clinical review

Dysphagia: Swallowing Therapy, indirect

indexing Metadata/Description
  Title/condition: Dysphagia: Swallowing Therapy, Indirect Synonyms: Swallowing disorder: swallowing therapy, indirect; deglutition disorder: swallowing therapy, indirect; oral dysphagia: swallowing therapy, indirect; pharyngeal dysphagia: swallowing therapy, indirect; esophageal dysphagia: swallowing therapy, indirect; difficulty swallowing: swallowing therapy, indirect; dysphagia, oral: swallowing therapy, indirect; dysphagia, pharyngeal: swallowing therapy, indirect; dysphagia, esophageal: swallowing therapy, indirect; swallowing difficulty: swallowing therapy, indirect; swallowing therapy, indirect: dysphagia; indirect swallowing therapy: dysphagia   Anatomical location/body part affected: Anatomy of swallowing, which can include the lips, tongue, buccal muscles, laryngeal structures, and/or pharyngeal structures Description: Dysphagia therapy can be conceptualized in two ways: direct vs. indirect therapy or facilitative vs. compensatory therapy.(1, 2) Direct dysphagia therapy is comprised of interventions that involve the presentation of food or liquid requiring a patient to swallow, and indirect dysphagia therapy is comprised of exercises that indirectly improve the swallow (i.e., the patient is NOT given food or liquids to swallow during the therapy sessions).(1, 2) Compensatory dysphagia therapy is comprised of interventions that alter the external factors related to swallowing and do not address the underlying dysphagia itself, while facilitative dysphagia therapy is comprised of interventions that are designed specifically to improve the swallow function.(1) This Clinical Review focuses on indirect dysphagia therapy. Indirect dysphagia therapy is provided to patients with very impaired swallowing function who will likely aspirate any consistency of food or liquid provided to them.(2) The decision to treat a patient with indirect dysphagia therapy only is made based on the results of an instrumental swallow evaluation such as a flexible endoscopic examination of swallowing (FEES), modified barium swallow study (MBS)/videofluoroscopic swallow study (VFSS)(2)

Therapy techniques that might be utilized in an indirect dysphagia therapy program include oral motor
exercises, oral stimulation, base of tongue exercises, and pharyngeal/laryngeal strengthening exercises(1, 2)  ICD-9 codes

 

787.20 dysphagia, unspecified 787.21 dysphagia, oral phase 787.22 dysphagia, oropharyngeal phase 787.23 dysphagia, pharyngeal phase 787.24 dysphagia, pharyngoesophageal phase

ICD-10 codes: R13 dysphagia Reimbursement: Reimbursement for therapy will depend on insurance contract coverage; no specific special agencies are applicable for this condition

causes, Pathogenesis, & Risk Factors


author
Heather Wiemer, MA, CCC-SLP

Dysphagia

Dysphagia is the term that refers to difficulty swallowing and/or a swallowing disorder(3, 4) Complications of dysphagia include malnutrition, dehydration, aspiration and aspiration pneumonia,
and death(3, 5, 6)

Reviewers
Amory Cable, PhD, CCC-SLP Cinahl Information Systems Glendale, California Rehabilitation Operations Council Glendale Adventist Medical Center Glendale, California

There are two types of dysphagia(4) Oropharyngeal dysphagia

 Dysphagia involving the oral phase, pharyngeal phase or both oral and pharyngeal phases of

swallowing(4, 7, 8)

Editor
Sharon Richman, MSPT Cinahl Information Systems

Dysphagia that affects the oral phase only is referred to as oral dysphagia(9) Dysphagia that affects the pharyngeal phase only is referred to as pharyngeal dysphagia(9) Dysphagia that affects both oral and pharyngeal phases of the swallow is referred to as
oropharyngeal dysphagia(9)
 Symptoms of oropharyngeal dysphagia include choking and/or coughing while eating and/or drinking,

pocketing food in the cheeks, and loss of food or liquid from the mouth while attempting to swallow(3, 7)
 Oropharyngeal dysphagia is the type of dysphagia for which indirect swallowing therapy techniques
February 3, 2012

are appropriate

Published by Cinahl Information Systems. Copyright2012, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

 Esophageal dysphagia
 Dysphagia resulting from an impairment of the esophagus or lower esophageal sphincter(4, 7, 8)  Patients generally report symptoms such as regurgitation or heartburn(3, 7, 8)

