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172 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
Applying these principles to swallowing therapy
means that rehabilitation should encourage patients
to swallow as much as possible, even for those who
are on a nonoral diet (use it or lose it; use it and
improve it), and the target exercises should involve
swallowing (specificity) and training on swallowingrelated muscles (transference). The frequency and
number of repetitions needed to induce changes are
also important principles in neuromuscular rehabilitation. Biofeedback may be used to provide realtime feedback on the motor performance during the
exercises, which may facilitate better motor learning
especially at the early stages of training.
Who is suitable for rehabilitative swallowing
therapy?
Rehabilitative swallowing therapy is suitable for
individuals who have the following:
n Adequate cognitive skills to follow instructions
n Motivation to improve
n Willingness to practice independently or with
encouragement from caregivers
n A need to increase muscle strength and range
of motion
control the passage of the bolus, increase awareness
of the bolus, and maximize the driving force of the
bolus in transit to the oropharynx.
Lip Exercises
Table 7–5 lists the most common exercises for
improving lip strength and awareness of the location of the bolus in the oral cavity.
27
These exercises are derived from various articulation treatment
protocols and may be applied in treatment plans
for patients with swallowing disorders. It can be
expected that patients with labial dysfunctions will
have difficulty in keeping the food bolus in the oral
cavity and the preparation of the bolus for transfer.
It remains to be seen how these dysfunctions affect
the entire coordination of the swallow.
Tongue Exercises
Tongue control provides transmission of the bolus
to the hypopharynx. In healthy adults, vocal fold
closure is already happening, as the bolus is being
propelled through the oral cavity.
Who is not suitable for rehabilitative swallowing
therapy?
Rehabilitative swallowing therapy is not suitable for
individuals with the following conditions:
n Severe cognitive impairments
n Susceptible to fatigue (eg, patients with
myasthenia gravis)
Oral Motor Exercises
Oral motor exercises (OME) have long been suggested as a way to increase control over the swallowing event by increasing strength and volitional
control over the movements of lips, tongue, and
larynx. Many of these exercises have been derived
from the speech and voice literature based on the
treatment of dysarthria. Because dysarthric speech
and voice generally improve when the patient controls the movements of the articulators, the rationale
for use of OMEs to treat swallowing disorders is to
Lingual strength exercises may constitute a
fundamental aspect of swallowing treatment
because of the crucial role that the tongue plays
in the oral preparatory, oral, and pharyngeal
phases of swallowing.
Lingual weakness may result from damage to
cranial nerves VII, IX, or XII. Tongue strength exercises also aim to improve tongue elevation and lateralization. One of Lazarus the earliest studies to show
the value of tongue strengthening exercises was
reported by and colleagues, using young healthy
adults.
28
The participants were asked to press a rubber bulb or their tongue blade against their hard palate. After a month, both groups showed improved
tongue strength compared to a group that received
no treatment. Robbins et al
29
initially found similar
results with 8 healthy elderly volunteers and then
Robbins and her group found lingual exercises to
improve lingual strength and swallowing outcomes
in 6 patients following CVA.
30
7. TREATMENT OF SWALLOWING DISORDERS 173
TABLE 7–5. Labial Exercises to Improve Strength and Awareness of Control of the
Swallowing Mechanism
1. Rapid labial opening and closing using the consonants /p, b/.
2. Extended lip squeeze followed by lip retraction.
3. Repeating the vowels /u, i/ with increased lip movement. Vocalization provides
additional stimulation and awareness.
4. Thermal stimulation of the lips with ice. Movement of the ice may be medial-lateral
or more focal if drooling on one side is prevalent.
5. Holding different objects between the lips such as straw, tongue blade, plastic
spoon, etc, to improve sensory awareness. Objects may be of different sizes,
shapes, and weights.
6. Apply various foods to lips, such as yogurt and peanut butter, and encourage the
patient to massage the lips together.
7. Use the index finger to apply a sudden or quick stretch to the edges of the upper
and lower lips.
8. Practice humming. Cue patient to start and stop humming. When humming stops,
the patient should open the lips, then close again.
