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478 R. Speyer
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studies on the effects of therapy in oropharyngeal
dysphagia give little attention to the effects on
quality of life (Speyer et al. 2010). In contrast, the
literature on the effects of dysphonia or voice
problems suggests that quality-of-life questionnaires
are essential to multidimensional voice assessment
(Speyer 2008).
Dysphagia can be caused by a variety of diseases
(e.g. neurological causes such as cerebrovascular
accidents or degenerative diseases). But it can also
manifest itself as a side effect of treatment, for
example, by radiation or surgical intervention in
patients with head and neck cancer. Usually, a team
of specialists will be involved in the diagnosis and
treatment. Within a multidisciplinary context or
interdisciplinary setting, each caregiver will focus on
a particular aspect of the swallowing problems.
In general, after the initial assessment and treatment
by medical specialists, nurses may be the first to
perform any bedside screening focused on dysphagia
(Bours et al. 2009). Subsequently, speech therapists
may take charge of any further assessment of the
swallow mechanism, the choice of behavioural
intervention, and the follow-up evaluation. In the
event of malnutrition or dehydration, or if there is a
severe nutritional risk, dieticians are involved to
ensure the patient has a sufficient caloric intake and
provide the patient with nutritional supplements if
necessary. Additionally, occupational therapists,
physiotherapists, social workers, or psychologists
may be involved in the multidisciplinary management of dysphagia.
Depending on the dysphagic findings, swallowing
treatment may include medical, surgical, and/or
behavioural options (Crary and Groher 2003). The
medical option could entail dietary modifications to
address underlying disease (e.g. diabetes or hypertension) or pharmacological treatment (e.g. antireflux
medication or mucolytics). The surgical option covers
a range of interventions: to improve glottal closure by
medialization thyroplasty or injection of biomaterials;
to enhance airway protection (e.g. total laryngectomy); or to optimize the pharyngo-oesophageal
segment opening by stretching the lumen of the segment by dilation, surgical myotomy of the cricopharyngeal muscle, or chemodenervation using
botulinum toxin injection. This chapter focuses on the
third option: treatment by speech therapists using
behavioural techniques.
Langmore (2001) described three patterns of
dysphagia: the ineffective swallow or incomplete
bolus clearance; the misdirected swallow or impaired
airway protection due to incomplete valving; and the
delayed or mistimed swallow. Regarding the motor
control of swallowing, the physiological parameters
are intact sensation, briskness of initiation of movement, speed of movement, force or strength of
movement, and amplitude of movement, as well as
precision, timing, and coordination of movement.
Therapeutic strategies used in swallowing therapy can
be classified as rehabilitative and/or compensatory
(Huckabee and Pelletier 1999). Interventions that are
mainly intended to restore or improve the actual
swallowing function are referred to as rehabilitative
techniques. Compensatory techniques, in contrast, are
intended to improve the ability to adapt and cope with
the problem. Laryngeal adductor exercises to improve
laryngeal valving are among the rehabilitative interventions, whereas strategies—such as the chin tuck
posture—to improve laryngeal protection or the use
of bolus modification are considered compensatory
techniques.
Behavioural treatment of oropharyngeal dysphagia
as performed by speech therapists may include a
range of interventions: (1) bolus modification and
management; (2) sensory and motor behavioural
techniques; (3) postural adjustments; and (4) swallow
manoeuvres—or any combination of these (Speyer
et al. 2010). Bolus modification refers to adjusting the
viscosity, volume, temperature, and/or acidity of the
bolus. The second category includes oral motor
exercises but also facilitation techniques that cover a
variety of interventions, ranging from surface electrical stimulation to thermal application at the anterior
faucial pillars. Behavioural techniques commonly
used to modify the swallow mechanism are postural
adjustments and swallow manoeuvres. Postural
adjustments involve whole-body and head-position
strategies. Swallow manoeuvres include the (super)
supraglottic swallow, the Mendelsohn manoeuvre, the
effortful swallow, the Masako manoeuvre, and the
Shaker exercise, among others. Adjunctive biofeedback may be used to facilitate processes of complex
motor learning. In the following sections, these
techniques will be described in detail.
