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182 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
consciousness, respiration status, upper airway
reflexes, instrumental results of swallow evaluation, and the integrity of the lower airway protective
mechanism all contribute to prevention of aspiration
pneumonia. Clinical judgment suggests that given
a decreased medical condition and signs of aspiration, one may ultimately expect aspiration pneumonia and therefore should do everything possible to
maintain swallow safety.
PROPHYLACTIC SWALLOWING THERAPY FOR HEAD AND NECK CANCER SURVIVORS
It is well documented that trismus and long-term
dysphagia may occur in patients who received
TABLE 7–12. Consensus Statements on Prevention of Dysphagia Among Patients With
Head and Neck Cancer Published by the American Academy of Otolaryngology-Head and
Neck Surgery
61
head and neck cancer treatment.
59,60
The American Academy of Otolaryngology-Head and Neck
Surgery published an expert consensus statement
on the management of dysphagia in patients who
experienced head and neck cancer.
61
Eleven statements in relation to prevention of dysphagia among
patients with head and neck cancer were published.
These statements are listed in Table 7–12. Prophylactic swallowing therapy is conducted before and
during nonsurgical cancer treatment with the aim
to minimize or prevent the short- and long-term
negative effects of (chemo)radiotherapy on swallowing functions. A range of exercises have been
proposed, such as Shaker, Mendelsohn maneuver,
effortful swallow, supraglottic swallow, Masako, and
jaw stretching exercises. The selection of exercises
is often based on a precancer treatment swallowing
evaluation and the type of head and neck cancer.
1. Nutritional evaluation and management by a registered dietitian nutritionist
contribute to improved nutritional outcomes of patients.
2. HNC patients have improved swallowing outcomes if encouraged to continue
eating and drinking, guided by a dysphagia specialist.
3. Radiation-associated dysphagia can be reduced by contouring and avoiding
swallowing organs at risk during head and neck radiotherapy.
4. A multidisciplinary team with members from head and neck surgery, radiation
oncology, medical oncology, speech-language pathology, nutrition, and nursing is
preferred to provide comprehensive care for HNC patients and minimize dysphagia
associated with treatment.
5. Prophylactic swallowing exercises benefit HNC patients undergoing radiation
therapy by optimizing functional status and quality of life.
6. Acute and chronic pain management in HNC patients contributes to improved
swallowing and nutritional outcomes.
7. The use of IMRT is associated with less xerostomia than conventional techniques,
which has a positive impact on swallowing function.
8. HNC patients treated with IMRT have improved swallowing outcomes in
comparison to those individuals treated with less conformal techniques.
9. Dysphagia-optimized IMRT improves patient-reported swallowing outcomes vs
standard IMRT.
10. The addition of chemotherapy to HNC treatment regimens is associated with worse
swallowing outcomes in HNC patients.
11. Cricopharyngeal myotomy improves swallowing outcomes in patients undergoing
laryngectomy.
Abbreviations: HNC, head and neck cancer; IMRT, intensity-modulated radiation therapy.
7. TREATMENT OF SWALLOWING DISORDERS 183
Early evidence suggests that prophylactic swallowing therapy may reduce the use of feeding tubes;
increase oral intake; maintain swallowing-related
muscle mass, strength, range and coordination; and
therefore, reduce risk of developing dysphagia.
There is still no clear evidence as to which exercise
clinician should prescribe and when and for how
long the patients should practice.
62
Studies have
shown that only approximately 50% of the patients
practiced the swallowing exercises during cancer
treatment.
63,64
Barriers to adherence to the exercises
included pain and fatigue during cancer treatment,
not appreciating the importance of the swallowing
exercises, lack of support and encouragement to
continue with the exercises, and simply forgetting
that they had to do the exercises.
OTHER SWALLOWING TREATMENT METHODS
The following swallowing treatment methods have
been proposed and tested scientifically. However,
there are no strong indications supporting or refuting these methods as yet because of limitations in
the studies. Clinicians are recommended to refer
to updated evidence before implementing these
methods clinically. These methods are often recommended to be used in conjunction with swallowing
therapy described earlier, rather than as a standalone treatment method.
Electrical Stimulation
Different ways are proposed in using electrical
stimulation to enhance swallowing. Neuromuscu-
lar electrical stimulation (NMES) is a technique
that has been proposed to stimulate swallow function by applying electrical stimulation to the neck
area as a means of stimulating laryngeal elevation.
