the glottis is open)
  • forced expiratory manoeuvre (huffing one or two times after an inhalation)
  • coughing

Diet

"Dietary modification—altering the consistency of foods and liquids—is a fundamental aspect of dysphagia management."

The International Dysphagia Diet Standardisation Initiative Functional Diet Scale (IDDSI) enables clinicians to reliably "capture diet texture restriction and progression in people with dysphagia." The IDDSI categorises foods and drinks according to their texture or flow characteristics, providing standardised terminology. Qualified clinicians must assess a patient to determine appropriate diet texture restrictions. The IDDSI framework has eight levels, which are represented in two intersecting pyramids (see Figure 1). Levels 0 and 7 are unmodified foods and drinks. Levels 0-4 correspond to drinks, and levels 3-7 correspond to foods. The middle levels contain progressively greater degrees of texture modification. Levels 3 and 4 represent an overlap zone "in which the characteristics of foods and drinks are equivalent." It is important to remember that ice cannot be added to thickened liquids as it will change the consistency of liquids as it melts.

Figure 1. The IDDSI framework.

Please refer to the IDDSI website if you would like to read detailed descriptions of food textures and drink thickness and their testing methods.

This optional video describes IDDSI for healthcare professionals:

There are other dysphagia diet pyramids available, including one based on the work of Kanaya et al. This 5-stage diet, called the Seirei Dysphagia Diet, is primarily used in Japan. It has five categories:

• L0: gelatin jelly (tea or fruit juice, etc.)
• L1: gelatin jelly (miso soup, milk, etc., containing protein)
• L2: gelatin jelly (mixer meal with gelatin)
• L3: puréed or mixed meal
• L4: softened diet

Resources

• Dysphagia Rehabilitation
• Dysphagia Rehabilitation Manual
• Dysphagia Global Guidelines and Cascades
• Swallowing: Exercises

References

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