It is now widely accepted that medical treatments
should be scrutinized by scientific methods. This
implies that paramedical therapies should also be
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evaluated according to current standards of evidencebased medicine. An evaluation of therapy in oropharyngeal dysphagia thus falls squarely into this area of
growing interest (Speyer et al. 2010). Besides
describing the behavioural techniques commonly
used in dysphagia therapy, studies should provide
information on the effects of therapy in oropharyngeal
dysphagia and the methodological issues that arise in
the literature. Moreover, outcome studies are essential
in order for caregivers to adjust and improve therapy
for patients with oropharyngeal dysphagia.
2 Choice of Intervention Techniques
After medical and swallowing assessment, there may
be a need for further intervention by speech therapists. However, many considerations may influence
which intervention techniques are indicated for a
particular patient.
First of all, many strategies require a patient’s full
cooperation as well as the capacity to follow complex
instructions under the supervision of a therapist. It
may be almost impossible to explain and teach certain
strategies to patients with severe cognitive limitations. Furthermore, a patient has to be internally
motivated or else have support from close relatives in
order to keep trying. Having family support or motivated caregivers is essential, especially for the
implementation of newly learned swallowing behaviours or compensation strategies in daily life.
When making decisions about oral feeding, one
has to take the patient’s general health into account.
The estimated safety of oral intake must be set off
against the risk of aspiration pneumonia. Concerns
about malnutrition or frailty, particularly among the
elderly (Rofes et al. 2011), may call for additional
tube feeding combined with nutritional supplements.
Oral feeding may be fatiguing and thus place a burden
on the patient. But the taste and smell of food or drink
may also be rewarding and motivating, allowing the
patient to enjoy family meals. In fact, participating in
daily dining routines might have a huge impact on the
patient’s quality of life. It is important to take a
patient’s food preferences and cultural background
into account when advising on the possibilities of oral
intake and on the use of food or liquid boluses in
therapeutic settings. It should be realized that even
when physicians and therapists consider oral intake to
be no longer safe, a patient may still refuse tube
feeding because of the reduced quality of life associated with such an intervention.
Obviously, the choice of interventions is also
determined by the medical diagnosis and corresponding prognosis for a disease. For example, for
someone diagnosed with neuromuscular disease,
rehabilitative techniques may result in fatigue and
exhaustion instead of increased muscle strength. Also,
if spontaneous recovery of the swallowing functions
can be expected during the acute period after a recent
cerebrovascular accident, compensatory techniques
may suffice to achieve sufficient oral intake. On the
other hand, in palliative care, intervention will be
restricted to minimize the effects of the dysphagia and
optimize a patient’s quality of life during the dying
phase (Veerbeek 2008).
Finally, cultural aspects may influence the way
swallowing disorders are treated. Basically, care for
dysphagia may be organized differently in different
countries. National health systems may differ in the
ratio of therapists to patients being hospitalized and
treated. Or the training provided for therapists may
differ with respect to the material being taught or the
level of education required for certification. Besides
national differences, the preferences or expertise of
individual therapists will also influence the treatment.
Decisions on therapy frequency, length of therapy
sessions, and treatment period, as well as the behavioural techniques applied, all play a role in the outcome of swallowing therapy.
3 Behavioural Treatment
of Dysphagia
Regarding the range of behavioural interventions used
in oropharyngeal dysphagia, various strategies may be
found in the literature. The most common techniques
and therapeutic approaches that can be applied by
speech and language therapists are covered in the
following five subsections.
