A swallowing disorder, known as dysphagia, may occur as a result of various medical conditions. Dysphagia is defined as problems involving the oral cavity, pharynx, esophagus, or gastroesophageal junction.
Models of swallowing function may represent the biomechanics of swallow function and bolus movement for liquids or may discuss physiological activity for liquid and solids (see, e.g., Logemann, 1998; Matsuo & Palmer, 2008). Clinicians consider each model relative to patient performance when assessing swallow function.
Malnutrition and dehydration, aspiration pneumonia, compromised general health, chronic lung disease, choking, and even death may be a consequence of dysphagia. Morbidity related to dysphagia is a major concern. Adults with dysphagia may also experience (a) disinterest and/or less enjoyment of eating or drinking and/or (b) embarrassment or isolation in social situations involving eating. Dysphagia may increase caregiver burden and may require significant lifestyle alterations for the patient and the patient's family.
Speech-language pathologists (SLPs) with appropriate training and competence are involved in the diagnosis and management of oral and pharyngeal dysphagia. SLPs also recognize causes and signs/symptoms of esophageal dysphagia and make appropriate referrals for its diagnosis and management. They are integral members of an interprofessional team. The SLP's specific role and level of involvement may vary for each clinician and across patients, work settings, and institutions.
Each year, approximately one in 25 adults will experience a swallowing problem in the United States (Bhattacharyya, 2014). Dysphagia cuts across so many diseases and age groups, its true prevalence in adult populations is not fully known and is often underestimated.
A number of epidemiologic reports indicate that the prevalence of dysphagia is more common among older individuals (Barczi, Sullivan, & Robbins, 2000; Bhattacharyya, 2014; Bloem et al., 1990; Cabré et al., 2014; Roden & Altman, 2013; Sura, Madhavan, Carnaby, & Crary, 2012). Conservative estimates suggest that dysphagia may be as high as 22% in adults over 50 years of age (Lindgren & Janzon, 1991; National Foundation of Swallowing Disorders, n.d.; Tibbling & Gustafsson, 1991); as high as 30% in elderly populations receiving inpatient medical treatment (Layne, Losinski, Zenner, & Ament, 1989); up to 68% for residents in long-term care settings (National Institute on Deafness and Other Communication Disorders [NIDCD], n.d.; Steele, Greenwood, Ens, Robertson, & Seidman-Carlson, 1997); and 13%–38% among elderly individuals who are living independently (Kawashima, Motohashi, & Fujishima, 2004; Serra-Prat et al., 2011). Additional studies suggest that elderly populations have an increased risk for the development of dysphagia-related complications such as pulmonary aspiration (Altman, Yu, & Schaefer, 2010; Marik, 2001; Schmidt, Holas, Halvorson, & Reding, 1994; Tracy et al., 1989). A report by the Agency for Health Care Policy and Research (AHCPR; now the Agency for Healthcare Research and Quality [AHRQ]) estimates that approximately one third of patients with dysphagia develop pneumonia and that 60,000 individuals die each year from such complications (AHCPR, 1999).
Various neurological diseases are known to be associated with dysphagia. The exact epidemiological numbers by condition or disease also remain poorly defined. This, in part, is due to the concomitant medical conditions being reported and the timing and type of diagnostic procedures being used to identify swallowing disorders across neurological populations. For example, a systematic review by Martino and colleagues (2005) found that the incidence of dysphagia in stroke populations was as low as 37% when identified using cursory screening procedures and as high as 78% when identified using instrumental assessments. A later study by Falsetti and colleagues (2009) found that dysphagia occurs in over one third of patients admitted to stroke rehabilitation units. Further studies suggest that dysphagia occurs in 29%–64% of stroke patients (Barer, 1989; Flowers, Silver, Fang, Rochon, & Martino, 2013; Gordon, Hewer, & Wade, 1987; Mann, Hankey, & Cameron, 1999).
