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Increased pharyngeal residue, especially in the
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vallecula; reduced laryngeal vestibule closure; and
delayed triggering of the pharyngeal swallow may
occur with Masako in HNC patients (Pauloski, 2008).
Increased distance and
resistance to lingual
retraction for activation
of the glossopharyngeus
muscle responsible for
tongue base retraction
and medialization of
The tongue is pulled
anteriorly away from the
posterior pharyngeal wall
to facilitate the anterior
bulge of the posterior
pharyngeal wall (Fujiu &
Logemann, 1996).
the superior pharyngeal
constrictors (Fujiu &
Logemann, 1996).
Secondary activation of
suprahyoid and infrahyoid
muscles (Félix-Lusterman
Prior studies demonstrate mixed results on the effect
Activation of the anterior
etal., 2021).
A device-driven exercise
Measurement of the phase of respiration for training
Promotion of swallowing
A protocol integrating
(Brooks et al., 2019).
can be clinically cumbersome. A wearable sensor
within a mid-lung volume
principles of motor
of expiratory muscle strength training on dysphagia
severity. For example, there has been no report of
significant reduction in the penetration or aspiration
scores in neurological patients (Mancopes et al.,
2020).
suprahyoid muscles,
geniohyoid muscle, and
expiratory muscles (Félix-
Lusterman et al., 2021).
thought to act on
the movement of the
suprahyoid muscle group
and subglottic expiratory
pressure-generating forces
has been used in clinical trial contexts but not yet
generalized to the clinical setting (Martin-Harris et
al., 2022).
range using an exhale–
swallow–exhale respiratory-
swallow pattern via motor
skill training (Martin-Harris
etal., 2015).
learning using the optimal
and suboptimal exhale-
swallow-exhale respiratory-
swallow pattern swallowing
as well as swallowing in
the mid-lung volume range
(Martin-Harris et al., 2015).
continued
Tongue hold or
Exercise Overview of the Exercise Rationale Limitations
Table 10 –1.
Masako
204
Expiratory muscle
strength training
(EMST)
Respiratory swallow
coordination training
LSVT offers promise in protecting against the
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respiratory and swallowing symptoms for people
with mild Parkinson’s disease in a non-invasive
manner. However, research on LSVT for swallowing
treatment is limited and requires further primary
research. LSVT is not a replacement for direct
swallowing treatment for this population at this time
(Miles et al., 2017).
Laryngeal lift has recently been shown to be
significantly less during pitch glide than during
swallow, potentially due to superior but not anterior
movement of the larynx during the maneuver
(Kennedy et al., 2020).
Superior results were found with the Shaker for
hyoid movement, thyroid shortening, laryngeal
lift, UES opening, and aspiration compared to the
Mendelsohn in HNC patients in a prophylactic
continues
exercise study (Loewen et al., 2021). However,
data from two additional studies suggest the
Mendelsohn as a compensatory strategy may be
more effective at preventing aspiration compared
to the super-supraglottic swallow maneuver
(McCabe et al., 2009).
System-wide effects
Systematic hierarchy of
Lee Silverman Voice
Exercise Overview of the Exercise Rationale Limitations
to the sensorimotor
speech system including
improvements in breath
speech exercises beyond
words and phrases
and into conversation
Therapy (LSVT)
support for respiratory
drive to the larynx as
well as reinforcing neural
pathways that increase
strength and recruitment
and carryover tasks.
Instrumental feedbag
of pitch and loudness is
provided during therapy
(Miles et al., 2017).
of laryngopharyngeal
muscles (Fox et al., 2006;
Miles et al., 2017).
Medialization of the
pharyngeal constrictors
and activation of anterior
hyoid movement (Kennedy
et al., 2020).
Laryngeal lift during pitch
glide in speech into a high
squeaky voice for several
seconds on the sound
/i/ is thought to promote
laryngeal lift during a
swallow (Miloro et al.,
2014).
Pharyngeal squeeze
or falsetto pitch
205
Sustained peak
hyolaryngeal excursion
during the swallow to
prolong activation of
suprahyoid contraction for
laryngeal excursion at the
midpoint of the swallow,
intended to increase the
extent and duration of
Mendelsohn Voluntary prolongation of
strength and endurance
(Pauloski, 2008).
laryngeal elevation and
thereby increase the
duration of UES opening
(Pauloski, 2008).