Bolus modification and management will be considered first, followed by sensory and motor behavioural techniques. Next, postural adjustments to
facilitate swallowing will be presented. This third
category includes general body positions such as
lying down or side-lying. It also includes head positions, particularly adjustments such as head extension,
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flexion, rotation, or tilt. The fourth category consists
of a variety of swallow manoeuvres: the supraglottic
and super supraglottic swallow; the Mendelsohn
manoeuvre; the effortful swallow; the Masako
manoeuvre; and the Shaker exercise. Finally, the
application of biofeedback will be discussed in the
fifth subsection.
3.1 Bolus Modification and Management
Bolus modification and management is an approach
that amounts to adjusting parameters such as viscosity, volume, temperature, and/or acidity of the
bolus (Speyer et al. 2010). Modifying the rheologic
properties of food and liquids may be one of the
most common strategies applied by therapists. Ways
to modify a food’s consistency may vary from the
use of commercial agents for thickening liquids to
the blending of solid foods. By thickening thin liquids, clinicians seek to decelerate the bolus transport
into the pharynx. By giving the patient more time to
handle the bolus, one reduces the risk of penetration
or aspiration. Thicker liquids may be helpful in the
case of a delayed or mistimed swallow (Langmore
2001). Solid foods can be modified with a blender or
masher. This reduces the need for chewing by
smoothing the particulate nature of certain boluses or
by blending foods of a mixed consistency. Patients
who fatigue easily and are at risk of malnutrition
may benefit from such a modified diet because of the
diminished amount of effort required for swallowing.
Those patients who have difficulty clearing a bolus
may also show improved swallow behaviour when
managing boluses of smoothed consistencies compared with handling crumbly or noncohesive foods.
In the latter case, when food consistencies do not
allow easy bolus-forming or preparation for swallowing, adding liquids may be considered. Smoothened bolus consistencies reduce the amount of
pharyngeal residue, thereby reducing the risk of
delayed aspiration as well. There is great variety in
the clinical terminology used for different bolus
consistencies, and consensus is lacking. However, to
determine the effectiveness of modifying food and
liquids in patients with oropharyngeal dysphagia and
to compare study outcomes, uniform definitions for
the rheologic properties of foods and liquids should
be used (Dealy 1995).
To determine the appropriate volume of food or
liquid boluses, the caregiver must know the patient’s
capacity to control and secure a safe oropharyngeal
bolus transit with minimal amount of postswallow
residue. Larger quantities may require optimal alertness of the swallow mechanism, whereas boluses that
are too small may provide insufficient sensory stimulus to initiate the swallowing act, as seen in patients
with Parkinson’s disease (Baijens and Speyer 2009).
Swallowing may also be influenced by temperature;
colder boluses are thought to trigger a quicker onset
of the swallowing reflex. Improved timing has also
been found when using acid boluses (Logemann et al.
1995). Naturally, when applying bolus modification,
one should keep in mind that achieving an optimal
taste and smell—that is, adjusted to an individual’s
preference—will provide rewarding and motivating
factors, which can improve the oral intake and in turn
the health status of a patient.
3.2 Sensory and Motor Behavioural
Techniques
Swallowing is the result of combined forces producing bolus passage through the pharynx and avoiding
the larynx or airway (Langmore 2001). A normal
sensory awareness in the oral cavity and pharynx is
crucial to secure bolus manipulation and transportation. Lips, tongue, palate, and mandible have to
operate in a coordinated order. Recruitment of adequate muscle strength, accuracy, and coordination
thus results in a safe swallow. Therapists often draw
upon sensory stimulation and oral motor exercises as
part of dysphagia treatment in an effort to modify the
swallow mechanism.
3.2.1 Oral Motor Exercises
The purpose of using oral motor exercises is to
increase awareness of the bolus, to control and direct
its passage, and to maximize the driving and propulsive force of the bolus in transit to the oropharynx.
The exercises can address the various features of
motor function: muscle strength, range of movement,
muscle tone, steadiness, and accuracy. But regaining
muscle function in terms of strength, range, and tone
will in itself not result in normal swallowing unless
the coordination of the swallow mechanism has been
optimized as well.