By stimulating the muscles in the neck via surface
electrodes, it has been hypothesized that the swallowing musculature will be strengthened or that
the sensory pathways important for swallowing will
have heightened awareness. This procedure, also
known as transcutaneous electrical stimulation,
is noninvasive. Contradictory findings have been
reported in the past. A review by Clark et al
65
in
2009 concluded that there were few promising findings related to NMES for swallowing therapy and
that there is a need for examining specific issues
such as dosage, timing, surface versus intramuscular
recording, and applications to specific populations.
A more recent study has investigated pairing NMES
with effortful swallow and swallowing therapy
66
in
poststroke individuals. Sixty-one poststroke individuals were recruited, all received NMES, effortful
swallow, and “conventional” swallowing therapy.
The participants were randomized into 2 treatment
methods, one with NMES at motor stimulation intensity and one at sensory stimulation intensity. Results
showed that those stimulated at motor stimulation
intensity had better anterior and superior hyoid
movement and Penetration Aspiration Score than
the sensory stimulation group after 6 weeks of treatment. There is increasing evidence in support of
using NMES while performing swallowing exercises
to maximize the treatment effect in the poststroke
population.
67–70
Pharyngeal electrical stimulation (PES) is a
technique that uses a transoral or transnasal catheter to place electrodes to the pharyngeal area.
Electrical current at an individualized tolerable
level is then passed through the electrodes to stimulate the pharyngeal area. Studies have shown that
this is a safe and tolerable treatment method.
large-scale international,
72
multicenter, randomized,
71
A
sham-controlled study with 162 subacute stroke
patients did not find significant improvement in
swallowing functions after 3 daily sessions of PES.
This is in contrast with another individual patient
data meta-analysis study, which concluded that PES
was associated with better swallowing outcomes
and shorter hospital stay for subacute poststroke
survivors.
73
In contrast to surface stimulation, intramuscu-
lar (IM) stimulation via hooked-wire electrodes are
inserted into specific muscles or electrodes are more
permanently implanted into the muscle to direct
current locally to increase muscle activity and thus
improve swallow functions. Ludlow
74
reviewed the
evidence related to electrical stimulation. Her report,
including data from up to 2009, suggests that electrical stimulation is most effective when the electrical
stimulus is applied directly to the muscle (IM). Intramuscular stimulation using electrodes inserted into
184 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
these muscles has been shown to produce laryngeal
elevation similar to that which occurs during normal
swallowing.
75
Cortical Neuromodulating Treatments
There are 2 types of noninvasive cortical neuromodulating methods proposed for improving swallowing functions, namely, repetitive transcranial
magnetic stimulation (rTMS) and transcranial
direct current stimulation (tDCS). The objectives
of these methods are to modulate neuronal activities at targeted cortical regions in order to promote
neural changes that may facilitate neuromuscular
rehabilitation.
The rTMS modulates neuronal activities by discharging electricity to a coil of wire to produce brief,
strong magnetic pulses. The coil is usually placed
on a targeted area on the head so that the magnetic field will pass through the skull to induce an
electrical field. The electrical field will then modulate cortical neural networks. Figure 7–3 shows an
example of equipment used for rTMS. Two general
FIGURE 7–3. Equipment used for conducting repetitive transcranial magnetic stimulation. From the left, camera for detecting
head and coil location trackers; neuronavigational system for real-time detection and recording of site of stimulation; electric
pulse generator and control panel for transcranial magnetic stimulation; head coil; coil trackers calibration block; headband
with location trackers.
7. TREATMENT OF SWALLOWING DISORDERS 185
types of rTMS have been proposed: low-frequency
or inhibitory rTMS (≤1 Hz) and high-frequency or
excitatory rTMS (≥5 Hz). Published studies in the
use of rTMS for dysphagia have mainly focused on
poststroke individuals. In general, current evidence
suggests that rTMS has potential to improve swallowing functions in poststroke individuals, especially in the acute phase.
76,77
The tDCS modulates the excitability threshold
of targeted neurons by passing a low-intensity electrical current between 2 electrodes that are carefully
placed at a predefined area of the head. Preliminary
findings from the small number of published studies on the poststroke population suggest that using
tDCS to stimulate the unaffected hemisphere may
improve swallowing functions in poststroke individuals.
78
Similar to the rTMS literature, the studies
differed in a number of methodological designs, and
it is not possible to conclude which tDCS protocol
would be effective and safe for use as a clinical
treatment method.