9. Have patient close the lips. Ask patient to keep them closed while you try to gently
break the lip seal.
10. Practice a “facial squeeze” by squeezing lips together. While keeping lips closed,
alternate bringing teeth together and separating them. This mimics chewing activity.
a
11. Practice inhaling and exhaling through the nose rather than the mouth. The patient
may want to watch this activity with a mirror.
12. Prior to swallowing, the patient should hold a glass or cup to the lips. Practice the
timing of opening the lips once the cup is laced on the lower lip.
13. Hold small objects such as button (connected to a string) and place it between
the lips and teeth. The clinician can put a gentle pull on the string to improve
lip strength.
14. Intraoral stimulation of cheeks with a brush, cold objects, or fingers.
15. Resistive exercises. For example, have the patient push the upper lip down while
the clinician resists the movement with a tongue blade. Have the patient push
the tongue against the cheek while the clinician resists against the outside of the
cheek.
a
Adapted from Murry.
27(p243)
Clark et al31 reported that although OMEs have
long been used to improve articulation in patients
with tongue weakness as well as rigidity, arguments have been made that these exercises offer
few long-term benefits. They studied normal healthy
individuals trained to increase lingual strength, protrusion, and lateralization over 9 weeks. They found
improvement in the measures following training
but suggested that the gains may diminish when
training is stopped. Based on their study and the
results of a previous study by Clark
Robbins etal,
30
tongue strength exercises appear
32
and data from
to be efficacious in the functional improvement of
swallowing but must be maintained to retain the
improvement.
The OMEs shown in Table 7–6 target tongue
strength, tongue lateralization, tongue protrusion,
and tongue contact with other structures.
33
Data by
174 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
TABLE 7–6. Exercises for Tongue and Mandible Strength and Movement
1. Tongue tip elevation. Place tongue tip on alveolar ridge. Hold it for 2 s.
2. Tongue tip sweep. After holding the tongue on the alveolar ridge, sweep posteriorly
against the palate.
3. Use the phonemes /t, d/ for rapid contact and release of the tongue tip to the
alveolar ridge.
4. Use the “ch” sound to improve tongue contact to the middle of the soft palate.
Similarly, the sounds “s” and “sh” help with lateral contact of tongue to palate as
well as help to groove the tongue.
5. The /k, g/ phonemes are used to increase posterior tongue to soft palate contact.
Combining syllables into quick movements such as “ta-ka” or “cha-ka” is helpful to
improve the sweeping motion of the tongue.
6. Range-of-motion exercises can be done by chewing on gauze initially, then adding
small amounts of food when it is safe.
7. To improve sensory awareness, use pressure and temperature stimulation:
a. A cold spoon may be placed on the tip, blade, or back of tongue. Light pressure
is applied and the patient is asked to lift the spoon.
b. The palate is touched with tongue blade or cotton and the patient is asked to
touch the area with the tongue.
c. Cold or sour materials are given to the patient. They may be frozen on a stick if
the patient is not yet cleared to swallow.
d. Various sizes and textures or bolus may be given to identify the size and texture
most easily transported by the tongue.
a
8. Patients with reduced mandible movement may want to use a device such as
TheraBite to increase mouth opening.
9. Resistive exercises to the mandible such as lowering or closing the mandible
against the pressure applied by the therapist on the chin.
10. Sucking exercises increase tongue palate contact and help the patient to manage
saliva. Sucking may be done with the tongue tip against the alveolar ridge and lips
and teeth slightly apart or with teeth closed using a “slurping” or “suctioning” pull
of the tongue to the midpalate area. The patient should try to do this with as much
sound as possible to increase sensory feedback.
a
Adapted from Murry.
27(p245)
Martin-Harris et al34 suggest that the tongue may
even play a role in the laryngeal phase of swallowing.
Martin-Harris and colleagues34 found that the
oropharyngeal swallow consists of a synergistic
mechanism in which there are overlapping
events that reflect interdependence with
each other in order to properly propel the
bolus through the swallow channels into the
esophagus in a safe manner.