For additional information on assessment and treatment of dysphagia, see the series of Clinical Reviews on this topic
 Risk factors for dysphagia Cervical osteophytes(4) Ear, nose, throat, or maxillofacial surgery(10) Advanced age(6, 8, 11) (for information on assessment and treatment of dysphagia in older adults, see Clinical Review Dysphagia in Older Adults; Accession Number: 5000011110) Head and neck cancer(3, 4) Infection(4) Botulism(4) Diphtheria(4) Lyme disease(4) Syphilis(4) Neurological disease(3, 4, 10) Amyotrophic lateral sclerosis (ALS)(4, 8) (for information on assessment and treatment of patients with ALS, see Clinical Review Dysphagia: Amyotrophic Lateral Sclerosis (ALS); Accession Number: 5000010996) Brainstem tumor(4) Stroke(3, 4, 8, 12) (for information on assessment and treatment of patients with stroke, see Clinical Review Stroke Rehabilitation: Speech Therapy; Accession Number: 5000009271) Dementia (for information on assessment and treatment of patients with dementia, see Clinical Review Dysphagia: Dementia; Accession Number: 5000010719)(3) Dermatomyositis/polymyositis(4) Multiple sclerosis(3, 4, 8) (for information on assessment and treatment of patients with multiple sclerosis, see Clinical Review Dysphagia: Multiple Sclerosis; Accession Number: 5000011039) Myasthenia gravis(4, 8) (for information on assessment and treatment of patients with myasthenia gravis, see Clinical Review Dysphagia: Myasthenia Gravis in Adults; Accession Number: 5000011602) Myotonic dystrophy (for information on assessment and treatment of patients with myotonic dystrophy, see Clinical Review Dysphagia: Myotonic Dystrophy in Adults; Accession Number: 5000011798)(4) Paraneoplastic syndrome(4) Parkinsons disease(3, 4, 8) (for information on assessment and treatment of patients with Parkinsons disease, see Clinical Review Dysphagia: Parkinson's Disease; Accession Number: 5000010718) Postpolio syndrome (for information on assessment and treatment of dysphagia in postpolio syndrome, see Clinical Review Dysphagia: Post-Polio Syndrome; Accession Number: 5000011663)(4) Sarcoidosis(4) Traumatic brain injury(4, 8) (for additional information on assessment and treatment of traumatic brain injury, see the series of Clinical Reviews on this topic) Cervical or esophageal surgery(4, 10) Prolonged endotracheal intubation(11) Zenkers diverticulum(4, 8)

Overall contraindications/Precautions
  Physician order must be obtained prior to evaluation and treatment of dysphagia See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/Plan of Care

Examination
  Contraindications/precautions to examination See full Contraindications/precautions to examination in the series of Clinical Reviews on dysphagia History History of present illness/injury Mechanism of injury or etiology of illness  An interview with the patient and/or family members might be appropriate to gather a detailed history of the symptoms and presentation(13)  Does the patient have a diagnosis that places him or her at an elevated risk for dysphagia?(13) Course of treatment  Medical management: Note current and previous medical management of diagnosis; does any of the medical treatments place patient at an elevated risk for dysphagia? Chemotherapy and radiation therapy can result in xerostomia (dry mouth);(11) xerostomia is frequently associated with dysphagia(8, 11) Current or previous ear, nose, throat, maxillofacial, cervical, or esophageal surgery/procedures(4, 10)

 Medications for current illness/injury: Determine what medications physician has prescribed; are they being taken? The concurrent use of

