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Folia Phoniatr Logop 1999;51:199–212

Behavioral Management for


Oropharyngeal Dysphagia
Jeri A. Logemann
Departments of Communication Sciences and Disorders, Neurology and Otolaryngology –
Head and Neck Surgery, Northwestern University, Evanston, Ill., USA

Key Words orale Prothesen. Die direkten Therapieverfahren be-


Swallowing therapy W Dysphagia W Postural effects W stehen aus Übungsprogrammen und Schluckmanö-
Swallow maneuvers W Sensory enhancement vern. Dieser Artikel beschreibt verschiedene verhal-
tenstherapeutische Verfahren und legt ihre physiolo-
gischen Grundprinzipien, Vorteile und Nachteile dar
Abstract und macht Vorschläge, wie die Wirksamkeit der Mass-
Behavioral management of oropharyngeal swallow- nahmen gemessen werden kann.
ing disorders includes the introduction of compensa-
tory strategies and direct therapy techniques. Com-
Mise en œuvre de techniques
pensatory strategies include postural changes, senso-
ry enhancements, changing feeding strategies, diet
comportementales dans le traitement
changes and intraoral prosthetics. Therapy proce- de la dysphagie oropharyngée
dures include exercise programs and swallowing ma- Les techniques comportementales pour la correction
neuvers. This article describes the various behavioral de troubles oropharyngés de la déglutition compren-
therapy procedures and presents their physiologic nent des stratégies compensatoires et des techniques
rationales and advantages and disadvantages and thérapeutiques directes. Les stratégies compensatoi-
suggests ways to measure their effectiveness. res sont les suivantes: modification des postures, ren-
forcements sensoriels, modification de la façon de
manger et du type d’aliments consommés et mise en
Verhaltenstherapie der place de prothèses intraorales. Les méthodes théra-
oropharyngealen Dysphagie peutiques directes comprennent un programme
Auf das Verhalten abzielende Behandlung oropharyn- d’exercices et l’enseignement de manœuvres de dé-
gealer Schluckstörungen beinhaltet die Einführung glutition. Le présent article décrit les différentes tech-
von Kompensationsstrategien und direkte Therapien. niques comportementales, précise leurs bases phy-
Zu den Kompensationsstrategien zählen Haltungsän- siologiques, leurs avantages et leurs inconvénients et
derungen, sensorische Verstärkung, Veränderung der fait des propositions sur la manière de mesurer leur
Essstrategien, Ernährungsumstellungen und intra- efficacité.

