Postural techniques

Postural techniques often are the first line of treatment considered because they are relatively easy to do, most patients do not have trouble moving their neck or head, and most are able to use these postures with minimal direction. There are five postures and several postural combinations that can have specific effects on the oropharyngeal swallow, generally in terms of how food is flowing and where it is flowing. The effectiveness of each posture has been examined in several populations . The five postures are chin down, chin elevated, head turned, head tilted, and lying down. Each posture has specific effects on the flow of food and the relationship of oropharyngeal structures.

Chin-down posture narrows the distance between the tongue base and pharyngeal wall and is helpful in patients who have a tongue base disorder. The chin-down posture widens the valleculae in some individuals, enabling the valleculae to capture the bolus during a pharyngeal delay and prevent aspiration before the swallow. The chin-down posture also is helpful when patients have reduced airway closure because the chin-down posture also narrows the airway entrance . The chin-elevated posture is helpful in patients who have oral tongue problems, such as those who have amyotrophic lateral sclerosis or who have part of the tongue removed because of head and neck cancer. These patients have difficulty generating adequate lingual pressures to drive the bolus out of the mouth and into the pharynx.

The chin-up posture enables the bolus to drop by gravity into the pharynx. A requirement of use of this posture is that the patients have a timely triggering of the pharyngeal swallow and that they have good airway closure. As a protection, patients can hold their breath before lifting the head (the supraglottic swallow), such that the airway is protected before the bolus drops from the mouth.

The third posture, head rotation, is useful when there is a unilateral pharyngeal wall paresis or paralysis or unilateral laryngeal paralysis. The head should be rotated to the side of the damage . This closes that side of the pharynx that the head is rotated toward and directs the bolus down the more normal side. If patients have a problem with oral transit and pharyngeal function on the same side, tilting the head toward the stronger side to direct the bolus down that side can be helpful. This can occur in patients treated for head and neck cancer at the back or base of the tongue. It also can happen to some patients who have had neurologic damage on one side of their mouth and pharynx.

The fifth posture is lying down. This is useful for patients who have bilateral pharyngeal damage or reduced laryngeal elevation causing aspiration after the swallow. Lying down changes the way gravity affects residue: it keeps residue in the pharynx from falling into the larynx and a follow-up swallow clears the residue into the esophagus.

Sensory stimuli

A second set of treatment procedures whose effectiveness can be evaluated during the radiographic study is the presentation of a heightened preliminary sensory stimulus. This includes changing the taste, volume, temperature, or carbonation to be swallowed as the bolus is the primary sensory stimulus for the swallow. Other procedures for heightening preswallow sensory stimulation include thermal tactile stimulation and providing additional pressure on the tongue with a spoon as food is presented. Patients who have a swallow disorder related to reduced sensation, such as delayed oral onset, delayed pharyngeal swallow, and apraxia of swallow, may benefit from these techniques. There is a more research needed to validate these techniques and their effects on the swallow in various types of patients. It has been reported that these sensory techniques are effective in patients who have sensory disorders, but how long should the stimulation continue and for how many minutes per day? This has yet to be studied in specific types of patients.

Sensory stimuli

A second set of treatment procedures whose effectiveness can be evaluated during the radiographic study is the presentation of a heightened preliminary sensory stimulus. This includes changing the taste, volume, temperature, or carbonation to be swallowed as the bolus is the primary sensory stimulus for the swallow. Other procedures for heightening preswallow sensory stimulation include thermal tactile stimulation and providing additional pressure on the tongue with a spoon as food is presented. Patients who have a swallow disorder related to reduced sensation, such as delayed oral onset, delayed pharyngeal swallow, and apraxia of swallow, may benefit from these techniques. There is a more research needed to validate these techniques and their effects on the swallow in various types of patients. It has been reported that these sensory techniques are effective in patients who have sensory disorders, but how long should the stimulation continue and for how many minutes per day? This has yet to be studied in specific types of patients.

Voluntary changes (swallow maneuvers) in the swallow

There are several voluntary changes that can be made during the pharyngeal swallow by dysphagic patients. These voluntary changes also are used spontaneously by normal patients and patients who have various disease entities . Included in these voluntary changes are (1) the superglottic swallow, (2) the super-supraglottic swallow, (3) the effortful swallow, and (4) the Mendelsohn maneuver. Each of these can be used to modify swallow physiology in specific ways.

The supraglottic swallow involves holding the breath before, during, and after the swallow and results in closure of the true vocal folds before, during, and after the swallow . The super-supraglottic swallow also prolongs airway closure before, during, and after the swallow with extra effort. The effort translates to closure of the airway entrance at the false vocal folds with the arytenoid cartilages tilting forward to the base of epiglottis . The effortful swallow involves contracting the muscles involved in swallowing with great effort to increase the oral and pharyngeal pressures generated during the swallow . The Mendelsohn maneuver is designed to voluntarily increase the movement of the larynx and hyoid during the pharyngeal swallow and thereby prolong and extend the opening of the upper esophageal sphincter (UES). The Mendelsohn maneuver is useful in patients who have suffered a brainstem stroke . A fifth voluntary maneuver, known as the tongue holding or Masako maneuver, involves pulling the tongue base forward, anchoring the oral tongue between the front teeth, and swallowing with the tongue in that position. This exercise involves stabilizing the oral tongue in a more forward position, thereby forcing the glossopharyngeus muscle, which connects the tongue base to the pharyngeal wall, to contract further. It may be most appropriate to use this exercise with patients who have weak pharyngeal contraction . Radiographic examination of this swallow maneuver reveals greater bulging in the posterior pharyngeal wall at the level of the glossopharyngeus muscle .