multiple medications is common in older adults who have complex medical conditions, and the side effects of these medications can adversely affect cognitive functioning(14)  Medication-induced dysphagia can occur even if dysphagia is not specifically listed as a possible side effect(15) Medications that reduce a patients alertness and awareness increase the risk of dysphagia(15) Drug interactions can cause xerostomia(15) Contact a pharmacist or physician regarding questions about side effects(14)  Diagnostic tests completed: Usual tests for this condition are the following: Bedside swallow examination (BSE) Chest X-ray VFSS or FEES  Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative therapies (e.g., acupuncture) and whether or not they help Occasionally patients and family members develop their own strategies for managing dysphagia (such as using gravies with all meats or chopping up the food into very small pieces) Patients with prior histories of dysphagia might already be using an altered diet prior to admission(16) Ask patient and/or caregiver what types of food or drink the patient prefers and/or avoids at home(16)  Previous therapy: Document whether patient has had speech, occupational, or physical therapy for this or other conditions and what specific treatments were helpful or not helpful Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased)(17)  Does the patient complain of difficulty of swallowing: With specific foods? With specific meals? Only halfway through the meal? When he or she is distracted or having a meal with a group of people?(6) Nature of symptoms: Document nature of symptoms  For patients who complain of difficulty swallowing, what exactly is the problem with swallowing?  Does food stick in the throat?(8)  Does the patient cough and/or choke while eating or drinking?  Is there pain associated with swallowing? Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M., night); also document changes in symptoms due to weather or other external variables  When did the symptoms of dysphagia first present?(18)  How frequently does the patient experience the symptoms of dysphagia?(18) Sleep disturbance: Does difficulty swallowing saliva and/or secretions interfere with patients ability to sleep?  Document number of wakings/night Respiratory status: Patients with a compromised respiratory status are at higher risk of complications (such as aspiration pneumonia) due to dysphagia(16, 17)  Does the patient require supplemental oxygen? Nasal cannula?(10)  Does the patient have a tracheostomy tube?(10) When the patient has an uncapped tracheostomy tube, subglottic pressure is reduced and the strength of the swallow is altered(17)  Does the patient require ventilator support? Patients who require ventilator support are at elevated risk for aspiration during swallowing(17) Barriers to learning  Are there any barriers to learning? Yes No  If Yes, describe _________________________ Medical history Past medical history  Previous history of same/similar diagnosis: Does the patient have a previous history of oropharyngeal dysphagia?(17)  Comorbid diagnoses: Ask patient about other problems, including diabetes, cancer, heart disease, complications of pregnancy, psychiatric disorders, orthopedic disorders, etc.  Other symptoms: Ask patient about other symptoms he/she may be experiencing Social/occupational history Patients goals: Document what the patient, family, and/or caregiver hope to accomplish with therapy and in general Functional limitations/assistance with ADLs/adaptive equipment  Adaptive feeding devices?  Does the patient require use of a communication device?  Does the patient require hearing aids? If so, are the hearing aids in good working order?  Does the patient wear glasses?  Does the patient require a wheelchair for mobility? Does the patient require a cane or walker?

 Living environment
 With whom the patient lives, caregivers, etc.(10)

Patients with dysphagia might need to eat their meals alone or in silence to prevent distraction, which can increase risk of aspiration
 Patients who will require an altered diet might require assistance with food preparation from family members and/or caregiver(10)  Is the patient receiving nutritional supplements orally or nonorally?(17)

Is there a feeding tube present?(10, 17)

 Does the patient require feeding assistance at home?(6, 10)

Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be appropriate to patient medical condition, functional status, and setting) Anthropometric characteristics: Depending on the type of therapy the speech-language pathologist (SLP) is planning to implement for the treatment of dysphagia, it might be appropriate to note anthropometric characteristics such as excessive adipose neck tissue In order to adequately place electrodes on the neck for neuromuscular electrical stimulation (NMES) therapy, the therapist must be able to palpate landmarks such as the hyoid bone and laryngeal notch(12) Arousal, attention, cognition (including memory, problem solving): Briefly assess patients cognition Patient should be able to maintain arousal and follow some type of directions (verbal or nonverbal) The Mini-Mental State Examination (MMSE) is an appropriate assessment tool to screen for arousal, attention, and other cognitive deficits(12)  The MMSE assesses overall cognitive impairment; sections include Orientation to Time, Orientation to Place, Registration, Attention and Calculation, Recall, Naming, Repetition, Comprehension, Reading, Writing, and Drawing(19)  If language or cognitive deficits are evident on the screening measure, patient might be appropriate for a complete language and cognitive evaluation Patient must be compliant in order to participate in indirect dysphagia therapy For patients in whom NMES therapy is planned, patient must be able to accurately report sensations experienced during electrical stimulation (such as grabbing, pulling, stinging, or burning) or respond accurately to yes or no questions regarding sensations experienced(12) Oral mechanism exam and related tests: A full oral mechanism examination should be completed prior to beginning indirect dysphagia therapy Examination should include the lips, buccal muscles, tongue, teeth, mandible, and hard/soft palates Posture: Is the patient able to maintain adequate sitting posture for feeding trials? Patients should be able to maintain upright positioning of the head and trunk while feeding If the patient does not have adequate strength or muscle tone to maintain upright positioning, refer to physical and occupational therapy for muscle strengthening and adaptive positioning equipment Special tests specific to diagnosis: Prior to beginning indirect dysphagia therapy, it is necessary to completely assess the type of dysphagia with which the patient presents. Complete the following tests as indicated: FEES  For additional information on FEES assessments, see the series of Clinical Reviews on this topic Functional Oral Intake Scale (FOIS)(12, 20)  7-point ordinal scale  Scored according to patients report of which foods/liquids are ingested safely on a regular basis  Strong reliability and validity in stroke population(20)  FOIS levels(12) Level 1: NPO (nothing by mouth) Level 2: Tube dependent with minimal attempts of food and liquids by mouth Level 3: Tube dependent with consistent oral intake of food and liquids Level 4: Total oral diet of a single consistency Level 5: Total oral diet with multiple consistencies; requires special preparation or compensations Level 6: Total oral diet with multiple consistencies; no special preparation; however, specific food limitations Level 7: Total oral diet with multiple consistencies; no restrictions In-depth BSE  For additional information on a BSE, see Clinical Review Dysphagia Assessment: In-depth Bedside Swallow Examination (Adults); Accession Number: 5000011441 and Clinical Review Dysphagia Assessment: In-depth Bedside Swallow Examination (Pediatrics); Accession Number: 5000011696 Manometry  For additional information on manometry, see Clinical Review Dysphagia Assessment: Manometry; Accession Number: 5000011446 MBS/VFSS  For additional information on an MBS/VFSS, see Clinical Review Dysphagia Assessment: Modified Barium Swallow (Adults); Accession Number: 5000011451 and Clinical Review Dysphagia Assessment: Modified Barium Swallow (Pediatrics); Accession Number: 5000011895

