Ch. 6

*Clinical Management of Swallowing Disorders

*What do we do first?

*What type of nutritional management is necessary?

*Should therapy be initiated and what type?

*What specific therapy strategies should be utilized?

*Primary Goal

*The continuous goal of any treatment program is the reestablishment of oral feeding while constantly maintaining adequate hydration and nutrition and safe swallowing.

*Treatment Planning

*What is the Diagnosis?

*What is the prognosis?

*What is the patient’s reaction to Compensatory strategies?

*What is the severity of the patient’s dysphagia?

*Can they follow directions?

*What is their respiratory function?

*Do they have supportive caregivers and family?

*What is the patient’s motivation and interest?

*Oral vs. Nonoral Feeding

*Factors to consider

*Time taken to swallow a single bolus of a particular consistency of food

*Aspiration- more than 10% of every bolus, regardless of consistency of food- should not be eating orally

*Compensatory Treatment Procedures

*Control the flow of food

*Eliminate the patient’s symptoms

*Do not necessarily change the physiology of the patient’s swallow.

*Can be used with patient’s of all ages and cognitive levels

*Postural changes

* Increasing sensory input

*Modifying volume and speed of food presentation

*Changing food consistency

*Postural Changes

*Chin-Down

*Pushes anterior wall posteriorly

*Tongue base and epiglottis are pushed closer to pharyngeal wall

*Airway entrance is narrowed

*Vallecular space is also widenced

*Helps with delay in triggering the pharyngeal swallow

*Helps with reduced tongue base retraction

*Helps with reduced airway closure

*Postural Changes

*Chin-Up

*Uses gravity to drain food from oral cavity

*Helpful with reduced tongue control

*Head Rotation

*Rotate to damaged side

*Allows food to flow down normal side

*Helpful when there is unilateral pharyngeal wall impairment

*Helpful with unilateral vocal fold weakness or paralysis

*Chin Down with Head Rotation

*Head Tilt

*Postural Changes

*Chin Down with Head Rotation

*Helpful for airway protection

*Head Tilt

*Helpful when a patient has both a unilateral oral impairment and a unilateral pharyngeal impairment on the same side

*Tilt to the better/stronger side

*Oral Sensory Awareness

*Utilized for the following

*Swallow apraxia

*Tactile agnosia for food

*Delayed onset of the oral swallow

*Reduced oral sensation

*Delayed triggering of the pharyngeal swallow

*Oral Sensory Awareness

*Increase downward pressure of spoon against the tongue when presenting the food to the patient

*Presenting a sour bolus

*Presenting a cold bolus

*Presenting a bolus requiring chewing

*Presenting a larger volume bolus

*Thermal-tactile stimulation

*Thermal Tactile Stimulation

*Help to improve the trigger of the pharyngeal swallow

*Rubbing anterior faucial arch firmly

*4-5 times on each side

*Use a laryngeal mirror that has been held in crushed ice for several minutes

*Alerts sensory stimulus to cortex and brainstem

*Modifying Volume/Speed

*Determining the volume of food per swallow that will elicit the fastest pharyngeal swalllow

*A larger bolus may facilitate triggering of the swallow

*Taking too much food too rapidly can result in a severe residue in pharynx and possible aspiration

*Diet Changes

*Thin liquids

*Oral tongue dysfunction

*Reduced tongue base retraction

*Reduced pharyngeal wall contraction

*Reduced laryngeal elevation

*Reduced Upper Esophageal Sphincter opening

*Diet Changes

*Thickened liquids

*Oral tongue dysfunction

*Delayed pharyngeal swallow

*Puree and thick foods

*Delayed pharyngeal swallow

*Reduced laryngeal closure

*Direct vs. Indirect Therapy

*Direct Therapy- work directly on the swallow- introduce food into the mouth and attempt to reinforce behaviors and motor control during the swallow

*Indirect Therapy-exercise programs or swallows of saliva, but no food or liquid is given

*Swallow Maneuvers

*Supraglottic swallow

*Super-supraglottic swallow

*Effortful swallow

*Mendelsohn Maneuver

*Oral Motor Exercises

*See Handout

*Bolus Control Exercises

*See Handout

*Laryngeal Elevation and Vocal Adduction

Exercises

*Sustain Phonation

*Cough/Glottal Attack

*Pitch scales

*Push/Pull with voicing

*When to begin Therapy?

*Inpatienets- Acute Care

*Bedside Swallow Evaluation and/or Videoswallow Study

*Awake and alert

*Seen daily for therapy

*Outpatients

*Videoswallow study results preferred prior to first visit

*Clinical Swallow Evaluation in the office

*Twice weekly