Jaw Exercises
Exercises to increase jaw opening using a device
such as the TheraBite allow the clinician and the
patient to set goals and track progress. When TheraBite or a similar device is not available, stacks of
tongue depressors (wooden blades) can be used
instead. For those patients who can increase mouth
opening, the placement of food may significantly
increase successful swallowing, especially if surgery
or radiation has caused an altering or removal of all
or part of some organs.
7. TREATMENT OF SWALLOWING DISORDERS 175
Laryngeal Exercises
Airway protection becomes a significant factor in
preventing aspiration. When the vocal folds fail to
close, the risk of aspiration increases. Table 7–7 lists
some of the common procedures to increase vocal
fold closure. These exercises have been advanced
primarily for patients with vocal fold paralysis. Clinicians have tried numerous ways to increase vocal
fold closure, including turning the head to the
weaker side. Of specific note is item 6 in Table7–7.
The Lee Silverman Voice Treatment (LSVT) was
developed for treating speech intelligibility in
patients with Parkinson disease. Studies by Ramig
and her colleagues have validated the efficacy of
these exercises.
36,37
The focus of this treatment is
on increasing the valving ability of the vocal folds.
Sharkawi et al 36 demonstrated that oral and
pharyngeal transit times were reduced significantly following the use of LSVT with patients
having oropharyngeal dysphagia.
Sharkawi’s group36 found a reduction of 51% in
temporal measures of swallowing (oral transit time
and pharyngeal transit time) in patients with Par-
TABLE 7–7. Vocal Fold Closure and Laryngeal Elevation
Techniques
1. Practice coughing.
2. Increase the loudness of the voice.
3. Initiate voice with a hard glottal onset.
4. Produce sustained phonation. Try to increase the
5. Sustain phonation at various pitches. This helps
6. A program of laryngeal exercise called Lee Silverman
a
Adapted from Murry.
s
duration while maintaining consistent voice quality.
with anterior vocal fold closure as well as laryngeal
elevation.
Voice Treatment (LSVT) was developed by Ramig and
her colleagues.
primarily to increase vocal effectiveness, it also offers
promise to those who require increased vocal fold
closure to reduce the risk of aspiration.
9
Although this program is designed
27(p246)
kinson disease 1 month after completing the LSVT
program. They also found a reduction in oral residue following treatment and an increase in vocal
intensity for sustained vowel production and oral
reading. A review of the LSVT procedure and outcomes can be found in Fox et al.
37
Exercise Programs
Specific impairments may benefit from repetition
of specific tasks. Table 7–8 lists 13 common impairments or defects found after tissue loss or neurological damage along with goals and tasks to reach each
38
goal.
The clinician should use the information
derived from the FEES or modified barium swallow
to focus on 1 or 2 goals at a time.
Documentation is important for tracking progress
and maintaining patient motivation to continue
treatment.
Accurate tracking of progress becomes essential not only for continued patient motivation but
also for determining when to conduct additional
tests of swallowing in order to assess changes that
might signal changes in swallowing therapy or the
onset of oral eating.
Tongue strengthening exercises such as those
in Table 7–6 are useful for improving oral phase
swallowing functions, such as bolus manipulation,
mastication, and bolus clearance in the oral cavity.
From a review of the current literature, it appears
that only limited empirical data are available to
validate neuromotor or OMEs for use in treating
swallowing disorders.
26
Factors such as the need to
increase strength of lip seal, tongue pump, tongue
range of motion, and endurance of lip/tongue/jaw
coordination remain to be determined.
33
Nonetheless, once the clinician understands the underlying
anatomy, physiology, and neural control of these
muscle groups, the clinician will have a better
understanding of whether and when to use a specific exercise.
For patients following head and neck cancer or
neurological disorders, it appears that noninvasive
exercises that do not require the patient to swallow
176 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
TABLE 7–8. Exercises for Specific Impairments
a
Impairment Goal Tasks May Include
Limited control, agility, or
neck rotation, extension,
and flexion
Trismus—Inability of the
jaw to open due to injury
to the trigeminal nerve or
muscular deficiency
Range, control, agility adequate
for needed task
Adequate opening for feeding
route (spoon, fork, cup, or
biting), for denture of palatal
prosthesis placement, and for
oral hygiene
Obtain consult from physical therapy, depending on
need. Tasks may focus on development of agility of
movement as well as control and range of motion (ROM).