When comparing populations with neurological dis-
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orders to those with HNC, stroke survivors were more
likely to improve to normal functional intake with the
Mendelsohn maneuver (McCabe et al., 2009).
Additional findings suggest that biofeedback pro-
duces improved outcomes for both populations with
neurological disorders or HNC (McCabe et al., 2009).
Does not alter either peak amplitude or duration of
the intrabolus pressure in stroke survivors; however,
the hyoid is held in a more superior position prior to
swallow onset and the use of the effortful swallow
in these patients significantly reduces depth of
Alteration of the
biomechanics of the
swallow pattern, thereby
bolus flow patterns,
increasing tongue base
pharyngeal pressure
during a swallow in which
the patient is instructed to
squeeze hard with all their
contrast penetration into the larynx and trachea
(Bülow et al., 2002).
May be more appropriate with HNC patients as
a higher pharyngeal pressure amplitude and
a longer pressure duration were seen in these
patients compared to values without the maneuver.
range of motion, contact
of the base of tongue and
posterior pharyngeal wall,
and muscle activity of the
floor of mouth (Clark &
Shelton, 2014).
muscles (Pauloski, 2008).
The quality of evidence has been low or very low
However, fibrotic tissue may increase fatigue during
effortful swallow, adversely affecting execution
for NMES. The majority of positive effects have been
overtime (McCabe et al., 2009).
Enhanced contraction
of the infrahyoid muscles
Electrode placements in
different areas of the neck
in stroke survivors, particularly when the stimulus is
adjusted at the sensory level or when applied on the
infrahyoid muscles during swallowing or traditional
swallowing therapy (Alamer et al., 2020; Poorjavad
etal., 2014). However, a large, randomized control
trial found NMES to worsen dysphagia symptoms in
HNC patients (Langmore et al., 2016).
or submental muscles,
depending on placement
of the electrodes
(Christiaanse et al., 2011;
Pauloski, 2008).
stimulate varying muscle
groups and alter the
swallowing physiology (Sun
et al., 2020).
continued
Mendelsohn
Exercise Overview of the Exercise Rationale Limitations
Table 10 –1.
continued
Effortful swallow Conceived to increase
206
Surface
neuromuscular
electrical stimulation
(NMES), EMS, or
E-STIM
The quality of evidence has also been low or very
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low for FES, primarily reported in healthy subjects
(Schauer, 2017).The resulting contraction strongly
depends on the muscular state of fatigue, the addi-
tional voluntary contribution by the patient and the
level of spasticity which are hardly predictable and
may continuously change during the application
Enhanced contraction of
the pharyngeal muscles
or suprahyoid muscles
(depending on placement
of the electrodes) during
a swallow in progress (Lin
etal., 2011).
Electrode placements
are similar to NMES
but combined with
instruments that sense
motion or activity, such
as electromyography, to
detect onset of the swallow
of FES. Due to the time-consuming manual tuning
and access and cost of equipment, the implemen-
tation is clinically taxing (Schauer, 2017).
When applied to suprahyoid muscles to target
amplitude and speed of laryngeal elevation,
in real time to trigger the
electrical stimulation
(Schauer, 2017; Schultheiss
et al., 2016).
though 73% of healthy subjects had increased
laryngeal elevation, 27% of subjects had decreased
laryngeal elevation (Schultheiss et al., 2016).
Laryngeal elevation movements elicited by direct
electrical stimulation were greater than in surface
electrodes in a case study of two healthy subjects
(Kagaya et al., 2011).
Enhanced contraction of
the geniohyoid, mylohyoid,
anterior belly of the
digastric, and thyrohyoid
muscles (Kagaya et al.,
Direct stimulation of
deep muscles via needle
electrodes, thereby
avoiding simultaneous
stimulation of superficial
2011).
muscles for a more
targeted contraction
Use of a mechanical device may increase jaw
Elongation of the masseter
Passive and slow stretching
(Kagaya et al., 2011).
opening more than other methods of stretching;
however, all methods are effective at increasing jaw
opening in treated HNC patients (Pauloski, 2008).
Assisted resistance jaw opening exercise is
and pterygoid muscles
(Cousins et al., 2013).
for restricted mouth
opening often resulting
from surgical scarring or
radiation-induced fibrosis
contraindicated in those with superficial or deep
jaw degeneration, such as HNC patients with acute
radiation toxicities or osteonecrosis (Kilinc & Ünver,
2022).
(Pauloski, 2008).