Additional systematic reviews and studies have reported variable estimates of dysphagia in other acquired and progressive neurogenic populations as well as other medical conditions. Alagiakrishnan, Bhanji, and Kurian (2013) reported prevalence ranges of dysphagia in dementia patients from 13% to 57%, whereas Kalf, de Swart, Bloem, and Munneke (2011) reported prevalence ranges from 35% to 82% for individuals with Parkinson's disease. A study by Coates and Bakheit (1997) suggests that dysphagia is as high as 90% in individuals diagnosed with Parkinson's disease or amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease). Other neurogenic populations with dysphagia include individuals with multiple sclerosis (24%–34%; Calcagno, Ruoppolo, Grasso, De Vincentiis, & Paolucci, 2002; De Pauw, Dejaeger, D'Hooghe, & Carton, 2002; Roden & Altman, 2013) and traumatic brain injury (38%–65%; Terre & Mearin, 2009).
There are also other conditions known to have the consequence of dysphagia. A study by Garcia-Peris and colleagues (2007) found that 50% of patients with head and neck cancer experience oropharyngeal dysphagia, with these numbers increasing after chemoradiation treatment. The overall prevalence of dysphagia associated with gastroesophageal reflux disease (GERD) is approximately 14% (Mold et al., 1991; Spechler, 1999), and the frequency of dysphagia ranged from 3% to 64% following endotracheal intubation (Skoretz, Flowers, & Martino, 2010) and from 5% to 8% for adults with intellectual disabilities (Chadwick, Jolliffe, Goldbart, & Burton, 2006).
Signs of dysphagia may include
It is important to consider signs and symptoms of dysphagia within a constellation of other clinical indicators, rather than relying on a single sign or symptom.
Dysphagia may result from numerous etiologies secondary to damage to the central nervous system (CNS) and/or cranial nerves, and unilateral cortical and subcortical lesions, due to
Dysphagia may also occur from problems affecting the head and neck, including
Specialized knowledge, skills, and clinical experience related to the evaluation and management of individuals with swallowing and swallowing problems may be acquired on the graduate or postgraduate level, in formal coursework, and/or in a continuing education framework. The standards for ASHA certification effective in 2014 require competence in dysphagia. The American Board of Swallowing and Swallowing Disorders, under the auspices of ASHA's specialty certification program, offers clinical specialty certification in swallowing and swallowing disorders. Board Certified Specialists in Swallowing are individuals who hold ASHA certification and have demonstrated advanced knowledge and clinical expertise in diagnosing and treating individuals with swallowing disorders.
SLPs have extensive knowledge of anatomy, physiology, and functional aspects of the upper aerodigestive tract—including oral, pharyngeal, and cervical esophageal anatomic regions—for swallowing and speech. In addition, SLPs have expertise in all aspects of communication disorders that include cognition, language, and behavioral interactions, many of which may affect the diagnosis and management of swallowing disorders. Because of the complexities of assessment and treatment in most persons with swallowing disorders, SLPs work collaboratively with other professionals, individuals, families and caregivers. Interprofessional practice (IPP) is critical to successfully achieving the desired improvements and outcomes.
SLPs play a central role in the assessment and management of individuals with swallowing disorders. An SLP's roles include
As indicated in the Code of Ethics (ASHA, 2016), SLPs who serve this population should be specifically educated and appropriately trained to do so. Assessment and management of dysphagia requires training and competence.
Swallowing screening is a pass/fail procedure to identify individuals who require a comprehensive assessment of swallowing function or a referral for other professional and/or medical services (ASHA, 2004b). Screening for dysphagia may be conducted by a speech-language pathologist or other member of the patient's care team. Screening does not provide a detailed description of the patient's swallow function but, rather, identifies individuals who are likely to have swallowing impairments related to function, activity, and/or participation as defined by the World Health Organization (WHO, 2001).
Individuals of all ages are screened as needed, requested, or mandated, or when other evidence (e.g., neurological or structural deficits) suggests that they are at risk for a swallowing disorder involving body structure/function and/or activities/participation.