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During the oral phase of swallowing, labial
awareness and control are essential to achieve adequate lip closure and prevent drooling. There are
exercises for the tongue to improve bolus propulsion,
which is created by posterior tongue thrust, and to
diminish bolus pocketing or the amount of residue, as
well as to reduce the risk of preswallow aspiration
because of failure of bolus control (Robbins et al.
2007). Stretching exercises may improve the range of
mandible movement in patients with reduced flexibility. Nasal regurgitation might be diminished by
stimulating the soft palatal closure using velopharyngeal closure exercises.
3.2.2 Sensory Stimulation
Sensory stimulation activities may involve changing
the taste of boluses or their temperature, applying
pressure, or using neuromuscular electrical stimulation. It has been theorized that providing a sensory
stimulus before a swallow attempt may serve as an
alert or trigger to the nervous system and thereby help
prepare the swallow mechanism for the subsequent
swallow.
Effects of the use of sour boluses have been
described in the literature, suggesting that an alteration is induced in swallowing behaviour—for
instance, improved timing of the onset of swallowing
(Logemann et al. 1995). Usually, tactile–thermal
application procedures consist of cold, tactile stimuli.
These may be presented to the anterior faucial pillars
by stroking the pillars with an ice stick (Rosenbek
et al. 1998) or with a cold laryngeal mirror taken from
a cup of ice. These procedures are thought to reduce
the delay in the initiation of swallowing, primarily in
the pharyngeal phase. Besides temperature stimulation, pressure may be used to improve sensory
awareness. For example, a spoon can be used to apply
light pressure to the blade of the tongue during
swallowing exercises.
3.2.3 Electrical Stimulation
The use of electrical stimulation has been the subject
of several recent studies (Blumenfeld et al. 2006;
Bülow et al. 2008; Ludlow et al. 2007; Power et al.
2006; Shaw et al. 2007). Surface electrical stimulation
(neuromuscular electrical stimulation) activates muscles by stimulating the intact peripheral motor nerves.
The main treatment goals are to strengthen weak
muscles and to help in the recovery of motor control
(Freed and Wijting 2003). Stimulation at the motor
level can be distinguished from stimulation at the
sensory level. As defined by Ludlow et al. (2007),
motor stimulation is the maximum tolerated stimulation level resulting in maximum muscle contraction
without spasm. The level of sensory stimulation is set
by gradually raising the intensity of the current until
the patient reports the first sensation of stimulation,
usually a tingling of the skin. Depending on the exact
placement of skin electrodes in the neck and face,
different groups of muscles are stimulated.
3.3 Postural Adjustments
Postural adjustment may involve head positioning
strategies such as head-turn or chin-tuck manoeuvres
or whole-body positioning strategies. In the literature,
it has been shown that adjusting the head and/or body
position can reduce or eliminate the risk of aspiration
(Lewin et al. 2001; Logemann et al. 1994a; Rasley
et al. 1993; Shanahan et al. 1993). Postural variations
redirect and facilitate the bolus flow; they may
improve oral and pharyngeal transit times, and they
decrease the amount of residue after swallowing
(Bogaert et al. 2003). These techniques are intended
to change the dimensions of the oropharynx in order
to accomplish a safer swallow by compensating for
anatomic deficiencies, sensory loss, or a reduced
propulsion or clearance of the bolus. Postural
adjustments can be introduced as temporary techniques during the process of recovery of the swallowing function. Alternatively, they may become a
permanent compensatory technique after rehabilitation to facilitate the changed swallow motor pattern or
mechanism.
3.3.1 General Postural Adjustments
General postural adjustments usually concern body
postures such as lying down or side-lying. Both of
these postures reduce the effects of gravity during
swallowing and the amount of postswallow residue.