© 1999 S. Karger AG, Basel Jeri A. Logemann, PhD


ABC 1021–7762/99/0515–0199$17.50/0 Northwestern University
Fax + 41 61 306 12 34 2299 North Campus Drive, Evanston, IL 60208 (USA)
E-Mail karger@karger.ch Accessible online at: Tel. +1 847 491 2490, Fax +1 847 491 5692
www.karger.com http://BioMedNet.com/karger E-Mail j-logemann@nwu.edu
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Behavioral therapy for oropharyngeal dys- the trial therapy and the therapy recom-
phagia begins with definition of the patient’s mended.
anatomic and physiologic swallowing disor-
der(s). This usually involves a radiographic
study of the oropharyngeal region during Compensatory Treatment
swallows of carefully defined bolus types Procedures
representing different viscosities and volumes
[1]. It may also involve videoendoscopy [2, Behavioral therapy may include compen-
3], ultrasound or manometry. Radiographic satory treatment procedures and active thera-
symptoms of oropharyngeal dysphagia in- py programs [4]. Compensatory treatment
clude residue (food remaining in the mouth, procedures are those which redirect and/or
valleculae, pyriform sinuses, or on the pha- improve the flow of food and eliminate the
ryngeal walls), penetration (food or liquid en- patient’s symptoms, such as aspiration, but do
tering the airway entrance), and aspiration not necessarily change the physiology of the
(food or liquid entering the airway to the level patient’s swallow. Compensatory procedures
of the trachea). Radiographic symptoms point are largely under the control of the caregiver/
toward specific swallowing disorders [1]. For clinician and can, therefore, be used with
example, residue in the valleculae indicates patients of all ages and cognitive levels. Com-
reduced tongue base movement or reduced pensatory strategies include: (1) postural
pharyngeal wall contraction. The distinction changes which potentially change the dimen-
between symptoms and disorders is critical in sions of the pharynx and the direction of food
therapy planning. Swallowing therapy is al- flow without increasing the patient’s work or
ways directed at the patient’s physiologic or effort during the swallow, (2) increasing sen-
anatomic disorders. sory input prior to or during the swallow, (3)
After defining the patient’s anatomic or modifying volume and speed of food presen-
physiologic swallowing problems, the diag- tation, (4) changing food consistency/viscosi-
nostic radiographic study should include the ty and (5) introducing intraoral prosthetics.
introduction of selected treatment strategies Some of these compensatory procedures may
to improve the swallow, i.e., to eliminate aspi- also serve a therapy role, such as techniques to
ration (the entry of food or liquid into the tra- increase sensory input. Also, any technique
chea below the vocal folds) or inefficient swal- which results in safe swallowing is a therapy
lowing (residue remaining in the mouth or technique. Compensatory treatment proce-
pharynx after the swallow). These treatment dures are usually introduced first during the
strategies are selected on the basis of the diagnostic procedure.
patient’s anatomic or physiologic swallow im-
pairments. Treatment strategies introduced Postural Techniques
will also depend on the patient’s medical diag- Postural techniques change pharyngeal di-
nosis, including the patient’s general physical mensions and redirect food flow in systematic
condition, mental status, cognitive ability, ways. Changing the patient’s head or body
and speech/language ability [4]. The report of posture can be effective in eliminating aspira-
the radiographic study should clearly identify tion in 75–80% of dysphagic patients, includ-
the symptoms of the patient’s swallowing dis- ing infants and children and some patients
order, the anatomic or physiologic swallowing with cognitive or language impairments [1, 4–
disorder causing the symptoms, the effects of 11]. However, some patients are unable to use

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Table 1. Postural techniques which can be effective in eliminating aspiration or residue and the disorder for
which they are appropriate and their rationale

Disorder observed on fluoroscopy Posture applied Rationale

Inefficient oral transit head back utilizes gravity to clear oral cavity [6]
(reduced lingual propulsion of bolus)
Delay in triggering the pharyngeal swallow chin down widens valleculae to prevent bolus entering
(bolus past ramus of mandible but airway;
pharyngeal swallow is not triggered) narrows airway entrance, reducing risk of
aspiration [11]
Reduced posterior motion of tongue base chin down pushes tongue base backward toward
(residue in valleculae) pharyngeal wall [11]
Unilateral vocal fold paralysis or surgical head rotated to places extrinsic pressure on thyroid cartilage,
removal damaged side improving vocal fold approximation, and
(aspiration during the swallow) directs bolus down stronger side [6, 16]
Reduced closure of laryngeal entrance and chin down puts epiglottis in more protective position;
vocal folds narrows laryngeal entrance [11]
(aspiration during the swallow) head rotated to improves vocal fold closure by applying
damaged side extrinsic pressure
Unilateral pharyngeal paresis head rotated to eliminates damaged side of pharynx from
(residue on one side of pharynx) damaged side bolus path [14, 16]
Reduced pharyngeal contraction lying down on eliminates gravitational effect on pharyngeal
(residue spread throughout pharynx) one side residue [6, 12, 15]
Unilateral oral and pharyngeal weakness on head tilt to directs bolus down stronger side by gravity
the same side stronger side [4, 6]
(residue in mouth and pharynx on same side)
Cricopharyngeal dysfunction head rotated pulls cricoid cartilage away from posterior
(residue in pyriform sinuses) pharyngeal wall, reducing resting pressure
in cricopharyngeal sphincter

postural strategies because of cognitive disor- The effectiveness of postural techniques


ders, head stabilization devices, or other phys- should be evaluated during the diagnostic
ical constraints. swallowing study. During the diagnostic ra-
Table 1 presents the postures currently uti- diographic procedure, the clinician cannot in-
lized therapeutically and their effects on spe- troduce all of the postures to assess their indi-
cific swallowing disorders and pharyngeal di- vidual effects. Instead, the clinician must se-
mensions. In general, postural techniques lect one or two postural techniques to fit the
work equally well in patients of all ages and patient’s physiologic or anatomic swallowing
with neurologically impaired individuals and disorders identified in the earlier portion of
in patients who have experienced head and the radiographic study [1, 6, 8]. Then, the
neck cancer resections or other structural patient uses the postural technique during
damage [1, 4, 6–16]. swallows of the same type as those which pre-