The purpose of the screening is to determine
Screening protocols may include
The Modified Evans Blue Dye Test (more informally referred to as "blue dye test") is completed in patients with a tracheotomy by tinting oral feedings blue/green with the intent to identify aspiration in these patients.
Screening may result in
It is common for precautions (e.g., no oral intake, stipulation of specific dietary precautions) to be put in place while the patient is waiting for further assessment (ASHA, 2009).
Assessment and treatment of swallowing and swallowing disorders may require use of appropriate personal protective equipment.
Consistent with the WHO (2001) framework, the purpose of assessment is to identify and describe
Swallowing assessment allows the SLP to integrate information from (a) the interview/case history, (b) medical/clinical records including the potential impact of medications, (c) the physical examination, (d) previous screening and assessments, and (e) collaboration with physicians and other caregivers. During assessment, SLPs determine whether the patient is an appropriate candidate for treatment and/or management; this determination is based on findings that include medical stability, cognitive status, nutritional status, and psychosocial, environmental, and behavioral factors.
Assessment may result in one or more of the following outcomes:
Change in a patient's functional or medical status may indicate the need for additional assessment. An SLP may additionally monitor a patient's swallow function at appropriate intervals to determine whether the patient remains safe on the current diet (including adequate intake) and to assess the progress of current intervention strategies. Ongoing assessment may include additional instrumental assessments or may be completed through observation of performance throughout therapy sessions.
SLPs conduct assessments in a manner that is sensitive to the individual's cultural background, religious beliefs, and preferences for medical treatment (See Cultural Competence for additional information). Consider how culture influences activities of daily living (Riquelme, 2004). Discuss dietary changes with the patient and with the family member who prepares the food. In some cases, caregivers may be encouraged to bring familiar food and drink that maintain compatibility with SLP recommendations. Recommendations may affect spiritual practices that involve food and drink. Using ethnographic interviewing strategies during the assessment process is an excellent way to gather information about an individual's specific needs (Westby, Burda, & Mehta, 2003).
There are specific indications for both non-instrumental and instrumental examinations. For patients with signs and symptoms of pharyngeal dysphagia, instrumental procedures can provide more sensitive and objective findings than the clinical examination.
The purpose of a non-instrumental swallowing assessment is to observe patient behaviors associated with swallow function—that is, to observe the presence (or absence) of signs and symptoms of dysphagia, with consideration for factors such as fatigue during a meal, posture, positioning, and environmental conditions. A non-instrumental assessment may provide sufficient information for a clinician to diagnose oral dysphagia; however, aspiration and other physiologic problems in the pharyngeal phase can be directly observed only via instrumental assessments.
A non-instrumental swallowing assessment may include the following procedures:
The effectiveness of various compensatory and rehabilitative techniques may also be assessed. Assessment may also include monitoring vital signs.
The clinical examination alone may form the basis for recommendations for the management of dysphagia—or it may serve as a tool for (a) identifying clinical presentations of dysphagia, (b) determining the potential need for additional instrumental evaluation, and (c) specifying diagnostic questions to be answered by any instrumental evaluations.
SLPs use instrumental techniques to evaluate oral, pharyngeal, laryngeal, upper esophageal, and respiratory function as they apply to normal and abnormal swallowing. In addition, instrumental procedures are used to determine the appropriateness and the effectiveness of a variety of treatment strategies.
Instrumental techniques are usually conducted either independently by the SLP or by the SLP in conjunction with other members of the interprofessional team (e.g., radiologist, radiologic technologist, physiatrist). Competence in videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES) requires appropriate training and education. SLPs help guide medical decision making regarding the appropriateness of these procedures given the severity and nature of the patient's swallowing deficits. SLPs interpret and apply the results of objective testing to the formulation of dysphagia treatment plans, and they also determine patient capacity and safety for oral feeding.