Functional electrical
Exercise Overview of the Exercise Rationale Limitations
stimulation (FES)
207
Direct muscle
stimulation
Unassisted jaw range
of motion exercises,
finger-assisted stretch-
ing exercises, stacked
tongue depressors,
or mechanical assis-
tance of jaw opening
with a device (e.g.,
TheraBite)
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
BOLUS MANIPULATION
Therapeutic probing during bedside/
clinical or videofluoroscopic evaluations may suggest that a patient can
manage particular types or amounts of
food materials safely and efficiently but
have difficulty with others. Therapeutic strategies directed at elaborating the
patient’s potential for improved swallowing by manipulating bolus materials and at establishing the patient’s
facility with these selected materials
are described here. In clinical practice,
strategies are tailored to an individual
patient, as there are few if any data
establishing the value of particular strategies with particular patient groups.
Bolus characteristics can be manipulated to compensate for timing/coordination or constriction/patency impairments of chambers or valves of the
upper aerodigestive tract. Characteristics of the bolus that lend themselves
to manipulation include: (a) properties
that maximize sensory feedback about the
bolus and its position and (b) properties
that affect bolus deformability and/or bolus
flow in response to gravity or compression. For simplicity, the properties are
presented here somewhat separately,
but in fact, bolus properties combine,
heightening some properties and minimizing others.
PROPERTIES THAT MAXIMIZE
SENSORY FEEDBACK ABOUT
THE BOLUS AND ITS POSITION
Properties that typically maximize sensory feedback include temperature,
taste, size, and texture. Swallow initiation has been reported to be facilitated
with cold instrument stimulation of the
faucial pillars (Lazzara et al., 1986) in
some populations (Kagel & Leopold,
1992), and some patients report that
thermal characteristics of the bolus
itself affect their dysphagia (Martin,
1994). On the other hand, Bisch et al.
(1994), investigating post–cerebrovascular accident (CVA) and neurologically impaired patients, did not find
significant effects on transit times or
durations with a chilled bolus. Temperature has been reported to affect esophageal function (Meyer & Castell, 1983).
We routinely include chilled bolus presentation in evaluation of patients with
suspected neural or neuromuscular etiologies. Air pulses applied in a similar
manner have demonstrated increased
cortical activity in normal individuals
(Lowell et al., 2008) and an increased
swallowing rate at rest in dysphagic
stroke patients when applied bilaterally
(Theurer et al., 2013).
Potentially irritating taste characteristics of the bolus may facilitate swallow initiation in some populations
(Logemann et al., 1995; Palmer et al.,
2005). Palmer et al. (2005), for example,
reported that in normal individuals, a
sour bolus produced stronger muscle
contractions in the mylohyoid, geniohyoid, and anterior belly of the digastricus muscles than a water bolus. Pelletier and Lawless (2003) noted that citrus
acid and citric acid–sucrose boluses
produced more dry swallows and decreased both aspiration and penetration in neurogenic patients compared
with a water bolus, possibly because
of increased gustatory and trigeminal
stimulation of the brainstem. A recent
study in head and neck cancer patients
demonstrated shorter pharyngeal transit times with a sour bolus (Pauloski
et al., 2013). Potential beneficial effects
notwithstanding, we have typically
exercised caution with this strategy
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209
in patients who have demonstrated,
or who are at high risk for, aspiration,
due to the potentially noxious effects of
bolus material in the nasal and tracheal
airways and lungs. Irritating tastes
may be safer and still useful when
introduced in tiny, dilute amounts to
the lips or anterior oral cavity where
they will stimulate saliva that must be
swallowed.
Carbonation increases the “texture”
of liquids and is known to improve
esophageal clearing (Wong & Johnson, 1983). Carbonation has also been
reported to shorten pharyngeal transit
times and reduce both aspiration and
amount of residue (Bülow et al., 2002).
Alternating thermal, taste, and texture
characteristics during therapeutic feeding or a meal may keep the interest of
the swallower, supporting vigilance
regarding swallow.
Finally, manipulation of bolus placement to maximize available sensory
capabilities is a valuable compensatory maneuver for patients with sensory impairment. If a sensory deficit is
unilateral, bolus material on the more
intact side may facilitate swallow. For
patients who are able, mastication,
another form of bolus manipulation,
may lead more easily to swallow. When
patients are not able to masticate, simply manipulating the bolus briefly in
the oral cavity may facilitate swallow
initiation.
