See the Treatment section of Dysphagia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.
The primary goals of dysphagia intervention are to
- safely support adequate nutrition and hydration and return to safe and efficient oral intake (including incorporating the patient's dietary preferences and consulting with family members/caregivers to ensure that the patient's daily living activities are being considered);
- determine the optimum feeding methods/technique to maximize swallowing safety and feeding efficiency;
- minimize the risk of pulmonary complications;
- reduce patient and caregiver burden while maximizing the patient's quality of life; and
- develop treatment plans to improve safety and efficiency of the swallow.
Management of individuals with dysphagia should be based on results of the comprehensive assessment. Decision making must take into account many factors about the individual's overall status and prognosis. This might include information concerning the individual's health and diagnosis, cognition, social situation, cultural values, economic status, motivation, and personal choice. Of primary concern is how the individual's health status can be maintained or maximized. The SLP should consider and integrate the patient's wishes and advocate on behalf of the patient to the health care team, the family, and other relevant individuals.
Consideration for the underlying neurophysiological impairment is necessary for understanding swallow function and deficits. Different management approaches may be necessary for individuals with dysphagia that has resulted from an acute event, chronic/stable condition, or progressive neurological disorder. Treatment targeting a specific function or structure may also affect function in other structures.
Treatment of dysphagia may include restoration of normal swallow function (rehabilitative), modifications to diet consistency and patient behavior (compensatory), or some combination of these two approaches.
Compensatory techniques alter the swallow when used but do not creating lasting functional change. An example of a compensatory technique includes a head rotation, which is used during the swallow to direct the bolus toward one of the lateral channels of the pharyngeal cavity. Although this technique may increase swallow safety during the swallow, there is no lasting benefit or improvement in physiology when the technique is not used. The purpose of the technique is to compensate for deficits that cannot be or are not yet rehabilitated sufficiently.
Rehabilitative techniques, such as exercises, are designed to create lasting change in an individual's swallowing over time by improving underlying physiological function. The intent of many exercises is to improve function in the future rather than compensate for a deficit in the moment.
In some circumstances, certain techniques may be used for both compensation and rehabilitative purposes. For example, the super-supraglottic swallow is a rehabilitative technique that increases closure at the entrance to the airway. If used during a meal, it can serve as a compensation to protect the airway.
Upon completion of the clinical and/or instrumental evaluation, the clinician should be able to use the acquired data to identify which treatment options would be most beneficial. Treatment options for patients with dysphagia should be selected on the basis of evidence-based practice, which includes a combination of the best available evidence from published literature, the patient's and family's wishes, and the clinician's experience. Options for dysphagia intervention include medical, surgical, and behavioral treatment.
Biofeedback incorporates the patient's ability to sense changes and aids in the treatment of feeding or swallowing disorders. For example, patients with sufficient cognitive skills can be taught to interpret the visual information provided by these assessments (e.g., surface electromyography, ultrasound, FEES) and to make physiological changes during the swallowing process.
Modifications to the texture of the food may be implemented to allow for safe oral intake. This may include changing the viscosity of liquids and/or softening, chopping, or pureeing solid foods. Modifications of the taste or temperature may also be employed to change the sensory input of the bolus. Clinicians consult with the patients and caregivers to identify patient preference and values for food when discussing modifications to oral intake. Consulting with the team, including a dietician, is also a relevant consideration when altering a diet to ensure that the patient's nutritional needs continue to be met.
The body of literature about electrical stimulation for swallowing is growing, and additional studies are underway to further the knowledge about this technique and its implications for dysphagia treatment. Electrical stimulation is promoted as a treatment technique for speech and/or swallowing disorders that uses an electrical current to stimulate the nerves either superficially via the skin or directly into the muscle in order to stimulate the peripheral nerve. Electrical stimulation for swallowing is intended to strengthen the muscles that move the larynx up and forward during swallow function.
Patients may benefit from the use of specific equipment/utensils to facilitate swallow function. A patient can use utensils to bypass specific phases of the swallow, to control for bolus size, or to facilitate oral control of the bolus. SLPs collaborate with other team members in identifying and implementing use of adaptive equipment.
Maneuvers are specific strategies that clinicians use to change the timing or strength of particular movements of swallowing. Some maneuvers require following multistep directions and may not be appropriate for patients with cognitive impairments. Examples of maneuvers include the following:
- Effortful swallow —increases posterior tongue base movement to facilitate bolus clearance. The patient is instructed to swallow and push hard with the tongue against the hard palate (Huckabee & Steele, 2006).
- Mendelsohn maneuver —designed to elevate the larynx and open the esophagus during the swallow to prevent food/liquid from falling into the airway. The patient holds the larynx in an elevated position at the peak of hyolaryngeal elevation.
- Supraglottic swallow —designed to close the vocal folds by voluntarily holding one's breath before and during swallow in order to protect the airway. The patient is instructed to hold his or her breath just before swallowing to close the vocal folds. The swallow is followed immediately by a volitional cough.