assessment/Plan of care
 Contraindications/precautions Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regard to modalities. Rehabilitation professionals should always use their professional judgment Patients with this diagnosis are at risk for falls; follow facility protocols for fall prevention and post fall prevention instructions at bedside, if

 

 

inpatient. Ensure that patient and family/caregivers are aware of the potential for falls and educated about fall prevention strategies. Discharge criteria should include independence with fall prevention strategies A physician order for dysphagia must specify Neuromuscular electrical stimulation therapy for dysphagia if the SLP intends to treat a patient with NMES Contraindications specific to NMES therapy  Dementia/exhibition of nonstop verbalization or jargon(21)  Significant, uncontrolled reflux from use of feeding tube(21)  Dysphagia as a result of drug toxicity(21)  Agitation or noncompliance(21)  Significantly decreased level of consciousness(21)  Pregnancy(21) For indirect dysphagia therapy techniques that require a patient to perform a Valsalva maneuver (i.e., bear down/forcibly exhale through closed vocal folds [as with vocal fold adduction exercises or the effortful swallow]), obtain physician order to ensure that it is safe for the patient to perform this type of maneuver Patients with uncontrolled blood pressure are not candidates for these types of exercises(2) Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patients physician. The summary below is meant to serve as a guide, not to replace orders from a physician or a clinics specific protocols Diagnosis/need for treatment: Following a thorough evaluation of the patients swallowing function, the SLP will make a statement regarding the type and severity of dysphagia (if present) Rule out: Esophageal dysphagia Refer patients in whom esophageal dysphagia is suspected to a gastroenterologist, as this condition is not treated by an SLP through indirect dysphagia therapy(13, 22) Prognosis: Prognosis for improvement of swallowing function varies from patient to patient; factors such as age, motivation for therapy, severity of dysphagia, and treatment approach can all impact prognosis(13) Referral to other disciplines Referral to gastroenterologist for patients in whom esophageal dysphagia is suspected(13, 22) Referral to neurologist for patients with dysphagia who do not have a known underlying diagnosis(13) Referral to pulmonologist for patients who appear to have poor respiratory status and/or function(13) Referral to otolaryngologist for patients who present with apparent vocal fold dysfunction(22) Referral to nutrition services/dietician for patients with poor per oral intake or those at risk for malnutrition(13, 17) Referral to physical and/or occupational therapy for patients with poor posture, difficulty sitting up in the bed or chair, or difficulty feeding themselves(13) Treatment summary: Indirect dysphagia therapy is a group of interventions in which a patient is trained to perform exercises that do not require him or her to swallow food or liquid, with the overall goal of improving swallow strength, function, and safety. Indirect dysphagia therapy includes exercises and modalities that differ across patients depending on the specific needs of the patient. The following types of indirect dysphagia therapy have may be effective in patients with dysphagia: Oral motor exercises: Exercises that are widely used in the dysphagia population; however, efficacy data in the research literature are lacking(1) A systematic review that included 16 studies that examined the effects of oral motor exercises on swallowing in children with dysphagia concluded that there was insufficient evidence that the exercises result in functional improvement of the swallowing mechanism(23)  The most positive treatment effect was found with the 12-month use of a stimulating oral plate for children with cerebral palsy to improve chewing(23) Can include exercises to improve ROM, strength, and/or coordination of the lips, jaw, oral tongue(1, 2) The following are examples of oral motor exercises that have been used for patients with dysphagia:  Labial ROM and strengthening exercises Patient produces sounds /p/, /b/, and /m/(1) Purse lips with jaw closed; attempt with jaw open(1) Stretch lips/retract into a smile(1) Patient can hold stacks of tongue blades between his or her lips with the SLP pulling them outward; gradually the number of blades is reduced(1) Patient can hold cork or gauze between his or her lips while they are pursed; the SLP pulls outward on the cork/gauze; gradually the size of the cork/gauze is decreased(1)  Jaw exercises Open and close the mouth; open as widely as possible(1) Patient moves the jaw from side to side and in circular movements to improve ROM(1) SLP applies resistance to opening or closing jaw movements attempted by the patient to strengthen jaw muscles(1)  Logemann describes exercises that can be utilized in indirect dysphagia therapy in her dysphagia textbook:(2) ROM lingual exercises (to be repeated 5-10 times per speech therapy session; patient should attempt to practice these exercises independently 4-5 times per day)(2)  Protrusion: open the mouth as widely as possible; elevate the tongue as high as possible; hold in place for one second(2)  Retraction: with mouth open wide, patient pulls his or her tongue back into the mouth as far as possible; hold for one second(2)  Alternate lingual protrusion and retraction exercises(1, 2)  Lateralization: patient moves the tongue back and forth between the corners of the mouth, stretching the tongue as far as possible(2) Lingual strengthening exercises