Properties That Affect
Bolus Deformability and
Flow in Response to
Gravity or Compression
Bolus consistency is a powerful tool,
and manipulation of it and, in particular, the use of “thickened liquids”
may currently represent the most frequently used approach to minimizing
aspiration in a variety of settings. Clinicians have typically used the term
“viscosity” to describe the consistency,
or degree of thickness of a liquid, but
the properties of bolus materials are
complex. From a rheological science
perspective, thickened foods and beverages are classified as complex fluids.
Unlike simple fluids
or water — the flow behavior of these
bolus types cannot be adequately
described by single values for viscosity and density alone. For example, the
viscosity of a starch or gum-thickened
drink depends on time under flow, and
the final “steady-state” viscosity value
depends on the shear rate, or how fast
the material flows, as well as on variables such as density and temperature,
to name a few. An appropriate selection
of parameters to describe the properties
of a complex fluid during swallowing
requires a fluid mechanical analysis of
the swallowing process itself. Unfortunately, much of the literature dealing
with “thickened” fluids and swallowing efficiency and safety has not specified these details in an objective manner, making conclusions drawn and
comparisons across studies difficult.
Clinically, consistency is typically
referred to in common categories: liquid, thick liquid, puree, soft solid, and
so on. However, these characteristics
exist as a continuum from water (least)
to (for example) hard candy (most). The
International Dysphagia Diet Standardization Initiative, or IDDSI (https://
iddsi.org/), developed by an international group of experts in nutrition
and dysphagia, proposes eight levels
of textures and thicknesses designed
to provide common terminology and
standardized applicability to foods
— for example, oil
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
and liquids recommended for dysphagic patients. An additional feature
of the IDDSI platform is its description
of a readily available measurement
tool, essentially, a syringe with specific
characteristics, for assessing not viscosity but gravity flow characteristics
of liquids considered for patient use.
Though not as sophisticated as instrumental assessments of fluids typically
conducted in a laboratory, the benefits
of standardization and utility offered to
clinicians and others by this methodology are excellent (https://iddsi.org/
framework/drink-testing-methods/).
Other variables that influence bolus
characteristics are related to the patient
— for example, saliva production,
mucosal integrity, or ability to prepare
a bolus to some uniform consistency
prior to swallowing it. Again, specification of consistency for a given bolus
in a particular patient is complex. For
the clinician charged with treating
dysphagic patients, it is important to
understand this and to recognize that
the tolerance range of consistencies is
likely to be compressed in dysphagic
patients, even those who are eating
orally, compared with normal. Understanding the unique mechanics of swallow impairment in individual patients
is particularly critical to identifying
bolus materials most likely to be managed safely and effectively. The discussion of bolus manipulation that follows
is from this perspective, that is, involves
matching bolus materials to a patient’s
specific mechanical impairment. Thin
liquids are easily deformed and move
very readily in response to gravity and
compression. Adequate transit relies
less on strength of constriction, patency
of the chambers, and mucosal/salivary
facilitation and more on agility and
coordination to control the bolus, time
its transit through the pharynx, and
protect the airway. Thin liquids such as
water, being almost completely deformable, will pass most easily through narrow sites in transit (e.g., a stricture, an
incompletely opened PES, or an incompletely closed airway).
As thickness of the bolus increases,
it moves more slowly in response to
gravity or compression. A more viscous bolus, thus, requires less agility and control and is more forgiving
when timing of swallow and coordination of transit with gestures is impaired.
However, with increases in viscosity,
adequate transit becomes more reliant
on strength of constriction and mucosal/salivary facilitation. As the bolus
becomes less deformable, it is less likely
to pass through narrow sites in transit
and may lodge above them instead.
Thus, a liquid may be aspirated, but
a less deformable bolus may obstruct
the airway. The thickest consistencies
require adequate mastication and salivary mixing prior to initiating oral or
pharyngeal transit.