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viously exhibited aspiration or significant res- the downward pressure of a spoon, the presen-
idue. If the posture is effective on those swal- tation of a bolus with increased volume, taste
lows, increased volumes and viscosities can or temperature characteristics, or thermal/
be introduced to define the extent of the pos- tactile stimulation may facilitate oral onset
ture’s effectiveness. In this way, the effective- and oral transit of the swallow. Generally, pre-
ness of the posture in eliminating the aspira- senting verbal instructions to an apraxic pa-
tion or reducing the residue can be defined [1, tient increases their difficulty. These tech-
10]. niques which enhance sensory input, such as
The best measure of postural effectiveness bolus taste, temperature, volume and viscosi-
is the judgment of the amount of aspiration or ty, may also result in reduced pharyngeal
residue with and without the posture [5, 6, delay times in some patients [17, 21].
10]. Postures may also improve oral and pha- Techniques to improve the speed of onset/
ryngeal transit times [9]. In general, postural triggering of the pharyngeal swallow are all
effects can best be observed and measured designed to enhance sensory input prior to the
from videofluoroscopy [7, 11]. Occasionally, patient’s attempt to swallow [4]. Thermal/tac-
postural effects on residue and aspiration can tile stimulation and suck-swallow are most
be observed from a videoendoscopic view of commonly used. Thermal/tactile stimulation
the pharynx before or after the swallow, but involves vertically rubbing the anterior fau-
not during the swallow. cial arch firmly, four or five times, with a size
00 laryngeal mirror (which has been held in
Techniques to Improve Oral Sensory crushed ice for several seconds) in advance of
Awareness and the Speed of Triggering the the presentation of a bolus and the patient’s
Pharyngeal Swallow attempt to swallow. This technique is de-
Techniques to improve oral sensory aware- signed to heighten oral awareness and provide
ness are generally utilized in patients with an alerting sensory stimulus to the cortex and
swallow apraxia, delayed onset of the oral brainstem such that, when the patient ini-
swallow (which may relate to swallow apraxia) tiates the oral stage of swallow, the pharyngeal
or delayed triggering of the pharyngeal swal- swallow will trigger more rapidly [24, 25].
low [1, 17, 18]. These procedures all involve This technique has been found to facilitate
providing a preliminary sensory stimulus faster triggering of the pharyngeal swallow
prior to the initiation of the patient’s swallow after the stimulation and to reduce the delay
attempt. Sensory enhancement techniques in- for several swallows thereafter [21, 26, 27]. An
clude: (1) increasing downward pressure of exaggerated suck-swallow using increased ver-
the spoon against the tongue when presenting tical tongue/jaw sucking movements with the
food in the mouth; (2) presenting a sour bolus lips closed also facilitates triggering the pha-
(50% lemon juice, 50% barium); (3) present- ryngeal swallow. This technique also draws
ing a cold bolus; (4) presenting a bolus requir- saliva to the back of the mouth, which is help-
ing chewing; (5) presenting a larger volume ful for patients with poor saliva control, such
bolus (3 ml or more); (6) allowing self-feeding as oral cancer patients.
so that the hand-to-mouth movement pro- Measures of the effectiveness of these pro-
vides additional sensory input, and (7) ther- cedures in increasing oral sensory input in-
mal/tactile stimulation [17, 19–23]. In some clude: (1) duration of time from command to
patients with swallow apraxia, increasing oral swallow until initiation of the oral stage of
sensation by a preliminary stimulus such as swallow; (2) oral transit time, and (3) pharyn-

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Table 2. Easiest food consistencies to swallow and food consistencies to be avoided by patients with each swal-
lowing disorder