Maintain mandible-maxilla alignment while increasing
passive and active range of mandible opening.
Movements should be made slowly. Maximum stretch
should be maintained ≥15 s. The TheraBite is a more
sophisticated device, especially useful for marked
trismus or when alignment of mandible and maxilla is
difficult to maintain.
Weakness or absence of
mandibular support/control
Symmetric mandible-maxilla
approximation supportive of
potentials for posture, oral
nutrition/hydration, and speech
Establish optimal alignment passively or actively and
present exercises graded for endurance. Increase
strength and control using graded resistance for
endurance. Increase strength and control using graded
resistance and biting. Munching tasks to strengthen
muscles of mandibular closure and opening.
Weakness or absence of
buccal tone
Increased buccal tone Isometric tightening of the buccal area or squeezing
of soft objects between check and teeth/gums or from
buccal sulcus to the molar surface.
Diminished labial opening. Adequate labial opening size
for eating, adequate shaping for
speech
Passive stretching and exercises to increase range and
strength of lateral commissure movement. Maintain
mandible alignment throughout.
Unilateral partial or
complete lingual weakness
or missing lateral lingual
tissue
Posterior bolus retentionrelease control for airway
protection, bolus and airflow
control (minimize lateral “leaks”)
Bilateral lingual weakness Oral transit with minimum oral
loss, maximum coordination
with initiation of swallow
gestures
Absent tongue Development of compensatory
mandibular, labial, and head/
neck movement strategies
Unilateral or complete
weakness or missing
tissue of the palate
Adequate velopharyngeal
closure if tissue is adequate,
effective obturation if tissue is
inadequate
Incomplete supraglottic
Improved supraglottic closure Habituate early and effortful laryngeal closure and
closure
Inadequate PES opening
Maximum PES opening Maximizing extent and timing of hyoid/laryngeal elevation
for swallow
Abbreviation: PES, pharyngoesophageal segment.
a
Adapted from Leonard and Kendall.
38
Maximize lingual symmetry at rest and in a variety
of nonspeech and speech gestures. Squeezing and
lingual manipulation tasks may be appropriate. Palatal
prosthesis may facilitate therapy.
Address sectionally, as discussed earlier.
Develop ROM and agility of movements needed for
compensations that take advantage of gravity. Consider
mandibular or maxillary shaping prosthesis.
Sustained blowing against resistance may strengthen
closure. Endoscopic feedback may be helpful even with
objurgation. Objurgation may actually recruit improved
compensatory participation in closure from the lateral
and posterior pharyngeal walls.
elevation for swallow. The Mendelsohn maneuver may
be used.
and the effects of pharyngeal compression of the bolus.
7. TREATMENT OF SWALLOWING DISORDERS 177
may have value despite lack of extensive clinical
trials. Studies by Logemann,
loski et al,
39
and Sonies40 have shown that active
17
Lazarus et al,10 Pau-
participation in a series of neuromuscular swallowing exercises by patients following head and neck
surgery improves swallow function.
The use of exercises such as those listed in
Tables 7–5 and 7–6 should be based on anatomical
and physiological findings from instrumental and
clinical assessments. These exercises may be coupled
with prosthetic management and other compensatory
and rehabilitative swallowing therapy. However, clinicians must guard against blindly treating patients with
OMEs unless they can specify a rationale for treatment
and document changes related to treatment, swallow
safety, quality of life, and/or weight gain.
Whenever possible, OMEs should be combined
with other treatment approaches.
Shaker Exercise
An important aspect of swallowing is the ability to
open the UES to allow the passage of the bolus.
Studies by Shaker and others have shown that the
UES opening is reduced in older adults compared
to healthy young individuals.
colleagues developed a head lift exercise (HLE)
to increase the opening of the UES and therefore
decrease the hypopharyngeal intrabolus pressure.
In 1997, they studied healthy older adult subjects
using manometry and videofluoroscopy to measure intrabolus pressure prior to and following a
program of HLEs.