Indications for an instrumental exam include the following:
Contraindications for an instrumental exam include the following:
Similar to non-instrumental assessment, instrumental assessment also includes a thorough case history; an oral mechanism exam; and assessment of overall physical, social, behavioral, and cognitive/communicative status (see previous section on Non-Instrumental Swallowing Assessment for details on these components of an evaluation). The purpose of the instrumental examination is to enable the SLP to
In clinical settings, SLPs typically use one of two types of instrumental evaluations: the videofluroscopic swallowing study (VFSS) or the fiberoptic endoscopic evaluation of swallowing (FEES). The implementation of the VFSS and FEES requires the SLP to have advanced knowledge and specific skills in order to determine an appropriate test protocol; make decisions regarding management options during the examination; assess oral, pharyngeal, and cervical esophageal swallowing physiology; make specific functional diagnoses and diet consistency recommendations; and understand issues relative to radiation equipment, equipment maintenance, and safety.
At some facilities, qualified SLPs may also screen for esophageal motility and GERD to identify the need for appropriate referral. Oropharyngeal function may be altered in some patients with esophageal motility issues.
The videofluroscopic swallowing study (VFSS), also known as the modified barium swallow study (MBSS), is a radiographic procedure that provides a direct, dynamic view of oral, pharyngeal, and upper esophageal function (Logemann, 1986). An SLP completes the VFSS by providing the patient with various consistencies of food and liquid mixed with barium, which allows the bolus to be visualized in real time on an x-ray during the swallow. The VFSS is beneficial not only in identifying whether aspiration has occurred but also in allowing assessment of amount and timing of aspiration as well as assessment of anatomy and pathophysiology of swallow function in the oral and pharyngeal phases. It provides clinically useful information on the influence of compensatory strategies and diet changes (Martin-Harris, Logemann, McMahon, Schleicher, & Sandidge, 2000).
VFSSs are typically performed with both a speech-language pathologist and radiologist present, allowing for professional collaboration. The speech-language pathologist focuses on swallowing physiology and functioning and the radiologist makes medical diagnoses. The VFSS assessment and report do not include medical diagnoses. The SLP should be aware of state legal and regulatory issues regarding the presence of a radiologist or other physician, as well as third party payer requirements.
The contraindications specific to VFSS may include the following:
At minimum, a VFSS includes the following protocols:
Clinicians select bolus type (e.g., consistency, volume) for each trial carefully, as some consistencies and/or volumes may influence the clinician's overall impression of the swallow function more than others (Martin-Harris et al., 2008; Sandidge, 2009). Clinicians also evaluate influence of the method and rate of presentations, such as when the patient is a) fed by the examiner, b) self-fed, or c) fed by a caregiver and d) when solids and liquids are alternated. Clinicians also note any differences in swallow function when the patient is instructed to swallow versus spontaneous swallows.
A complete VFSS requires a sufficient number of swallowing attempts to (a) make a clinically informed decision about route of intake, consistency of oral diet (if appropriate), exercises to improve swallowing function, and compensatory techniques to maintain patient safety while consuming an oral diet and (b) determine the need for additional assessments/interventions through interprofessional team referral(s). Clinicians additionally note the individual's tolerance of and response to the examination (e.g., following directions, fatigue, signs of stress related to medically complex patients, ability to repeat therapeutic interventions). Indications of an adverse reaction to the examination may include, but are not limited to, agitation, changes in breathing pattern, changes in alertness, changes in coloring, nausea and vomiting, changes in overall medical status which may be assessed via the pulse oximeter, heart rate monitor, etc.
Given the speed and dynamic nature of swallow function, it is highly beneficial that the SLP record these studies and their results so that review and confirmation of findings can be observed in real time.
During VFSS or review of the recording, clinicians identify the anatomical structures, as illustrated in Table 1, including any anatomical and/or physiological abnormalities.