Swallowing disorder Easiest food consistencies Food consistencies to avoid

Reduced range of tongue motion thick liquid initially, then, thick foods
thin liquid
Reduced tongue coordination liquid thick foods
Reduced tongue strength thin liquid thick, heavy foods
Delayed pharyngeal swallow thick liquids and thicker foods thin liquids
Reduced airway closure pudding and thick foods thin liquids
Reduced laryngeal movement/cricopharyngeal
dysfunction thin liquid thicker, higher viscosity foods
Reduced pharyngeal wall contraction thin liquid thick, higher viscosity foods
Reduced tongue base posterior movement thin liquid higher viscosity foods

geal delay time [1, 17]. These can be measured Food Consistency (Diet) Changes
from videofluoroscopy; the first two can also Generally, elimination of certain food con-
be measured with ultrasound. In some pa- sistencies from the diet should be the last
tients, pharyngeal delay time can be measured compensatory strategy examined [1]. Elimi-
from videoendoscopy. However, if a patient nating certain food consistencies, such as thin
exhibits premature spillage of a bolus because liquids, from the diet can be difficult for the
of oral abnormalities, videoendoscopy will patient. This should only be done if other
not be capable of distinguishing premature compensatory or therapy strategies are not
spillage from the onset of pharyngeal delay feasible, as in a patient with a movement dis-
time with the same accuracy as videofluoros- order whose posture changes continuously,
copy, since the oral stage of swallow cannot be who cannot follow directions and use swallow
visualized with videoendoscopy. maneuvers, and for whom oral sensory proce-
dures are inappropriate. Table 2 presents the
Modifications in Volume and Speed of easiest food consistencies and the food consis-
Food Presentation tencies to be avoided for each swallow disor-
For some patients, a particular volume of der.
food per swallow elicits the fastest pharyngeal
swallow [20, 28]. In patients with a delay in Intraoral Prosthetics
pharyngeal triggering or with weakened pha- Intraoral prosthetics can be an important
ryngeal swallows which require 2–3 swallows compensatory procedure to improve swallow-
per bolus, taking too much food too rapidly ing in oral cancer patients with significant loss
can result in a sizable collection of food in the of oral tongue tissue (25% or more) or tongue
pharynx and aspiration. Simply taking small- movement, in neurologic patients with bilat-
er boluses at a slower rate may eliminate any eral hypoglossal paralysis, in oral cancer pa-
risk of aspiration in these patients. tient groups with surgical ablation of part or
all of the soft palate, and in neurologic pa-
tients with palatal paralysis.

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Fig. 1. Diagram of an intraoral pal-
atal reshaping prosthesis designed
to recontour the patient’s hard pal-
ate to interact with the remaining
tongue.

A palatal lift prosthesis lifts the soft palate of controlling food in the mouth for chewing
into an elevated (closed) position in patients or swallowing.
with velar paralysis. A palatal obturator can These intraoral prosthetics are usually con-
be used in oral cancer patients with significant structed by a maxillofacial prosthodontist in
resection of the soft palate. The palatal re- cooperation with the speech-language pathol-
shaping prosthesis recontours the hard palate ogist/swallowing therapist. Construction
to interact with the remaining tongue, filling should begin within the first 4–6 weeks post-
in the areas of the hard palate where the operatively to prevent the patient’s develop-
patient’s tongue cannot make contact and en- ment of poor habits for swallowing which will
abling the patient to control and propel the need to be dishabituated when they receive
bolus more efficiently (fig. 1). A palatal aug- the prosthesis. The speech-language patholo-
mentation or reshaping prosthesis can be ex- gist/swallowing therapist provides input re-
tremely effective in patients with significant garding the amount of palate lowering needed
tongue resections or bilateral tongue paralysis and the best contour of the palate.
[29, 30]. Postoperative patients often indicate Compensatory procedures are usually used
that it feels as if their tongue ‘fits their mouth temporarily until the patient’s swallow recov-
again’ with the prosthesis in place. Without ers or direct therapy procedures to improve
the prosthesis the patient has a large oral cavi- oropharyngeal motor function take effect. Oc-
ty and a very small tongue which is incapable casionally, patients with severe neurologic or