13
The HLE consists of lying in
a supine position and doing a series of head lifts
while the shoulders remain on the floor or bed.
The HLE, or Shaker exercise, was developed
to treat UES dysfunction by strengthening the
suprahyoid muscles.
This would be expected to lead to an increase
in the anteroposterior deglutive opening diameter
13,41-44
Shaker and
and cross-sectional area of the UES. The goals of the
Shaker exercise are as follows:
n To strengthen the muscles that contribute
to the opening of the UES, specifically
the geniohyoid, thyrohyoid, and digastric
muscles
n To significantly decrease the hypopharyngeal
bolus pressure as it enters the UES, thus
permitting bolus passage with less resistance
The Shaker exercise increases the UES opening and thus may contribute to the elimination of
aspiration in individuals with residue in the pharynx after a swallow due to poor UES opening.
42
Strengthening the suprahyoid muscles through the
Shaker exercise should result in a more efficient
UES opening.
The original Shaker exercise involves isometric
and isokinetic neck exercises while the individual
lies in a supine position.
43
The individual alternates
between 3 isometric repetitions of sustained 1-minute head raisings and 1-minute rest periods. The
individual must raise their head high enough to see
the toes without lifting the shoulders off the ground.
The second part of the exercise consists of 30 consecutive head lifts without holding. The shoulders
must also be kept on the ground during this por-
44
tion.
The instructions for the patient are shown in
Table 7–9. If the patient cannot sustain the head lift
for 1 minute, an alternate baseline time can be used
at the start of the exercises. Figure 7–1 shows the
extended posture for the Shaker exercise once the
head is lifted off the ground. Video 7–2 is a demonstration of the exercise.
Not only does the Shaker exercise strengthen
the suprahyoid muscles, it also enhances shortening of the thyrohyoid muscle. According to Mepani
46
et al,
the thyrohyoid muscle works in conjunction with the suprahyoid muscles to augment UES
opening. In their recent study, they compared the
effects of traditional dysphagia therapy (focusing on
laryngeal and tongue range-of-motion exercises and
swallowing maneuvers) and the Shaker exercise on
thyrohyoid shortening across a course of 6 weeks.
Thyrohyoid muscle shortening was measured before
and after the 6-week period using videofluoroscopy
to quantify any gains made in either group. Results
www
178 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
TABLE 7–9. Shaker Exercise Protocol
Please perform this exercise 3 times per day for the next _____ weeks.
1. Lay flat on your back on the floor or bed.
2. Hold your head off of the floor looking at your feet for 1 min. Relax with
your head back down for 1 min and repeat the sequence 2 more times.
3. Raise your head 30 more times and look at your toes. Do not sustain
these head lifts.
a
Do not lift your shoulders while performing this exercise.
a
a
FIGURE 7–1. Depiction of the starting position for the Shaker exercise. Note that the shoulders
remain in contact with the floor surface.
from this study showed that the Shaker exercise
proved significantly more effective in increasing
thyrohyoid shortening compared to the traditional
therapy. This would suggest that the Shaker exercise
has a positive outcome on deglutition by enhancing
UES opening.
46
Although Mepani et al46 were unable
to quantify the statistical significance of changes
in thyrohyoid shortening compared to changes in
UES opening and clinical improvement due to small
subject size, they noted a relationship between thyrohyoid muscle shortening and suprahyoid muscle
contraction on UES opening.
Several drawbacks exist with the Shaker exer-
cise. In the Easterling et al
45
study, subjects needed
repeated instruction, cueing, and encouragement
to accurately perform the exercise. Subjects also
reported neck muscle soreness and dizziness during
the early weeks of the exercise program.
45
Fatigue
may also be a factor for discontinuing the Shaker
exercise. A study by White et al
43
found both positives and negatives for the Shaker exercise when
looking at the relationship between the exercise and
fatigue. Subjects performed the Shaker exercise with
surface electromyography electrodes positioned to
evaluate the progression of fatigue in the suprahyoid muscles, infrahyoid muscles, and the sternocleidomastoid. After a 6-week training program, they
found that the Shaker exercise fatigues the sternocleidomastoid, which may preclude the continuation
of the exercise in some situations, especially with
older adult subjects. This suggests that the Shaker
exercise may not be appropriate for individuals
prone to fatigue (ie, those with amyotrophic lateral
sclerosis or other neuromuscular diseases).