 Patient pushes his or her tongue against a tongue blade, popsicle, lollipop, or finger(2)  Patient pushes the tongue blade toward the front as well as along the sides of the tongue, holding the pressure for at least 1 second each time(1, 2)

Bolus control exercises(2)

 Patient is given something large that can be controlled by the SLP to manipulate in the mouth(2)  A rolled 4 x 4 gauze pad or licorice rope can be used for the patient to manipulate in his or her mouth while the SLP controls one end(2)  Initially, the patient simply holds the item in place; as strength and coordination improve, patient moves the item from side to side and forward

and backward(2)  To improve patients ability to hold a cohesive bolus in the mouth, the SLP can place a small amount of puree or thickened liquid in the patients cupped tongue with instructions to hold the bolus in place; following this exercise, patient should spit the bolus into a cup so as not to allow it to be swallowed(2)  To improve bolus propulsion, the SLP can provide the patient with a 4 x 4 gauze pad rolled up and soaked in orange or cranberry juice (for flavor); the patient is cued to push the gauze against the hard palate enough to squeeze a small amount of liquid out of the gauze(2) Base of tongue exercises Logemann describes exercises that can be utilized in indirect dysphagia therapy in her dysphagia textbook:(2)  Patient stretches his or her tongue as far back into the oral cavity as possible; holds for 1 second and repeats(2)  Patient pretends to gargle causing the tongue base to be retracted(2)  Patient yawns or pretends to yawn pulling the tongue base back(2) Effortful swallow  Can be done with or without food/liquid boluses For indirect dysphagia therapy, patient is instructed to perform these exercises with saliva swallows  The patient is instructed to exert increased pressure during the swallow; sometimes patient is cued to visualize himself or herself swallowing a larger or harder bolus, such as a rock(1, 2)  When used in indirect dysphagia therapy, the effortful swallow is used as an exercise to increase base of tongue retraction(2) Laryngeal/pharyngeal strengthening exercises Logemann describes exercises that can be utilized in indirect dysphagia therapy in her dysphagia textbook:(2)  Airway closure exercises(2) Patient is to complete this series 5-10 times daily for 5 minutes at a time(2) Patient sits in a chair, holds his or her breath to bear down for a second, and then exhales the breath(2) As the patient improves with voluntary breath-holding, he or she can push down on or pull up on the chair while holding his or her breath to increase airway closure further(2)  Vocal fold adduction exercises(2) Patient bears down on a chair with one hand while vocalizing a strong clear ah sound; patient repeats 5 times(2) The patient then produces 5 harder glottal attacks on the vowel sound ah(2) Repeat these two exercises 3 times each; perform 5-10 times per day(2)  Falsetto exercise (for laryngeal elevation)(2) Patient slides up the pitch scale from a low note to the highest possible (falsetto) note in his or her vocal range(2)  During the production of this high, falsetto voice, the patients larynx is required to elevate almost as much as during a swallow(2) Masako maneuver (tongue-holding maneuver): An exercise intended to increase posterior pharyngeal wall contraction resulting in improved contact between pharyngeal wall and base of tongue during the swallow(24)  This maneuver is accomplished by having the patient maximally protrude the tongue and asking him or her to hold the tongue between the teeth (central incisors) while swallowing(24) The retraction of the base of tongue is restricted, causing increased bulging and stretching of the posterior pharyngeal wall during swallowing(24)  In a research study, 10 healthy males aged 19-26 years with no history of dysphagia were trained to perform this maneuver(24) Patients were given 3-mL boluses of barium liquid and asked to swallow 6 times; 3 times with the Masako maneuver and 3 times without the maneuver(24) Videofluoroscopic swallow images were taken of all 6 swallows and compared(24) In these normal healthy adult subjects, there was shown to be a significant difference in the amount of anterior bulge of the posterior pharyngeal wall when the subjects were performing the Masako maneuver(24)  The anterior bulge of the posterior pharyngeal wall during swallowing was significantly greater with the Masako maneuver at mid and inferior C2 level of the spine(24) Mendelsohn maneuver: Intended to increase the duration of time that the larynx is elevated and pulled forward during a swallow, thereby allowing for increased clearance of the pharyngeal cavity and upper esophageal sphincter (UES); it can be utilized as a laryngeal elevation exercise as well(1, 25)  Can be done with or without food/liquid boluses; for indirect dysphagia therapy, patient will be instructed to perform the maneuver using saliva swallows only  The patient is instructed to begin to swallow and hold his or her swallow halfway through at the point of maximal laryngeal elevation  A research study examined the effect of the Mendelsohn maneuver on normal swallowing physiology(25) Researchers conducted concurrent videofluoroscopic and manometric studies of swallowing in 8 healthy male volunteers ages 22-28 without any history of dysphagia(25) Measurements of the UES opening, swallow-related hyoid movement, laryngeal elevation, and bolus preparation with 3 1-mL boluses of barium