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structural damage must use compensatory the best exercise for swallowing may be to
procedures permanently to eliminate aspira- encourage swallowing if it can be done safely,
tion and ensure adequate swallow efficiency i.e., without aspiration.
to facilitate oral intake [31, 32].
Swallow Maneuvers: Taking Voluntary
Control over Selected Aspects of
Therapy Procedures Pharyngeal Swallow Physiology
Swallow maneuvers are designed to place
Therapy procedures are designed to specific aspects of pharyngeal swallow physi-
change swallow physiology, in contrast to ology under voluntary control [1, 4, 31, 35–
compensatory strategies which are designed 39]. Four swallow maneuvers have been de-
to redirect or improve food flow and elimi- veloped to date: (1) the supraglottic swallow,
nate symptoms such as aspiration. Therapy (2) the super-supraglottic swallow, (3) the ef-
procedures are generally designed to improve fortful swallow and (4) the Mendelsohn ma-
the range of motion of oral or pharyngeal neuver (table 3).
structures, improve sensory motor integra- The supraglottic swallow is designed to
tion, or take voluntary control over the timing close the airway at the level of the true vocal
or the coordination of selected oropharyngeal folds before and during the swallow [1, 4, 38].
movements during swallow [4]. To get best Instructions for the supraglottic swallow are
effect, therapy procedures generally, but not [38, 39]:
always, require the patient to follow direc-
tions and practice independently of the clini- Inhale and hold your breath. (Breath hold usually
closes the vocal folds, thus closing the airway.) Swallow
cian.
while holding your breath. Cough immediately after
your swallow without breathing in.
Resistance, Range of Motion and Bolus Alternative instructions: Inhale and exhale a little.
Control Exercises Hold your breath and keep holding your breath as you
Range of motion exercises can be used to swallow. After you swallow, cough.
improve the extent of movement of the lips,
jaw, tongue, larynx and vocal folds (adduction The super-supraglottic swallow is designed
exercises) [4, 33]. Range of motion exercises to close the airway entrance before and during
involve extending the target structure in the the swallow [1, 38, 39]. The instructions for
desired direction until a strong stretch is felt. the super-supraglottic swallow are:
The structure is held in extension for 1 s, then
Inhale, hold your breath and bear down. The effort
relaxed. Bolus control and chewing exercises of bearing down usually closes the false vocal folds and
can be used to improve fine motor control of tilts the arytenoids anteriorly to meet the thickening
the tongue. Bolus control and chewing exer- base of epiglottis. After the swallow, cough to clear any
cises are both best done using gauze or other leftover food.
Alternate instructions: Inhale and exhale a little.
cloth, at least initially [4]. Sliding into falsetto
Hold your breath and bear down hard. Keep holding
(a very high pitched, squeaky voice) can exer- your breath hard as you swallow. After you swallow,
cise laryngeal elevation. cough.
There is some evidence that swallowing
requires more muscle effort than other func- The effortful swallow is designed to in-
tions of the upper aerodigestive tract [34]. crease posterior motion of the tongue base
Because of this high level of muscle activity, during the pharyngeal swallow and thus im-

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Table 3. Swallow maneuvers, i.e., voluntary control over selected aspects of the pharyngeal stage of swallow, the
swallowing disorders for which they are appropriate and their rationale

Swallow maneuver Problem for which maneuver Rationale


is appropriate

Supraglottic swallow Reduced or late vocal fold closure voluntary breath hold usually closes vocal
folds before and during swallow [38]
delayed pharyngeal swallow closes vocal folds before and during delay
Super-supraglottic swallow reduced closure of airway entrance effortful breath hold tilts arytenoid forward
closing airway entrance before and during
swallow [38, 39]
slow laryngeal elevation speeds laryngeal elevation [39, 56]
Effortful swallow reduced posterior movement of the effort increases posterior tongue base
tongue base, reduced oropharyngeal movement [42]
pressure
Mendelsohn maneuver reduced range of laryngeal movement laryngeal movement opens the UES;
prolonging laryngeal elevation prolongs
UES opening [32, 35, 36]
discoordinated swallow normalizes timing of pharyngeal swallow
events [31]

UES = Upper esophageal sphincter.