All of these voluntary changes in the swallow result in specific changes in oropharyngeal swallow, which have been documented and measured. The length of time patients need to use these maneuvers varies with the cause of their dysphagia. There are no studies that examine the optimum number of repetitions of these voluntary maneuvers or the number of weeks needed to practice them by various types of dysphagic patients. Such studies are much needed. In some cases, patents need to use these swallow maneuvers permanently to facilitate oral feeding . In other cases, frequent practice of the maneuver lead to lasting changes in swallow physiology. This also needs more study.

Exercises

There are several exercise programs needed by some types of patients to build strength and coordination of muscles in the oropharyngeal swallow and enable return to oral feeding. These exercises require pre- and postexercise assessments. Their effectiveness is not immediate. Each exercise takes time (1 to 6 weeks) to be effective. Each exercise has a specific purpose and should be used in patients who have that specific swallow disorder or cause. For example, range-of-motion exercises typically are used in patients who have had treatment of head and neck cancer or other peripheral damage, such as might occur after a motor vehicle accident. Any of these patients can sustain damage reducing range of lip, tongue, or jaw motion, which affect oropharyngeal swallow. In each range-of-motion exercise for each structure, the structure is extended as far as possible in each direction and held firmly in the extended position for at least a count of 3. Typically, patients are requested to repeat each motion 5 times for 5 to 10 times per day. Lips, tongue, and jaw movement can be improved with these range-of-motion exercises, and the improvement can be measured using a millimeter ruler and asking patients to extend the structure as far as possible in each direction .

Combinations of treatment approaches

During the videofluoroscopic (modified barium swallow) study of a patient, techniques can be combined and the effects observed for best results. For example, head rotation to the weak side for a patient who has unilateral pharyngeal weakness while performing the Mendelsohn maneuver can result in the best improvement in cricopharyngeal opening. In patients who have laryngeal closure problems resulting in aspiration during the swallow, best outcomes may include chin-down posture to narrow the airway entrance with the supraglottic or super-supraglottic swallow. It is critical that clinicians use a patient’s instrumental diagnostic study to assess the effectiveness of procedures to improve the swallow. This constitutes an evaluation of a patient’s individual treatment efficacy. The videofluoroscopic study is an excellent teaching tool for speech-language pathologists to illustrate treatment effects for the patients and families, physicians, and nurses.

Although there are few large-scale treatment studies showing the effectiveness of various treatments of oropharyngeal dysphagia, there are individual case study illustrations and several large-scale studies (described later).

Dietary change

One method to improve safety and efficiency of a patient’s swallow may involve changing the food consistency in the diet. It cannot be assumed, however, that thickening liquids will solve a patient’s dysphagia problem. Instead, a clinician must examine the effects of the various food viscosities on an individual patient’s swallow. Unfortunately, many clinicians in nursing homes automatically thicken liquids for a patient who coughs at mealtime. Thickening liquids to various viscosities may not result in greater safety as revealed in the results from a recent clinical trial .

This large study, involving more than 500 patients, recently has been completed by the Communication Sciences and Disorders Clinical Trials Research Group (CSDRG). This two-part clinical trial examined the effect of two common dysphagia interventions (chin down and two viscosities of thickened liquids) on immediate prevention of aspiration during the modified barium swallow (Part I) and on the incidence of pneumonia after 3 months of use with the interventions for patients who had Parkinson’s disease or dementia .

The focus of this clinical trial was pneumonia because it is “the most common cause of infectious death in the U.S. among persons over age 65 and the third leading cause of death for persons over 85 . One hospital admission for pneumonia is estimated to cost $7,166 . Rates of hospital discharge for Medicare beneficiaries with pneumonia as a primary diagnosis have risen by 93.5% in the last decade , length of stay has increased, and there has been an increase in death rates” .

Aspiration of liquids in older individuals suffering from debilitation and dementia is believed the most common type of aspiration . Relative risk for aspiration leading to pneumonia is highest in demented patients followed by those who are institutionalized . Research indicates that 70% to 80% of people who have Alzheimer’s disease have dysphagia , and as many as 50% of people who have Parkinson’s disease are dysphagic. An added challenge with these populations is the high incidence of silent aspiration .

Thickened liquid diets are a common treatment of liquid aspiration even in the absence of efficacy data. This intervention is costly financially and regarding quality of life. It costs approximately $200 per month for an individual to drink thickened liquids .

A common alternative to thickened liquids is using a chin-down posture, which is believed to prevent aspiration of liquids. Welch and colleagues reported that posterior shift of anterior pharyngeal structures with the chin down improved airway protection. Rasley and colleagues demonstrated that many patients who have liquid aspiration can swallow safely with their chin down. Although previous reports have provided a basis for the widespread clinical use of chin-down posture, these studies do not provide long-term effects on rate of pneumonia.

The CSDRG was funded to conduct the largest randomized clinical trial ever completed in dysphagia and designed to investigate the effectiveness of two commonly used interventions for treatment of thin liquid aspiration: chin-down posture and thickened liquids (nectar thick and honey thick). The study, entitled, “Randomized Study of Two interventions for Liquid Aspiration: Short- and Long-term Effects,” was funded by the National Institute on Deafness and Other Communication Disorders.