7. TREATMENT OF SWALLOWING DISORDERS 179
tive as Shaker exercise in improving swallowing
It is important to note that the Shaker exercise
cannot be used with individuals who have
cervical spine deficits, reduced neck movement
ability, and/or cognitive issues that may affect
compliance.
functions in poststroke individuals. Patients found
the CTAR exercises easier and less tiring than the
Shaker exercise.
50,51
Clinicians may consider using
CTAR as an alternative to Shaker exercise, especially
for patients who are easily fatigued.
Unfortunately, these contraindications may
eliminate a large group of individuals who would
otherwise benefit from the Shaker exercise.
According to Burkhead, Sapienza, and Rosen-
47
bek,
the principles of exercise found to be effective in other areas such as physical rehabilitation
and sports training also extend to exercise treatment
of dysphagia. These principles include identifying
the optimal volume and duration of the regimen,
both of which are involved in the Shaker exercise.
It has been shown that the Shaker exercise has been
effective in treatment of swallowing dysfunction;
however, the optimal volume and duration for the
exercise need further investigation. As reported by
Burkhead et al,
47
exercises must place a load on the
system, involve enough practice, and last for some
duration to allow adaptation to the new behavior.
Further research is needed to refine the Shaker
exercise, as well as other swallowing exercises, to
make it as effective as possible and to increase the
likelihood of its continuation by patients. Although
there are drawbacks in terms of patient populations
and need for lengthy use, the Shaker exercise offers
the patient whose problems are focused at the cricopharyngeal level an opportunity to improve swallow
function.
Chin Tuck Against Resistance
The Chin Tuck Against Resistance (CTAR) exercise
was recently developed to target the suprahyoid
muscles to help improve the UES opening.
exercise requires the patient to be seated upright,
then place a small rubber ball under the chin
and compress it by tucking the chin. Studies with
healthy participants showed that the CTAR exercise
resulted in higher muscle activity than the Shaker
exercise for the suprahyoid muscles.
studies found that CTAR exercises were as effec-
48,49
Clinical
48
The
Expiratory Muscle Strength Training
In 2005, Kim and Sapienza52 reported on a series
of studies that demonstrated that expiratory muscle
strength training (EMST) improves both ventilatory
and nonventilatory functions such as with speech
production, cough, and swallow in normal healthy
individuals, hypotonic children, and patients with
multiple sclerosis. Since then, studies focusing specifically on swallow function have also shown that
EMST may be a valuable adjunctive rehabilitative
technique to use with patients who show muscular
weakness resulting from neurological or neuromuscular diseases.
EMST is a technique of respiratory muscle
strengthening through exhaling in a controlled
manner into a specific device with a one-way
valve that is used to block the expiratory airflow
until a sufficient expiratory pressure is produced.
Strength training of limb muscles has been
shown effective for increasing muscle hypertrophy, suggesting that strength training of respiratory
muscles may induce the same effect.
of well-designed studies have examined the impact
of EMST on swallowing in different populations.
Wheeler-Hegland et al
55
studied hyoid movement
using surface EMG under 3 conditions: Mendelsohn
maneuver, effortful swallow, and EMST. They found
that EMST achieved higher maximum and average
submental surface EMG activity vs normal swallowing. They suggested that the EMST training has
the potential to induce strength gains to increase
the activation speed in the submental musculature.
Other studies have shown that there is evidence
of improved swallowing following training with an
EMST device such as the one shown in Figure 7–2
53,54
A number
180 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
FIGURE 7–2. Expiratory muscle strength training device
used to improve force for various types of patients.
for patients with Parkinson disease, multiple sclerosis, and sedentary older adults. Note that EMST may
increase blood pressure during the exercise. Clinicians may wish to discuss with physicians whether
this exercise is appropriate for the patient if there
are concerns with hypertension.