prove bolus clearance from the valleculae [1, low, don’t let your Adam’s apple drop. Hold it up with
40–42]. The instructions for the effortful your muscles for several seconds.
Alternate instructions: Swallow your saliva several
swallow are:
times and pay attention to the feeling in your throat as
you swallow. Can you feel that in the middle of the
As you swallow, squeeze hard with all of your mus- swallow everything squeezes together at the top of your
cles. throat? Next time when you swallow, hold the squeeze
for several seconds and don’t let go.
The Mendelsohn maneuver is designed to
increase the extent and duration of laryngeal All of these maneuvers can be practiced
elevation and thereby increase the duration with the patient, using no food. The patient
and width of cricopharyngeal opening [31, 32, can be given slow, step-by-step instructions
43–47]. This latter maneuver can also im- for practice, asking them to swallow their
prove the overall coordination of the swallow saliva.
[31]. Instructions for the Mendelsohn ma- During the diagnostic videofluorographic
neuver are: study, if postural techniques and oral sensory
facilitation techniques do not improve swal-
Swallow your saliva several times and pay atten-
low physiology sufficiently to allow the pa-
tion to your neck as you swallow. Tell me if you can
feel that something (your Adam’s apple or voice box) tient to begin some oral intake, voluntary
lifts and lowers as you swallow. Now, this time, when swallow maneuvers may be appropriate.
you swallow and you feel something lift as you swal- However, these maneuvers require the ability

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Table 4. Combinations of maneuvers and postures which often result in the best swallow for some patients

Swallow maneuver Complementary swallow Problem for which this combination


posture is appropriate

Supraglottic swallow chin down closure of airway at vocal folds


Super-supraglottic swallow chin down B head rotation closure of airway at entrance
Effortful swallow chin down reduced oropharyngeal pressure
Mendelsohn maneuver head rotation reduced laryngeal elevation and unilateral
pharyngeal wall weakness

to follow directions carefully and are not fea- these maneuvers during the swallow, a signif-
sible in patients who have cognitive or signifi- icant limitation.
cant language impairment. These maneuvers Recently, a new exercise, a head-raising
also require increased muscular effort and are exercise [49], has been described to strengthen
not appropriate in patients who fatigue easily. laryngeal motion during swallowing and
Usually, voluntary maneuvers are utilized thereby affect opening of the upper esophage-
temporarily as the patient’s swallow recovers, al sphincter. The exercise effect has been ex-
and are then discarded as the patient’s swal- amined in older normal individuals where
low physiology returns to normal. However, hyoid and laryngeal motion tends to dimin-
there are patients who can only swallow safely ish. Hyoid motion is responsible in large mea-
and efficiently using a voluntary maneuver sure for upward forward laryngeal motion
permanently [31, 32, 48]. For some patients, during swallow which, in turn, is largely re-
best swallow is achieved by a combination of sponsible for opening the upper esophageal
postural changes and swallow maneuvers. Op- sphincter [36, 43]. The exercise consists of 3
timal contributions of postures and maneu- repetitions of the individual lying on their
vers are presented in table 4. back and lifting their head up so they can see
Each swallow maneuver has a specific their toes without raising their shoulders and
goal to change a selected aspect of pharyngeal holding it for 1 min and then relaxing for
swallow physiology [1]. Changes in these tar- 1 min. Then 30 repetitive short head raisings
get components of the oropharyngeal swal- are done and the exercise done 3 times a day.
low can be observed or measured, e.g., dura- Results of application of the exercise to nor-
tion and onset of closure of the airway en- mal older subjects revealed improved anterior
trance (super-supraglottic swallow), extent laryngeal movement, extent of upper esopha-
and duration of laryngeal elevation (Mendel- geal sphincter anterioposterior opening and
sohn maneuver) [31, 32, 35–38, 40, 41, 44– reduced hypopharyngeal intrabolus pressure.
46]. In general, the effects of swallow ma- Indirect therapy involves exercise pro-
neuvers are best observed and measured us- grams or swallows of saliva but no food or liq-
ing videofluoroscopy. The effects of these uid is given. Any of the therapy procedures
maneuvers on swallow safety (aspiration) described above can be done indirectly or
and efficiency (residue) may be observed at directly. Even swallow maneuvers can be
times using videoendoscopy. However, vid- practiced with saliva only. Indirect therapy is
eoendoscopy does not allow visualization of used in patients who aspirate on all food vis-