Patients with dysphagia, as mentioned, are unlikely to tolerate a full range
of bolus consistencies but may be able
to eat orally by compressing the range
(see Chapter 13 for examples). When
bolus manipulation is being considered
in treatment planning, it is important to
keep these principles in mind:
Bolus size affects bolus flow in response
to gravity or compression. Studies have
demonstrated earlier airway protection
and increased pharyngeal and UES
pressures with increased bolus volumes, as well as changes in temporal
relationships between bolus transit and
swallow gestures (Cock et al., 2017;
Logemann et al., 1992). Large liquid
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211
bolus sizes may be compensatory for
incomplete oral or pharyngeal constriction and decrease work per meal
but may be risky if laryngeal function is compromised. Small bolus sizes
increase swallows/work per meal but
are less reliant on competent laryngeal
function to protect the airway. Choice
of bolus size may also be influenced by
mechanical factors. For example, PES
opening is volume dependent, that is,
increases with increases in bolus volume. A patient with limited opening
may therefore have greater success
with smaller bolus sizes (Leonard et al.,
2000). Another example of volume effect
is illustrated in the videos for Chap-
www
ter19 (Video 19–2, CSpineBolusVolManipulation). In the video, a patient with
spinal hardware and impaired epiglottic inversion is swallowing boluses of
the same consistency, but in different
amounts, with differential effects on
epiglottic inversion.
Bolus placement at a particular site
on the tongue or in the oropharynx
can take advantage of the swallower’s
anatomic and motoric strengths or, as
noted before, greater sensory integrity,
while avoiding their weaknesses.
Beyond these considerations, we
would emphasize that clinicians involved in treating dysphagic patients
recognize that there is not a single bolus
that fits every situation and that, in fact,
bolus selection can be quite difficult. As
one relatively straightforward example,
a recent study by Leonard et al. (2014)
investigated the effects of three bolus
consistencies, carefully controlled to be
equal in amount and presented in random order to 100 dysphagic patients
during fluoroscopic swallow studies.
The bolus materials included thin liquid barium, liquid barium thickened
with starch, and liquid barium thickened with gum. Effects of consistency
on aspiration was the major focus of the
study. Interestingly, though the gumbased product was rheologically “thinner” than the starch-based product, it
produced the least number of aspiration events. Of 56 episodes of aspiration
observed, 28 were on thin, 16 on starch,
and 12 on gum bolus material (only the
difference between gum and thin was
significant, p < .05). These results reflect
the complexity of bolus rheology on swallow
and should encourage clinicians to understand that, for example, thickened boluses
are not necessarily the best recommendation
for a patient who demonstrates aspiration
or who is otherwise at risk for airway safety.
POSTURAL COMPENSATIONS
Postural manipulation is indicated
when it appears that a patient can either
redirect bolus material in a manner
that improves swallowing efficiency
(i.e., amount of bolus attempted that
actually makes it to the esophagus),
improves protection of the airway, or
both. Changes in head/neck and upper
body position, first described by Larsen
(1972) and Logemann (1983), can have a
powerful effect on bolus flow through
the oral and pharyngeal chambers. Tilt-
ing the upper body or the head changes the
impact of gravity on the bolus and, in
some cases, on poorly supported anatomy. In addition, capital flexion, extension,
or rotation changes the size and shape
of the pharyngeal chamber and may
impact PES opening. Positional changes
do not necessarily have to be dramatic
to be effective. In our practice, positions
are frequently combined to facilitate safe
oral and pharyngeal transit.
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DYSPHAGIA ASSESSMENT AND TREATMENT PLANNING: A TEAM APPROACH
Position Strategies That
Exploit Gravity
Tilting the Upper Body
Effective use of upper body tilting requires
that the cervical spine remain in neutral relation to the thoracic spine and
the shoulders. If neutral position is not
maintained, the effects of upper body
tilting may be lost. If the upper body is
tilted laterally or posteriorly, bolus flow
will be biased to the “downhill” side,
diverting it (to a point) away from the
airway. Upper body tilting is useful when
bolus transit and the sequence of pharyngeal
swallow gestures are discoordinated, when
pharyngeal constriction is incomplete, or
when pharyngeal transit is prolonged. The
degree of “tilt” will impact (depending
on bolus viscosity) bolus transit time
and the size of bolus tolerated without
overflow into the airway. When postural support of the anterior pharyngeal wall structures (the tongue and
hyoid/laryngeal complex) is poor, as is
the case in some anatomic, neurologic,
or neuromuscular conditions, the pharyngeal airway may be improved when
the upper body is tilted anteriorly.