and 3 10-mL boluses of barium during normal swallows and during swallows in which the Mendelsohn maneuver was performed(25) The results of the study indicated that all of these normal volunteers were able to alter their swallowing mechanism by using the Mendelsohn maneuver  The use of the Mendelsohn maneuver resulted in a slight prolongation in the duration of UES opening and a significant increase in laryngeal and hyoid movement during the swallows(25)  The use of the Mendelsohn maneuver did not appear to alter the pressure inside the pharyngeal cavity(25) NMES: NMES is a therapy technique designed to deliver electrical stimulation to the key muscles for swallowing for the intended purpose of increasing strength in these muscles and improving swallow function A single-blind, randomized, controlled, interventional study conducted in stroke survivors with persistent (lasting longer than 2 weeks) pharyngeal dysphagia(12)  28 dysphagia patients were randomly divided into two treatment groups rehabilitation swallowing treatments (thermal-tactile stimulation, head/ neck positioning, supraglottic swallow technique, Mendelsohn maneuver and effortful swallowing) and NMES therapy(12) 23 patients completed the study(12)  Both treatment groups were treated with facial exercises and diet modifications as appropriate for each individual patient(12)  Both treatment groups received their respective types of swallowing therapy in 60-minute sessions for 5 consecutive days, followed by a 2-day rest period over a 4-week period(12)  NMES therapy Delivered using the VitalStim device, Model 5900 (dual-channel electrical stimulation device with a pulsed current at a fixed pulse of 80 Hz and fixed pulse duration of 700 ms)(12) Therapy is administered by a trained physiatrist(12)  Prior to providing NMES therapy, the administering clinician must be trained and certified in this type of therapy Prior to the start of treatment, patients were educated regarding the sensations they might experience, including tingling, crawling, burning, and grabbing; patients were taught to successfully identify each of these sensations(12) Once the thyroid notch was palpated, the 4 electrodes were placed (1) midline 1 mm above thyroid notch; (2) immediately superior to the first electrode; (3) midline 1 mm below thyroid notch; (4) immediately inferior to the third electrode(12) The administrating physiatrist set the amplitude according to the patients verbal feedback, increasing amplitude gradually until the grabbing sensation was achieved(12) Once the grabbing sensation was achieved, the amplitude was maintained at this level for the remainder of the session(12)  Upon completion of the 4-week dysphagia treatment programs, outcome measures were completed and compared between groups There were no significant differences between the two groups as related to the stroke characteristics, severity of dysphagia, and overall number of treatment sessions completed(12) As measured by the Functional Oral Intake Scale (FOIS), 91.3% of patients improved in swallowing function by at least one level (out of seven total levels)(12)  90.91% of patients in the traditional treatment group  91.67% of patients in the NMES group 58.33% of the patients in the NMES group improved by four levels on the FOIS scale; 33.34% improved by two or three levels(12) 45.46% of the patients in the traditional treatment group improved by three levels; 36.36% improved by two levels  Researchers concluded that while both treatment methods were effective in improving swallowing function, NMES appeared to be more effective with more superior functional outcomes(12) A research study compared outcomes of NMES therapy for dysphagia to that of traditional swallowing therapy techniques(21)  Study sought to answer the question: Do patients treated with NMES experience better functional outcomes than patients treated with traditional swallowing therapy techniques?(21)  Twenty-two patients with dysphagia included in the study(21) Dysphagia in these patients resulted from varying underlying etiologies(21)  The control group received traditional dysphagia therapy; the experimental group received NMES therapy (specifically, VitalStim treatment)(21)  Four SLPs who were certified and trained in VitalStim administered the NMES therapy(21) The 11 patients treated with NMES therapy received between 2 and 13 NMES therapy sessions depending on specific medical condition as well as length of stay in his or her specific setting (including inpatient rehabilitation, skilled nursing facility, outpatient rehabilitation center or home health)(21) Electrodes were placed according to VitalStim protocol for Placement 1(21)  The 11 patients in the control group who were treated with traditional swallowing therapy received one or more of the following types of therapy: oral motor exercises, pharyngeal swallowing exercises, compensatory strategies, or thermal stimulation(21) These patients received between 1 and 6 sessions of swallowing therapy(21)  Prior to the start of therapy and following the conclusion of therapy, the swallowing function of each of the patients was evaluated by either VFSS or FEES(21) Following the VFSS/FEES, the SLP rated each stage of the patients swallowing function (oral and pharyngeal stages) on a scale of 1-7 (1 = profound dysphagia; 7 = normal swallowing function) The average scores of the control group were as follows:

 Prior to therapy oral stage: 4.5  Following therapy oral stage: 6.0  Prior to therapy pharyngeal stage: 3.1  Following therapy oral stage: 5.4

The average scores of the experimental group were as follows:

 Prior to therapy oral stage: 5.1  Following therapy oral stage: 5.4  Prior to therapy pharyngeal stage: 3.6  Following therapy oral stage: 4.7  In addition to comparing the patients pre- and post-therapy VFSS/FEES scores, researches also tracked pre- and post-therapy diet

recommendations(21) Following completion of therapy, 10/11 subjects in the control group were given recommendations for an advanced diet Following completion of therapy, 9/11 subjects in the control group were given recommendations for an advanced diet  The researchers for this study did not find statistically significant differences between the two types of therapy (NMES and traditional)(21) Researchers acknowledged several factors, which might have led to these nonsignificant findings(21) Among the factors that might have had an impact on the findings of this study include variability in the number of treatment sessions, variability in the duration of treatment sessions, variability in the time between date of onset and start of dysphagia treatment, and variability between treating SLPs as well as the limited sample size(21)

Problem
Oral dysphagia (including reduced lingual, labial or buccal strength, rate, ROM or coordination)

Goal
Increase effectiveness and safety of the oral stage of the swallow

Intervention
Oral motor exercises SLP guides patient through appropriate exercises during treatment sessions cueing patient regarding corrections as necessary See Treatment summary, above

Expected Progression
Improved lingual, labial, and buccal rate, ROM, and strength is expected over time Progression of the exercises will vary with respect to the goals of the patient Improved base of tongue retraction during swallowing is expected over time With repeated sessions of NMES, the patients swallowing abilities will become stronger and more effective Progression of the exercises will vary with respect to the goals of the patient

Home Program
Home program will vary according to the goals of the patient; SLP can instruct patient to perform exercises independently at home

Reduced tongue base retraction

Increase base of tongue retraction; to reduce vallecular and pharyngeal residue sometimes associated with reduced tongue base retraction

Base of tongue exercises SLP guides patient through appropriate exercises during treatment sessions cueing patient regarding corrections as necessary NMES (See description above) Use as indicated per patient diagnosis and dysphagia For indirect dysphagia therapy, NMES would be performed while the patient is doing his or her exercises or completing saliva swallows; food or liquid would not be introduced See Treatment summary, above

Home program will vary according to the goals of the patient; SLP can instruct patient to perform exercises independently at home