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cosities and volumes despite introduction of However, there are patients who cannot swal-
compensatory strategies. Therefore, these pa- low successfully without swallow maneuvers
tients are unsafe for any oral intake [4, 46]. [31, 32, 48].
However, indirect therapy can be combined In some cases, introduction of therapy
with direct therapy. techniques into the diagnostic procedure can
Direct therapy is used when patients are immediately enable the patient to begin eat-
practicing their swallow techniques with some ing. Introduction of these treatment strategies
small amounts of food or liquid. Direct thera- is particularly important because there is a
py is used when the patient can successfully growing body of literature indicating a rela-
swallow at least small amounts of selected liq- tionship between disturbed swallowing and
uid or food viscosities with no aspiration [4, aspiration observed on the radiographic study
46]. and risk for aspiration pneumonia [50–52]. If
aspiration can be eliminated during the video-
Introduction of Treatment Strategies in the fluoroscopic procedure and during subse-
Diagnostic Radiographic Study quent oral intake, risk of pneumonia is re-
In general, the introduction of treatment duced. In other cases, evaluation of the effec-
strategies in the diagnostic radiographic study tiveness of the therapy procedure can validate
will begin with utilization of postural tech- its appropriateness for use with a patient in
niques, followed by introduction of tech- building the neuromuscular control necessary
niques to increase oral sensation, when appro- to return to oral intake.
priate, followed by swallowing maneuvers, Not all therapy procedures can be intro-
then combinations of these as appropriate or duced into the diagnostic setting, however;
needed, and finally, diet (food consistency, some therapy procedures take time to take
viscosity) changes, if needed [1, 6, 10]. The effect and, therefore, do not result in imme-
rationale for this sequencing of interventions diate change. For example, resistance and
is based upon the muscle effort required by range of motion exercises for the lips, tongue
the patient and the ease of application and and/or jaw do not have an immediate effect
learning of the various procedures. In general, but, depending upon the extent and severity
postural techniques are easily utilized by a of neuromuscular involvement, can show an
wide range of patients, even those with re- effect after 2–3 weeks of practice. However,
duced cognition, children and patients with the clinician can still quantify the effects of
some degree of restricted physical mobility. range of motion exercises by measuring the
Procedures designed to increase oral sensa- patient’s structural movement at each therapy
tion can also be utilized with a wide range of session. When a second assessment is com-
patients, as they are clinician-controlled and pleted, change in range of motion of the target
do not require the patient to actively cooper- structure can be assessed by comparing the
ate, other than allowing the clinician to place first and second studies.
something into their mouth. Swallow ma- The introduction of treatment techniques
neuvers, on the other hand, require ability to into the diagnostic swallowing assessment re-
follow directions and voluntarily manipulate quires the clinician to interpret or ‘read’ the
the oropharyngeal swallow as it is ongoing. radiographic study or other imaging proce-
Swallow maneuvers also involve increased dure immediately and identify the physiolog-
work or muscular effort in most cases, thus ic dysfunction(s) so that appropriate therapy
increasing the patient’s potential for fatigue. procedures can be selected and introduced.