- Super-supraglottic swallow —designed to voluntarily move the arytenoids anteriorly, closing the entrance to the laryngeal vestibule before and during the swallow. The super-supraglottic swallow is similar to the supraglottic swallow; however, it involves increased effort during the breath hold before the swallow, which facilitates glottal closure (Donzelli & Brady, 2004).
Oral-motor treatments include stimulation to or actions of the lips, jaw, tongue, soft palate, pharynx, larynx, and respiratory muscles that are intended to influence the physiologic underpinnings of the oropharyngeal mechanism in order to improve its functions. Some of these interventions can also incorporate sensory stimulation. Oral-motor treatments range from passive to the more active (e.g., range-of-motion activities, resistance exercises, or chewing and swallowing exercises). Examples of exercises include the following:
- Laryngeal elevation —similar to the Mendelsohn maneuver (discussed in "Maneuvers" section above), the patient uses laryngeal elevation exercises to lift and maintain the larynx in an elevated position. The patient is asked to slide up a pitch scale and hold a high note for several seconds. This maintains the larynx in an elevated position.
- Masako or tongue hold —the patient holds the tongue forward between the teeth while swallowing; this is performed without food or liquid in the mouth, to prevent coughing or choking. Although sometimes referred to as the Masako "maneuver," the Masako (tongue hold) is considered an exercise (not a maneuver), and its intent is to improve movement and strength of the posterior pharyngeal wall during the swallow.
- Shaker exercise, head-lifting exercises —the patient rests in a supine position and lifts his or her head to look at the toes to facilitate an increased opening of the upper esophageal sphincter through increased hyoid and laryngeal anterior and superior excursion.
- Lingual isometric exercises —the patient is provided lingual resistance across exercises to increase strength.
Pacing and Feeding Strategies
Specific volumes of food per swallow may result in faster pharyngeal swallow responses. Clinicians modify the bolus size (i.e., bigger/smaller bolus amounts), particularly for patients that require a greater volume to adequately stimulate a swallow response or for patients that require multiple swallows per bolus. Patients may also require cuing and assistance to maintain an appropriate rate during meals. Impulsivity and/or decreased initiation are examples of cognitive deficits evident across a number of disorders that may affect a patient's pace during meals.
Postural techniques redirect the movement of the bolus in the oral cavity and pharynx and modify pharyngeal dimensions in a systematic way. Postural techniques may be appropriate to use with patients with neurological impairments, head and neck cancer resections, and other structure damage. Postural techniques may be used in patients of all ages. Examples of postural techniques include the following:
- Chin-down posture —the chin is tucked down toward the neck during the swallow, which may bring the tongue base closer to the posterior pharyngeal wall, narrow the opening to the airway, and widen the vallecular space.
- Chin-up posture —the chin is tilted up, which may facilitate movement of the bolus from the oral cavity.
- Head rotation (turn to the side) —the head is turned to either the left or the right side, typically toward the damaged or weak side (although the opposite side may be attempted if there is limited success with the first side) to direct the bolus to the stronger of the lateral channels of the pharynx.
- Head tilt —the head is tilted toward the strong side to keep the food on the chewing surface.
Postures and maneuvers may be combined in an appropriate manner, taking care to minimize patient effort/burden, where possible.
Prosthetics (e.g., palatal obturator, palatal lift prosthesis) can be used to normalize pressures and movements in the intraoral cavity by providing compensation or physical support for patients with structural deficits/damage to the oropharyngeal mechanism. With this support, swallowing efficiency and function may be improved. Intraoral appliances (e.g., palatal plates) are removable devices with small knobs that provide tactile stimulation inside the mouth to encourage lip closure and appropriate lip and tongue position for improved swallow function. This treatment option is most often used with patients following treatment for head and neck cancer; however, it may be implemented with other patients suffering from similar challenges.
Note: Future Practice Portal pages on head and neck cancer and on craniofacial anomalies will further discuss prosthetics and appliances. Check back regularly with the Practice Portal website for updates.
Sensory stimulation techniques vary and may include thermal-tactile stimulation (e.g., using iced lemon glycerin swab, cold laryngeal mirror) or tactile stimulation applied to the tongue, around the mouth, and/or in the oropharynx. Patients who are tactically defensive may need approaches that reduce the level of sensory input initially, with incremental increases as tolerance improves. The opportunity for sensory stimulation may be needed for those with reduced responses, overactive responses, or limited opportunities for sensory experiences. Sensory stimulation may prime the swallow system for the subsequently presented bolus to lower the threshold needed to initiate a swallow response and improve the timeliness of the swallow.
Medical Management Of Swallowing Disorders
Due to the interprofessional management of dysphagia, clinicians should be aware of multiple options for dysphagia intervention, including medical, surgical, and behavioral treatment. Such knowledge increases pertinent communication with other health care providers and facilitates selection of the best treatment options for individual patients (Groher & Crary, 2010).