Tilting the Head
If the head is tilted laterally, bolus flow
through the oral chamber will be biased
to the downhill side. If only the head is
tilted, the site of bolus entry into the
pharynx is affected (it would enter on
the downhill side) but not the course
the bolus takes through the pharynx. In
www
Video 19–3, CSpineBolusRedirect (see
videos for Chapter 19), an example of
a patient with poor epiglottic inversion
demonstrating a slight head tilt to the
right that allows more bolus material
to flow around the epiglottis and valleculae is presented. Lateral head tilting
may also be useful when lingual movement, sensation, or anatomy is unilaterally impaired or, as noted, when epiglottic inversion is impaired. Tilting the
head anteriorly even to a small extent
(capital flexion) will keep the bolus in the
anterior oral cavity unless it is actively
transferred by compression. Neck flexion
(chin tuck), on the other hand, requires
purposeful initiation of pharyngeal
transit/bolus entry into the pharynx
and may be useful when linguapalatal
valving is impaired. Neck flexion also
minimizes the likelihood that oral residue will fall into the pharynx after the
swallow. On the other hand, tilting the
head posteriorly (capital extension) facilitates oral transit of consistencies that
will flow with gravity. Safe use requires
adequate laryngeal airway protection.
Because extension can at times be an
obstacle to pharyngeal transit, it is
usually used in sequence with flexion
(extend-flex).
An example of a patient with partial tongue resection using the extension strategy to bypass the oral cavity
is included on the companion website
for Chapter 10 (Video 10–1, Strategy1).
Avariation of position strategies is illustrated in Video 10–2, Strategy 2A and
Video 10–3, Strategy2B. Video 10–2,
Strategy 2A illustrates an infant having difficulty extracting bolus material
through a nipple; in Video 10–3, Strategy 2B, the feeder provides jaw support,
which helps stabilize the oral cavity
and facilitates the baby’s management
of the nipple. In our experience with
infants, this kind of strategy, and identifying a nipple that allows the baby to
www
www
www
www
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213
control flow (neither too fast nor too
effortful), is often quite successful.
Positions That Impact Pharyngeal
Chamber Shape and Function
Capital flexion, extension, and rotation
change the shape of the pharyngeal
chamber, thus impacting bolus flow.
Capital flexion alters the oropharyngeal
space such that airway protection is
facilitated for some patients (Larsen,
1972; Logemann, 1983). An example of
a patient with supracricoid laryngectomy and only the arytenoid-epiglottis
valve available for airway protection is
www
seen using this strategy in Video 10–4,
Strategy 3 (companion website for
Chapter 10). In our experience, capital
extension narrows the pharynx, closes
the valleculae, and impacts mobility
of the hyoid/larynx complex. Some
patients with poor oral capabilities but
good ability to protect the airway may
benefit from this posture. Capital rota-
tion diverts the bolus toward the opposite side and can be very useful when
pharyngeal constriction is incomplete,
sometimes even when the impairment
appears symmetric, but certainly when
constriction and PES opening are asymmetric (Logemann, Kahrilas, Kobaraet
al., 1989). Because it diverts the bolus
to one side of the pharynx or the other
(around the epiglottis in some patients),
capital rotation may also be useful for
patients with incomplete vallecular
clearing, especially for a more viscous
bolus. In our experience, when capital rotation is used to compensate for
asymmetric pharyngeal wall function,
the direction of most facilitative rotation is not completely predictable. In
other words, in some patients, pha-
ryngeal transit is facilitated by rotation
away from the affected side.
FACILITATIVE MANEUVERS
This category of therapeutic strategy
refers to physiologic postures or gestures that have been demonstrated
to improve swallowing efficiency or
safety and that a patient can learn to
use for these purposes. Such maneuvers differ from strategies discussed
earlier in this chapter, which can to
some extent be imposed on the swallower by a feeder (bolus manipulation, positional changes). Facilitative
maneuvers, as discussed here, require
sophisticated and active participation by
the swallower, good muscular kinesthetic and proprioceptive sense, movement control, and ability to understand,
learn, and apply the strategy during
the swallow. Often, patients who perceive their dysphagia are seen to apply
certain of these strategies spontaneously, for example, generally increased
effort (during a single swallow or by
repeating swallows), jaw thrust, and
expectoration of pharyngeal residue. For
other patients, time and effort will be
required to develop the strategies to
the point of habituation and may primarily be appropriate when less laborintensive maneuvers fail.
Other maneuvers are likely to be
unfamiliar and perhaps more difficult to learn for many patients. These
involve altering the extent and/or timing of laryngeal behaviors for swallow,
with the goals of providing improved
laryngeal closure for airway protection and/or improved PES opening for
pharyngeal clearing. Another feature of
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