Reduced elevation and anterior movement of the hyolaryngeal complex

Increase hyolaryngeal anterior movement and elevation

Pharyngeal/laryngeal strengthening exercises SLP guides patient through appropriate exercises during treatment sessions, cueing patient regarding corrections as necessary NMES (See description above) Use as indicated per patient diagnosis and dysphagia For indirect dysphagia therapy, NMES would be performed while the patient is doing his or her exercises or completing saliva swallows; food or liquid would not be introduced See Treatment summary, above

With repeated sessions of NMES, the patients swallowing abilities will become stronger and more effective Progression of the exercises will vary with respect to the goals of the patient

Home program will vary according to the goals of the patient; SLP can instruct patient to perform exercises independently at home

Problem
Reduced opening of the UES

Goal
Increase the opening of the UES during swallowing; to reduce residue in the pharyngeal cavity/ pyriform sinuses

Intervention
Mendelsohn maneuver For indirect dysphagia therapy, the Mendelsohn maneuver would be done with saliva swallows; food or liquid would not be introduced See Treatment summary, above

Expected Progression
As patient learns the Mendelsohn maneuver technique, his or her larynx should move forward and elevate more effectively, resulting in safer, more efficient swallowing Progression of the exercises will vary with respect to the goals of the patient

Home Program
Home program will vary according to the goals of the patient; SLP can instruct patient to use Mendelsohn maneuver with saliva swallows

Desired Outcomes/Outcome Measures

 Desired outcomes: The desired outcome of any dysphagia therapy program is improved swallowing function Related outcomes include reduction or elimination of aspiration during swallowing, reduction or elimination of aspiration pneumonia, improved oral intake and nutrition, and improved management of secretions Outcome measures: The outcomes of dysphagia therapy can be measured by repeating initial diagnostic tests and comparing to the original tests, including FEES FOIS(12) BSE Manometry MBS/VFSS

Maintenance or Prevention
 Home maintenance programs for dysphagia therapy patients will be determined by the treating SLP

Patient Education
 The American Speech-Language-Hearing Association (ASHA) is dedicated to the mission of helping people with speech, language, swallowing, and hearing disorders receive services to help them eat and communicate successfully. Information on dysphagia is available for patients and family members on the ASHA Web site at http://www.asha.org/public/speech/swallowing/

coding Matrix
References in this Clinical Review are rated using the following codes, listed in order of strength: M Published meta-analysis SR Published systematic or integrative literature review RCT Published research (randomized controlled trial) R Published research (not randomized controlled trial) C Case histories, case studies G Published guidelines RV Published review of the literature RU Published research utilization report QI Published quality improvement report L Legislation PGR Published government report PFR Published funded report PP Policies, procedures, protocols X Practice exemplars, stories, opinions GI General or background information/texts/reports U Unpublished research, reviews, poster presentations or other such materials CP Conference proceedings, abstracts, presentations

References
1. Poertner LC, Coleman RF. Swallowing therapy in adults. Otolaryngol Clin North Am. 1998;31(3):561-579. (RV) 2. Logemann JA. Management of the patient with oropharyngeal swallowing disorders. In: Logemann JA. Evaluation and Treatment of Swallowing Disorders. 2nd ed. Austin, TX: Pro-Ed; 1997:191-250. (G) 3. Nazarko L. Nutrition part 5: dysphagia. Br J Healthc Assist. 2009;3(5):228-232. (RV) 4. Katz PO, Anand G. Dysphagia and esophageal obstruction. In: Bope ET, Rakel RE, Kellerman R, eds. Conns Current Therapy 2010. Philadelphia, PA: Saunders Elsevier; 2009:513-516. (GI) 5. White GN, O'Rourke F, Ong BS, Cordato DJ, Chan DK. Dysphagia: causes, assessment, treatment, and management. Geriatrics. 2008;63(5):15-20. (RV) 6. Ginocchio D, Borghi E, Schindler A. Dysphagia assessment in the elderly. Nutr Ther Metab. 2009;27(1):9-15. (RV) 7. Robbins J, Kays S, McCallum S. Team management of dysphagia in the institutional setting. J Nutr Elder. 2007;26(3-4):59-104. (RV) 8. Cook IJ. Oropharyngeal dysphagia. Gastroenterol Clin North Am. 2009;38(3):411-431. (RV) 9. Edelman DA, Sheehy-Deardorff DA, White MT. Bedside assessment of swallowing is predictive of an abnormal barium swallow examination. J Burn Care Res. 2008;29(1):89-96. (R) 10. Ricci Maccarini A, Filippini A, Padovani D, Limarzi M, Loffredo M, Casolino D. Clinical non-instrumental evaluation of dysphagia. Acta Otorhinolaryngol Ital. 2007;27(6):299-305. (RV)

11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25.

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