Side-lying may be beneficial when there is a difference in pharyngeal function between the left and the
right side. The patient must lie down on the stronger
side, thereby using gravity to direct the bolus or
residue towards the stronger and/or more sensitive
hemipharynx (Drake et al. 1997). However, changing
the posture may have a negative influence on the
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oesophageal motor functions. Patients with suspected
gastro-oesophageal reflux disease or poor oesophageal motility may benefit from an upright position
during and after feeding. In the case of nocturnal
reflux, head-of-bed elevation may be recommended
during the night, thus reducing or prohibiting acid
reflux from the oesophagus.
3.3.2 Head Postural Adjustment
Head postural adjustment includes the following
positions: head flexion, head extension, head rotation,
and head tilt. Head flexion, also called chin tuck,
narrows the oropharynx and shortens the distance
between the hyoid and the larynx, thus narrowing the
laryngeal entrance (Bülow et al. 2001). It facilitates
airway protection and may be used in patients
with difficulties in oral control or timing. However,
head flexion may also result in a weaker pharyngeal
contraction during swallowing, causing problems
of bolus propulsion in patients with pharyngeal
weakness.
Unlike flexion, the aim of head extension is to
widen the oropharynx by raising the chin, resulting in
a head-back position. An extended head adjustment
uses gravity for bolus propulsion into the pharynx. It
may be useful in patients showing deficiencies in oral
control and bolus transport during the oral (preparatory) phase of swallowing. Head extension can only
be used in patients with an intact pharyngeal phase.
Head extension may also have a negative impact on
the pharyngo-oesophageal segment, increasing the
intraluminal pressure and decreasing the duration
of relaxation of the segment (Crary and Groher
2003). Furthermore, head extension reduces laryngeal
closure. Thus, the swallowing outcome may deteriorate in patients with diminished laryngeal airway
protection or deficits in pharyngo-oesophageal segment functioning.
The head rotation or head-turn manoeuvre is
mainly used in patients with unilateral deficits
(unilateral pharyngeal or vocal fold paralysis or paresis). Rotating the head towards the weakened side
before swallowing results in the swallowing tract or
piriform sinus on this damaged side being narrowed or
even closed off. This directs the bolus down the stronger side (Logemannet al. 1989). Thecricoid cartilage is
pulled away from the posterior pharyngeal wall,
reducing the pressure in the cricopharyngeal sphincter
and thereby increasing the size of sphincter opening.
This, in turn, will reduce amount of bolus residue after
swallowing as well as the risk of aspiration.
If the patient has unilateral oral and pharyngeal
weakness on the same side, the head-tilt adjustment
can be applied. When the head is tilted to the stronger
side prior to the swallow, the bolus is directed down
to the stronger side by utilizing the effects of gravity,
thus reducing the amount of bolus residue (Rasley
et al. 1993).
3.4 Swallow Manoeuvres
Apart from sensory and motor behavioural techniques
or postural adjustments, behavioural swallowing
therapy may combine a variety of swallow manoeuvres. These allow the patients to gain improved and
voluntary control of the swallowing process, including bolus propulsion and airway protection. Many of
these manoeuvres require active patient participation
and intensive practice to induce the necessary physiological modification of the swallow mechanism.
3.4.1 Supraglottic Swallow
The supraglottic swallow manoeuvre may be suitable
and advisable under certain conditions: in the event of
restricted airway protection or risk of aspiration as a
result of a delayed pharyngeal swallow, a reduced or
late vocal fold closure, or laryngeal sensory deficits.
The manoeuvre consists of several steps. Patients are
first asked to inhale and hold their breath. Next, they
place a bolus in the mouth and swallow while still
holding their breath. Then, after swallowing and
before inhaling, patients cough voluntarily. Finally,
they swallow again. The aim of this manoeuvre is to
close the vocal folds by holding one’s breath and to
clear any possible residue from the laryngeal vestibule that may have entered while swallowing
(Logemann 1998). However, vocal fold closure may
not always be achieved in patients when holding their
breath.