TABLE 7–10. Nonsurgical Methods for Controlling
Aspiration
1. Oral motor exercises:
2. Head position maneuvers:
3. Postural compensation techniques:
4. Swallowing retraining:
5. Diet modification:
6. Nonoral diet (NPO)
a
Adapted and revised from Pou and Carrau.
a
Lip seal
Tongue retraction and elevation
Tongue strengthening
Chin tuck
Head lift
Rotating head to side of lesion in pharyngeal or vocal
fold paresis
Sitting upright
Lying on side
Supraglottic swallow
Super-supraglottic swallow
Mendelsohn maneuver
Multiple swallows
Frequent throat clearing
Change in bolus size
Change in food consistencies
Changes in temperature and taste
56
Swallowing Therapy and Aspiration
It is to be expected that patients recovering from
swallowing disorders will experience occasional
aspiration. Using the swallowing therapy reviewed
in this chapter can be efficacious in reducing aspiration events and preventing aspiration pneumonia.
This may be a patient-by-patient experience, given
that patients rarely present with a uniform case history and medical status. A summary of the nonsurgical methods to reduce or eliminate aspiration is
shown in Table 7–10. Caution should be used by the
clinician when applying these approaches.
A more comprehensive list summarizing the
nonsurgical swallowing interventions for patients
who experienced head and neck cancer is shown in
Table 7–11.
manuscript by Pauloski,
14
These data, taken from a public access
57
offer range-of-motion,
compensatory, and rehabilitative techniques for the
management of various swallow-related disorders.
Groher 58 reported that the variables that separate those who develop aspiration pneumonia
from those who do not remain speculative.
To be sure, many more people, with or without
swallowing problems, aspirate compared to those
who develop aspiration pneumonia. Factors such
as prior history of aspiration, mobility, age, state of
7. TREATMENT OF SWALLOWING DISORDERS 181
TABLE 7–11. Swallowing Disorders Most Often Reported for Patients Treated for Head and Neck Cancer Are Listed With
Associated Postures, Maneuvers, Exercises, and Other Interventions That May Be Effective in Alleviating the Disorder or
Reducing Its Negative Impact on Swallowing
a
Swallow-Related Disorder Possible Interventions
Reduced mouth opening Jaw ROM exercises
Reduced tongue control/shaping Chin-down posture
SSG swallow
Tongue ROM exercises
Reduced vertical tongue movement Tongue ROM exercises
Maxillary reshaping prosthesis
Reduced anterior-posterior tongue
movement
Head-back posture
Multiple swallows
Alternate liquids and solids
Reduced tongue strength Effortful swallow
Tongue strengthening exercises
Delayed pharyngeal swallow Chin-down posture
SSG swallow
Thermal/tactile stimulation
Reduced tongue base retraction Chin-down posture
Effortful swallow
SSG swallow
Tongue hold maneuver
Reduced laryngeal vestibule
closure
Chin-down posture
SSG swallow
Effortful swallow
Bolus manipulation exercises
Tongue strengthening exercises
Tongue ROM exercises
Bolus manipulation exercises
Maxillary reshaping prosthesis
Mendelsohn maneuver
Tongue ROM exercises
Gargle/yawn for tongue base retraction
Mendelsohn maneuver
Gargle/yawn for tongue base retraction
Reduced laryngeal elevation Mendelsohn maneuver
Chin-down posture
SSG swallow
Reduced glottis closure Head rotation to weaker side
SSG swallow
Thickened liquids
Vocal fold adduction exercises
Reduced pharyngeal constriction/
clearance
Head rotation to weaker side
Effortful swallow
Mendelsohn maneuver
Multiple swallows
Reduced/impaired cricopharyngeal
opening
Head rotation to weaker side
Mendelsohn maneuver
Shaker exercise
Effortful swallow
Abbreviations: ROM, range of motion; SSG, super-supraglottic.
a
From Pauloski.
14
Effortful swallow
Laryngeal ROM exercises
Shaker exercise
Alternate liquids and solids
Gargle/yawn for tongue base retraction
Tongue hold maneuver