Common Medical Options for Dysphagia Treatment
- Anti-reflux medications
- Prokinetic agents
- Salivary management
Common Surgical Options for Dysphagia Treatment
Improved Glottal Closure
- Medialization thyroplasty
- Injection of biomaterials
Protection of the Airway
- Laryngotracheal separation
- Tracheostomy tubes
- Feeding tubes
Improved Pharyngoesophageal Segment Opening
- Botulinum toxin injection
Tube Feeding for Dysphagia Treatment
If the individual's swallowing safety and efficiency cannot reach a level of adequate function, or if swallow function does not support nutrition and hydration adequately, the swallowing and feeding team may recommend alternative avenues of intake (e.g., nasogastric [NG] tube, gastrostomy). In these instances, team members consider whether the individual will need the alternative source for a short or extended period of time. Education and counseling may be provided concerning issues related to tube feeding, such as appropriate positioning and duration of feeding times. Alternative feeding does not preclude the need for rehabilitative techniques to facilitate sensory and motor capabilities necessary for oral feeding. Percutaneous endoscopic gastrostomy (PEG) tubes may not be appropriate in all populations and may not necessarily improve outcomes or quality of life (Plonk, 2005).
The decision to recommend use of a feeding tube is made in collaboration with the medical team. The physician is ultimately responsible for selecting which type of tube is used, but a brief description of several options is provided below, for the benefit of clinicians.
- Gastrostomy tube (PEG, G-tube)— inserted through the abdomen to provide non-oral nutrition. A percutaneous endoscopic gastrostomy tube, or PEG tube, is a common type of G-tube.
- Jejunostomy tube (PEJ, J-tube)— inserted through the abdomen and into the jejunum, the second part of the small intestine, to provide non-oral nutrition.
- Nasogastric tube (NG-tube)— inserted through the patient's nose and passed through the esophagus to the stomach to provide non-oral nutrition. NG-tubes are often the preferred option for short-term use (over G-tubes or J-tubes). Tube size may vary and may influence swallow function.
The patient, with his or her proxy, then chooses to accept or reject use of alternative nutrition and hydration following a shared decision making, informed consent discussion.
The role of the SLP in treating individuals with progressive neurological disorders is designed to maximize current function, compensate for irreversible loss of function, assess and reassess changes in status, and educate and counsel patients regarding the progression of the disorder and potential options, including non-oral means of nutrition.
SLPs may encounter patients approaching the end of life. These patients may have complex medical conditions related to feeding and swallowing. SLPs may work with these patients and caregivers to develop compensatory strategies that will allow the patients to eat an oral diet for as long as possible. As a member of the interprofessional team, the SLP may contribute to decision making regarding the use of alternative nutrition and hydration.
Understanding emotional and psychological issues related to death are essential to treating patients with swallowing problems at the end of life. When considering end-of-life issues, it is important for clinicians to respect the patient's wishes, including social and cultural considerations. Patients and caregivers may not agree with clinical recommendations and may feel that these recommendations do not provide the best quality of life for their loved one.
One model for ethical decision making includes consideration of (Jonsen, Siegler, & Winslade, 1992):
- Medical indications— Consider the patient's medical history, prognosis, and available viable treatment options.
- Patient preferences— Consider the patient's cultural and personal background influence, his or her preference to pursue or reject treatment, the patient's ability to make and communicate these decisions, and the presence of an advance directive.
- Quality of life— Consider if the treatment creates a burden that outweighs the potential benefit
- Contextual features— Consider the implications for caregiver burden if the patient chooses to pursue or reject treatment and if there are relevant legal ramifications to consider
Clinicians provide information regarding these considerations without factoring in their own personal beliefs. Conflict may occur when medical recommendations do not match patient preferences. After being educated about the risks and benefits of a particular recommendation (e.g., oral vs. non-oral means of nutrition, diet level, rehabilitative technique), if a patient (or his or her decision maker) chooses an alternate course of action, then the SLP makes any appropriate recommendations and offers treatment as appropriate. The SLP educates involved parties on the possible health consequences and documents all communication with the patient and caretakers. If no treatment is warranted, then the SLP may make recommendations about the safest course (and still document the risks of such action) and may provide training to caregivers and family, as appropriate. The SLP may then decide to discharge the patient but should avail him/herself to additional consultation or communication with the parties involved, as appropriate. Many facilities have an ethics consultation service that can help clinicians, patients, and families address challenges when an ethical issue arises.
See the Service Delivery section of the Dysphagia evidence map for pertinent scientific evidence, expert opinion and client/caregiver perspective.
In addition to determining the type of assessment and treatment that is optimal for adults with dysphagia, SLPs consider other service delivery variables that may affect swallowing outcomes—variables such as format, provider, dosage, and timing.
Format refers to the structure of the assessment or treatment session, such as whether a person is seen for treatment one on one (i.e., individual), as part of a group during meal time, or via telepractice.
Provider refers to the person providing the assessment or treatment (e.g., SLP, trained volunteer, caregiver).
Dosage primarily refers to the amount of treatment provided (e.g., the frequency, intensity, and duration of service).
Timing refers to the timing of rehabilitation relative to the onset of dysphagia.
Setting refers to the location of treatment (e.g., home-based, community-based).