SUMMARY
Swallowing therapy is now commonly provided for
acute and chronic swallowing disorders resulting
from postcancer treatment in head and neck cancer, neuromuscular disorders, neurological disorders, and debilitation associated with a cohort of
aging conditions that affect the nerves and muscles
involved in swallowing. Compensatory and rehabilitative therapies continue to evolve and be tested
in both healthy participants and in patients with
dysphagia. Procedures such as LSVT and EMST,
treatments that were developed for nonswallowing disorders, are now being explored in patients
with swallowing disorders. The application of neuromuscular rehabilitation principles such as “use it
or lose it,” transference, repetition, and intensity in
DISCUSSION QUESTIONS
1. Most swallowing exercises target a specific
organ or posture. Martin-Harris
swallowing is a parallel process, with glottic
closure beginning when the bolus has not
yet reached the anterior facial arch. Write a
rationale for studying one of the exercises in
Tables 7–5, 7–6, or 7–7. Discuss the exercise
within the framework of parallel processing,
and suggest how that exercise can improve
swallowing and how it will interact and
improve the other phases of swallowing.
2. Discuss how the principles of neuromuscular
rehabilitation may be applied to rehabilitative
swallowing exercises, such as those listed in
Tables 7–5 through 7–8.
3. Discuss the roles of different professionals in
managing the following clients:
A. Patient who received cancer treatment
and is in your SLP clinic for swallowing
management but has not gone back to the
oncologist for review/follow-up.
B. A patient who is 6 months post stroke
who has swallowing disorders, adequate
cognitive functions, limited mobility, and
lives in a nursing home.
C. Individual with Parkinson disease who is
experiencing swallowing difficulties.
34
suggests that
STUDY QUESTIONS
1. Exercises for patients with upper motor
neuron injury might include
A. Lip strength
B. Tongue strength
C. Mendelsohn maneuver
D. All of the above
for the nonsurgical treatment of swallowing. Such a
rationale may provide a basis for developing additional evidence for continued exploration of methods to improve swallow safety and quality of life in
patients with dysphagia.
2. The use of the chin tuck during swallowing
A. Prevents aspiration and penetration
B. Increases speed of bolus to the oropharynx
C. Reduces the speed of bolus transit in the
oral cavity
186 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
D. Reduces the distance between the thyroid
cartilage and hyoid bone
3. The primary outcome from studies using the
Shaker exercise is
A. Significant increase in the anterior
excursion of the larynx
B. Reduced opening of the upper esophageal
sphincter
C. Increased thyrohyoid shortening and
opening of upper esophageal sphincter
D. No improvement in the types of liquid that
patients with UES difficulty could swallow
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Nutrition and Diets
CHAPTER OUTLINE
Introduction
Dietitian and Dysphagia
Properties of Liquids and Foods
Applications of Rheology
Oral Nutrition and Dysphagia Diets
Diets and Consistencies
Foods
Dysphagia Diet Guidelines
Nonoral Diets
Introduction
Nasogastric, Nasoduodenal, and Nasojejunal
Tubes
Gastrostomy Tubes
Malnutrition and Dehydration
Stroke
Neurodegenerative Diseases
Head and Neck Cancer
Summary
Discussion Questions
Study Questions
References
Chapter
8
189
190 CLINICAL MANAGEMENT OF SWALLOWING DISORDERS
A Look at the Chapter
Individuals with dysphagia often need to
modify their nutritional intake to ensure safe
swallowing. The diet modifications may involve
thickening fluids, changing the texture of solid
food, or changing to a nonoral diet. In this
chapter, the different types of diet modifications
are described. Readers should be aware that
different terminologies or systems are used
to describe different levels of liquid and food
consistency. This chapter introduces the more
common systems used internationally. Types of
nonoral feeding are introduced at the end of this
chapter. Ethical choices in relation to diet choices,
especially in relating to patients with dementia or
end of life are discussed in Chapter9.
In this chapter, the properties of liquids and
foods are examined in relationship to the safety and
nutrition of the dysphagic patient. Oral diets and
nonoral feeding alternatives are reviewed. Malnutrition and its consequences as they relate to dysphagia are considered. Nutrition and its importance in
recovery from sickness, injury, or surgery are extensive topics and have far-reaching implications. Comprehensive reviews of nutrition including enteral
feeding requirements and calorie intake calculation
are summarized, and references are provided for
those who need specific patient requirements.