3.4.2 Super Supraglottic Swallow
Patients who do not succeed in bringing about the
required airway protective closure during the supraglottic swallow manoeuvre need to perform a forceful
breath-hold or super supraglottic swallow manoeuvre.
Adding force to the swallow manoeuvre increases the
chances of establishing a complete vocal fold closure
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and may promote shorter swallowing transit times
(Logemann 1998). Patient instruction is similar to that
given during the supraglottic swallow manoeuvre,
except for the request to bear down hard instead of
just performing a swallow act. The rationale for
applying either the supraglottic manoeuvre or the
super supraglottic manoeuvre is similar. The difference lies in the amount of effort required. Bearing
down causes the arytenoid muscles to be tilted anteriorly, closing the false vocal folds as well as the
entrance to the trachea.
3.4.3 Mendelsohn Manoeuvre
The aim of the Mendelsohn manoeuvre is to increase
the extent and duration of laryngeal elevation and
thereby enhance the duration and width of the cricopharyngeal opening (Logemann 1999). While the
upper oesophageal sphincter is open, bolus transfer
may be facilitated, leaving less oropharyngeal residue. It is hypothesized that prolonging the swallow at
the peak of hyolaryngeal elevation and pharyngeal
contraction causes the frequency and the amount of
aspiration to decline owing to improved upper
oesophageal sphincter opening. The manoeuvre is
designed for patients with a reduced range of
laryngeal movement or a discoordinated swallow.
Patients are instructed to press lightly on the thyroid
cartilage with their fingers, keeping it in a raised
position for several seconds directly after swallowing.
Because the instruction to patients could be confusing
and difficult to translate into practice, it may be
advisable to offer adjunctive biofeedback such as
surface electromyography during training. With
electromyographic biofeedback, patients will have
immediate visualization of their muscle activity while
learning the Mendelsohn manoeuvre.
3.4.4 Effortful Swallow
The effortful swallow is also known as the hard
swallow manoeuvre. The technique increases the
posterior motion of the tongue base during the pharyngeal swallow, thereby improving bolus clearance
from the valleculae (Logemann 1999). Thus, the
effortful swallow may be recommended in the case of
reduced posterior movement of the tongue base or
reduced oropharyngeal pressure. During training, the
patient is instructed to squeeze with maximal effort
while swallowing. This manoeuvre is considered to be
easily taught and easily implemented. However,
because it may be difficult to determine which muscles are being activated or recruited and to what
degree, instrumental measurements or biofeedback
(e.g. surface electromyography) may be useful during
rehabilitation.
3.4.5 Masako Manoeuvre
During swallowing, the pharyngeal wall tends to
bulge forwards, contacting the tongue base. It is
hypothesized that pushing the tongue out and holding
the anterior tongue between the teeth while swallowing will increase tongue base pressure and duration of contact with the posterior pharyngeal wall.
This technique is known as the Masako manoeuvre or
tongue holding. In the case of lingual weakness, for
example after oral surgery, it might be considered a
rehabilitative technique (Lazarus et al. 2002). By
practising the Masako manoeuvre, the patient may
train the pharyngeal wall to compensate for the lack
of posterior tongue movement. The presumed result
will be improved contact between the tongue base
and the pharyngeal wall, thus creating a pressure
source for bolus propulsion through the oropharynx.
It is not advisable to combine this manoeuvre with
swallowing food boluses because of the reduced
duration of airway closure, the increased amount of
residue after swallowing, and the increased delay in
pharyngeal swallow initiation (Crary and Groher
2003).
3.4.6 Shaker Exercise
The Shaker exercise, otherwise known as the isotonic/isometric exercise, serves as rehabilitative
training of the suprahyoid muscles responsible for
the opening of the upper oesophageal sphincter. This
manoeuvre may solve the problem of a reduced
cricopharyngeal opening, thus decreasing the amount
of postswallow residue. Patients are instructed to lie
supine and raise their head without raising their
shoulders. This position is maintained for about
1 min, after which the patient will rest before
repeating this head-raising manoeuvre. A suprahyoid
muscle-strengthening exercise programme has been
found to be effective in patients with deglutitive
failure due to an abnormal upper oesophageal
sphincter opening. The exercise stimulates the restoration of oral feeding, diminishes the amount of
postdeglutitive residue, and resolves aspiration
(Shaker et al. 2002).