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Because videofluorography involves X-ray is usually provided daily for inpatients and
exposure to the patient, all possible treatment weekly for outpatients.
techniques cannot be attempted randomly to In general, tracheostomy tubes and non-
look at their relative value in X-ray. Rather, oral feeding tubes are left in place during swal-
the clinician must select those treatment tech- lowing assessment and therapy, as these have
niques believed to be most appropriate for not been found to significantly deter rehabili-
that patient’s anatomy and swallow physiolo- tation. However, the cuff of the tracheostomy
gy. The usual limit for radiation exposure in tube should be deflated if medically feasible
adults is 5 min. It is usually possible to assess during the assessment and therapy. An in-
the effects of selected management/treatment flated cuff can restrict laryngeal elevation and
procedures within that amount of exposure cricopharyngeal opening during the swallow.
time. An inflated tracheostomy cuff can also cause
tracheal irritation by rubbing on the tracheal
walls as the larynx elevates during swallow.
Timing of Swallow Therapy Therefore, it is inappropriate to feed a patient
with a tracheostomy cuff inflated. If the pa-
As soon as an inpatient in acute care is tient is aspirating, they should not be fed oral-
medically stable and identified as dysphagic, ly. On occasion it may be absolutely necessary
a videofluorographic assessment of their swal- to leave the cuff inflated, such as when the
low function should be accomplished by the patient is ventilator-dependent. Many venti-
swallow therapist and radiologist. From this lators require cuff inflation.
assessment, an appropriate therapy plan
should be initiated, with the patient seen daily
in the hospital and weekly thereafter. For sur- Medications for Swallowing
gically treated head and neck cancer patients, Disorders
assessment and treatment of swallow dysfunc-
tion should begin as soon as healing has pro- Currently, there are few studies of the ther-
gressed enough to allow them to try to swallow apeutic benefits of medications on specific
(usually 7–14 days postoperatively with no oropharyngeal swallowing disorders. Utiliza-
healing complications) [53]. If a patient is tion of atropine to reduce drooling [54] has
undergoing radiation therapy and begins been documented. No other medications to
complaining of swallowing problems, assess- improve specific oropharyngeal swallowing
ment and treatment should begin at that time. disorders have been identified. In patients
For stroke patients, assessment should take with neurologic disease such as myasthenia
place when they are awake and alert, usually gravis and Parkinson’s disease, medication
4–7 days post ictus. Outpatients who are dys- for their disease may improve swallow physi-
phagic should receive the same careful video- ology. It is usually best to reevaluate the
fluorographic assessment and therapy as inpa- patient’s swallow function after they have
tients. Even if patients have been dysphagic reached optimal medication levels and to ini-
for some time, they should receive the same tiate swallowing therapy when the patient has
type of assessment and intensive therapy. Pa- continued to demonstrate a swallowing prob-
tients who receive therapy months or years lem.
after the onset of their problem are still capa- Patients with progressive neurologic dis-
ble of achieving oral intake [31, 32]. Therapy ease, i.e. Parkinson’s disease, multiple sclero-

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sis, and myasthenia gravis, sometimes experi- ment in the aspects of swallowing targeted in
ence improvement in oropharyngeal swallow- therapy such as extent of laryngeal elevation,
ing when placed on medications for their dis- duration of airway closure, duration of any
ease process. Unfortunately, detailed studies pharyngeal swallow delay, etc. In addition,
of the effects of specific medications on the clinicians should collect data on the out-
oropharyngeal function of these patients have come(s) of their therapy including the length
not been completed. of time until the patient returns to liquid oral
intake, solid food oral intake, and complete
oral intake. It is these latter kinds of measures
The Clinician’s Responsibility which third-party payers are most interested
regarding Clinical Efficacy in receiving.

Each clinician working in dysphagia


should be knowledgeable about the literature Summary
supporting each treatment procedure he uses. In summary, behavioral management of oropha-
Before applying a new treatment procedure, ryngeal dysphagia by the speech-language pathologist
the clinician should be aware of the existing can be quite effective when: (1) the exact nature of the
data published in peer-reviewed journals re- patient’s abnormal swallowing physiology or any ana-
tomic swallow disorders are defined; (2) the clinician
garding the efficacy and outcomes of the pro-
examines the effectiveness of swallowing therapy pro-
cedure [55]. This is the basis of evidence- cedures during any diagnostic assessment, and (3) the
based practice. Therapy procedures should swallowing therapist applies these procedures to pa-
not be utilized that have no such published tients with appropriate ability to learn and utilize them
evidence. on a regular basis. Taking patients onto the caseload
who clearly cannot benefit from therapy, such as those
Each clinician should also collect efficacy
with advanced Alzheimer’s disease, can only reflect
and outcome data on each of their patients to poorly on the clinician, the success of dysphagia man-
document their clinical effectiveness. Efficacy agement and the overall effectiveness of our profes-
data include measurement of the improve- sion.

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