Table 1. Clinical Observations of Physiologic Swallowing Components During MBS
|Aspect of Swallowing||Observation|
|Lip closure||Patient's ability to approximate top and bottom lip|
|Tongue control||Volitional and controlled lingual movement|
|Bolus preparation||Patient's ability to create a well-contained bolus|
|Bolus transport||Patient's ability to move the bolus from the oral cavity to the pharyngeal cavity|
|Oral residue||Remaining residue in the oral cavity following oral transport|
|Initiation of the pharyngeal swallow response||Position of the bolus at the initiation of the pharyngeal swallow response|
|Soft palate elevation||Upward movement of the soft palate to create velopharyngeal closure|
|Laryngeal elevation||Extent and timeliness of upward movement of the larynx during the swallow|
|Anterior hyoid motion||Extent and timeliness of forward movement of the hyoid|
|Epiloglottic movement||Extent and timeliness of passive epiglottic inversion to meet with the arytenoids (moving anteriorly and superiorly)|
|Laryngeal closure||Medial movement of the larynx observed at the vocal folds; may only be able to observe from anterior–posterior view|
|Pharyngeal stripping wave||Contraction of the posterior pharyngeal wall from top moving downward|
|Pharyngeal contraction||Approximation of the pharyngeal walls|
|Pharyngeal esophageal sphincter opening||Opening of the pharyngeal esophageal sphincter, including the upper esophageal sphincter, to allow the bolus to move from the pharynx to the esophagus|
|Tongue base retraction||Posterior movement of the tongue base to make contact with the posterior pharyngeal wall|
|Pharyngeal residue||Remaining residue in the pharynx sfollowing the pharyngeal swallow|
|Esophageal clearance in upright position||Residue that is not cleared following swallow|
Physiological components of swallowing identified and further discussed by Martin-Harris et al, 2008
Observation of Penetration and Aspiration During VFSS
In addition to observing the physiological components of swallow function, accurate assessment and diagnosis also requires clinicians to note episodes of penetration and aspiration during VFSS in order to appropriately plan for safe and effective treatment. Episodes of both penetration and aspiration can occur before, during, or after the swallow event occurs. The Penetration-Aspiration Scale (Rosenbek, Robbins, Roecker, Coyle, & Wood, 1996) is an eight-point scale used to describe penetration and aspiration events. The clinician observes the bolus and the patient's response to the bolus, including the following scenarios:
Limitations of the VFSS include
The speech-language pathologist should be aware of the principles of ionizing radiation and dosage when performing VFSS. Considerations are detailed in the list below.
Significant swallowing deficits or decreased clinician experience may lead to an increase in fluoroscopy times (Bonilha et al., 2013b).
Federal regulations mandate that all fluoroscopic equipment contain a timer that has a maximum of 5 minutes (U.S. Food and Drug Administration, n.d.). Although the timer may sound during a VFSS, it is not an indication that the VFSS must stop. It is only a reminder to the clinician(s) that 5 minutes of radiation have elapsed. The clinician takes care to reduce radiation beyond this time point, and additional swallow attempts beyond this point are well-justified, allowing for additional information for recommendations.
For additional more information, see ASHA's Radiation Safety Resource Page. Additional information regarding equipment and radiologic care is also available from the American College of Radiology's Practice Parameter for the Performance of Modified Barium Swallow.
Fiberoptic endoscopic assessment of swallowing function (FEES) is a portable procedure that may be completed in outpatient clinic space or at bedside by passing an endoscope transnasally (Langmore, Kenneth, & Olsen, 1988). FEES additionally provides the opportunity for frequent use without concerns of radiation exposure and can be used within therapeutic contexts and for diagnostic therapy to assess current progress and effectiveness of therapy. Unlike assessment via the VFSS, FEES does not permit visualization of either the oral or the esophageal phase of swallowing.
Passage of the bolus and movement of the pharyngeal structures cannot be observed during the swallow because of reflected light from pharyngeal and laryngeal tissues into the endoscope, causing a brief condition referred to as "white-out."