Proper nutrition can be achieved through oral
or nonoral diets or from a combination of the two.
In the recovery process from head and neck cancer, nutrition sometimes begins with a nonoral diet,
often a nasogastric tube, and then proceeds to a
combined oral and nonoral diet and finally an oral
diet in most cases.
INTRODUCTION
The importance of proper nutrition cannot be overestimated in the management of swallowing disorders. Nutritional status can have a significant impact
on recovery from disease and swallowing rehabilitation. Diet modification can also have significant
negative impact on the patient’s quality of life, especially those factors related to self-esteem and psychosocial concomitants of oral eating.
The highest priority in the management of
the dysphagic patient is swallow safety. The
dysphagia team must also ensure that, no matter
how the dysphagic patient is managed, the
patient must receive adequate nourishment,
measured by the number of calories received, the
content of the calories, and the degree of satisfaction when eating or drinking those calories.
Stroke recovery is similar; however, with the stroke
patient, the patient’s cognitive status, degree of
alertness, and understanding of the nutritional
process must also be taken into account.
DIETITIAN AND DYSPHAGIA
A comprehensive dysphagia treatment program
involves extensive input from the nutritionist/dietitian (the term “dietitian” is used in this chapter
in reference to “registered dietitian”) in order to
prevent malnutrition, maintain or increase strength,
and maintain immune status.
The dietitian is a trained professional who
selects the proper calorie and nutritional content
of the diet and monitors the nutritional status and
continuing needs of the patient.
Failure to achieve proper nutrition, whether
it is via an oral or nonoral pathway, will result in
malnutrition, a major complication in the recovery
process.
As such, it is important for the speech-language
pathologist (SLP) and dietitian to work together, as
nutritional needs will change with changing medical
8. NUTRITION AND DIETS 191
status. The dietitian may elect to perform a comprehensive nutrition assessment, as seen in Table 8–1,
or may limit the assessment to the specific needs
of the patient at treatment modification stages. The
dietitian also works closely with other rehabilitation team members to select foods or supplements
TABLE 8–1. Comprehensive Examination in Conjunction
With a Nutritional Assessment by a Dietitian
Medical History
Primary diagnosis
Planned medical procedures
Medical comorbidities
Current cognitive status
Gastrointestinal history
History of pneumonia
Neurological status
Review of medications
Review results of previous swallow studies
Physical Assessments
Current weight and recent weight change
Coordination skills
Dentition
Edema
Handedness and recent change in handedness
Feeding skills
Living status
Nutritional History
Diet history
Recent diet changes
Tolerances to foods
Use of nutritional supplements
Medical restrictions to types of foods
Vitamin supplements
History of anorexia
Alcohol intake
Recent Biochemical Data
Albumin, transferrin, prealbumin
Glucose
Electrolytes
Hemoglobin/hematocrit
BUN/creatine
a
Adapted and revised from Molseed.
3(p150)
a
for oral feeding that provide proper nourishment
while at the same time maximize proper oral control, transit, and timing of swallowing. If nutrition
is nonoral, the dietitian monitors and determines
amounts and timing of enteral feeding to assure
proper energy requirements and to ensure that the
foods/supplements selected do not interfere with
other conditions such as cardiac disease and diabetes. A comprehensive review of the roles of the
dietitian may be found in the publications of the
Academy of Nutrition and Dietetics.
1,2
What is an RDN and NDTR? Information can be
found by scanning the accompanying QR code.
PROPERTIES OF LIQUIDS AND FOODS
Rheology is the study of the deformation and flow
of matter. The need to use the proper thickeners and
food textures in treating patients with dysphagia has
influenced the recent development of this science
specific to swallowing disorders.
Although their clinical significance is not
completely determined, the rheological properties of food may be useful for the study and
development of standard dysphagia diets and
feeding protocols.
More importantly, by obtaining a set of standards for different food and liquid consistencies,
instrumental testing (whether it is the modified barium swallow [MBS], flexible endoscopic evaluation
of swallowing [FEES], or other instrumental testing)
can also approach standardization.
Recently, the International Dysphagia Diet Standardisation Initiative (IDDSI) developed a comprehensive framework establishing standards for foods
and drinks.
according to their rheological properties. To understand this analysis completely goes beyond the
scope of this chapter. However, a basic knowledge
of rheology and how it relates to dysphagia is
important to the clinician (Table 8–2).
4
Fluids and solid foods are categorized