In addition to the general indications for instrumental evaluation, the following indications are specific for FEES:
In addition to the contraindications for all instrumental evaluation, the following are specific to FEES:
The protocol for FEES minimally includes the following:
At times, food is minimally colored to assist in assessing secretions and residue in the pharynx after the swallow is completed.
Sensation in the hypopharynx and larynx can be tested directly with a modification of the FEES procedure. The flexible endoscopic evaluation of swallowing with sensory testing (FEESST) requires a two-channel scope and uses pulses of air to assess sensory perception of the larynx and to monitor the laryngeal adductor reflex, characterized by a brief closure of the true vocal folds. FEEST is rarely used.
SLPs with appropriate training and competence in performing FEES are qualified to use this procedure independently for the purpose of assessing swallow function and related functions of structures within the aerodigestive tract. Physicians may also be involved in the functional evaluation of swallowing and/or may be present to assess the integrity of the laryngeal and pharyngeal structures in order to provide a medical diagnosis. SLPs should be aware of state laws, facility policy, and third-party payer requirements related to the presence of a physician during FEES. See ASHA's page on States with Specific Endoscopy Requirements.
The patient may, on rare occasions, experience adverse effects when undergoing a FEES. These may include, but are not limited to, discomfort, vomiting, nosebleed, mucosal perforation, allergic reaction/hypersensitivity to topical anesthesia or nasal spray, and laryngospasm.
The overall risk is minimal, but it is recommended that clinicians be well trained in the signs and symptoms of adverse reactions and be ready to take appropriate action if they occur. In developing a FEES program, clinicians should know their facility's proper response to adverse reactions and should develop a plan for reaction and intervention should an adverse reaction occur.
If an SLP performs the examination independently and administers topical anesthesia and/or decongestants in an effort to maximize comfort, it must be approved in writing by the institution. SLPs follow institutional and pharmacy guidelines for administration of topical anesthesia, decongestants, and barium. Because of the risk of anesthetizing the pharyngeal and laryngeal mucosa and compromising the swallow, many clinicians perform FEES with either no anesthesia or only a small amount of a well-placed topical anesthetic in the nares. Use of anesthesia has not been shown to reduce patient discomfort during FEES (Leder, Ross, Briskin, & Sasaki, 1997).
The other area of concern with regard to safety is the possibility that a serious medical condition may be missed if an SLP were to complete the procedure independently; however, FEES is a procedure used to address swallow function and to screen for anatomical and physiological abnormalities in the nasal cavity, pharynx, and larynx. If there are clinical indications for a laryngoscopy evaluation (e.g., hoarse voice, pain on swallowing, etc.), the physician should make a referral to an otolaryngologist to rule out the possibility of disease in the nasal, pharyngeal, or laryngeal region.
SLPs follow universal precautions and facility procedures for infection control (e.g., adequate disinfection of equipment, etc.). Decontamination, cleaning, disinfection, and sterilization of multiple-use equipment before reuse are carried out according to facility-specific infection control policies and services and according to manufacturer's instructions. All equipment is used and maintained in accordance with the manufacturer's specifications.
Other instrumental procedures are used primarily in research at this time but may develop into clinical diagnostic tools. Ultrasonography involves the use of a transducer to observe movement of structures used for swallowing, including the tongue and hyoid (Hsiao, Wahyuni, & Wang, 2013). Surface electromyography records electrical activity of the muscles involved in swallowing (O'Kane, Groher, Silva, & Osborn, 2010).
SLPs should also be familiar with other diagnostic procedures performed by different medical specialists that yield information about swallowing function. These include procedures such as the esophagram/barium swallow, manofluorography, scintigraphy, pharyngeal manometry, 24-hour pH monitoring, and esophagoscopy.
The primary goals of dysphagia intervention are to
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 create 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:
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:
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:
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.
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
Common Surgical Options for Dysphagia Treatment
Improved Glottal Closure
Protection of the Airway
Improved Pharyngoesophageal Segment Opening
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.
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):
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.
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).
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Adult Dysphagia page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Adult Dysphagia. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Adult-Dysphagia/.