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3.5 Adjunctive Biofeedback
Most swallow manoeuvres require complex learning
or relearning of motor patterns by patients. The
application of biofeedback as an adjunct to swallowing therapy may facilitate the learning processes
and be valuable in enhancing the rate of motor
learning. Several techniques can be used to reveal
some of the internal physiological events, normal and
abnormal, using visual or auditory signals. Patients
will be able to manipulate these otherwise involuntary
or unfelt events (Basmajian and Deluca 1985).
The literature describes positive effects of surface
electromyographic feedback in dysphagia treatment
(Bogaardt et al. 2009; Crary et al. 2004). For example,
when surface electrodes are placed under the chin,
between the front of the mandible and the hyoid,
muscle activity in the submental muscles can be
recorded. During therapeutic sessions, patients are
asked to perform repeatedly the Mendelsohn
manoeuvre while being provided with visual feedback
of the electromyographic recordings that present
muscle activity as a function of a time frame. Patients
are able to judge for themselves the amount of success
in prolonging the laryngeal excursion as they
watch the surface electromyographic signal on a
computer monitor, thus receiving immediate feedback
on their swallowing performance (Bogaardt et al.
2009). Surface electromyographic feedback may help
teach the patient muscle relaxation, straining, and
strengthening, and the feedback may stimulate muscle
coordination.
Other biofeedback techniques may be helpful in
functional rehabilitation as well. The use of flexible
videoendoscopic biofeedback in swallowing therapy,
serving as pharyngeal image biofeedback, has been
studied. It shorted the period of functional rehabilitation (Denk and Kaider 1997). Endoscopic feedback
may be helpful to teach patients breath-hold
manoeuvres such as the super supraglottic swallow or
the supraglottic swallow. It can help by visualizing
the degree of vocal fold closure or residue at the
laryngeal vestibule. Instead of endoscopic recordings,
videoradiographic recordings of swallowing may be
used. Another technique, cervical auscultation,
might be used to listen to swallow sounds as an
adjunct to clinical swallowing assessment (Leslie
et al. 2004). It has been speculated that swallow
sounds provide audible cues that permit a reliable
dichotomized classification of normal swallowing
versus dysphagic swallowing with signs of penetration and/or aspiration.
4 Effects of Behavioural Treatment
It is not only treatments by physicians that have to
be evaluated according to current standards of
evidence-based medicine; so do interventions by
allied health professionals. By extension, the therapy
outcome of behavioural treatment of oropharyngeal
dysphagia needs objective evaluation as well
(Speyer et al. 2010). According to Logemann
(1999), therapy procedures should not be implemented until data on their efficacy and positive
outcomes have been published in peer-reviewed
journals. Indeed, clinicians must be acquainted with
the relevant literature in order to justify their choice
of therapy strategies during the clinical decisionmaking process. Therapists are responsible for
collecting clinicalefficacy andoutcome data on each of
their patients. Only then can they objectify whether the
goals set at the start of therapy have been adequately
met at the end. Evidence-based practice is thereby the
result of combining current research, the clinician’s
expertise, and the patient’s values and preferences
(Wheeler-Hegland et al. 2009).
Several reviews have been published summarizing
the literature on the behavioural treatment of oropharyngeal dysphagia. Some narrative reviews provide extensive information about treatment
possibilities (Logemann 2006). Other studies describe
the effects of swallowing therapy in general as applied
by speech and language therapists. The latter reviews
are based on a systematic literature search using
diverse electronic databases (Speyer et al. 2010).
Furthermore, a few systematic reviews have restricted
the literature search to certain types of therapy. Some
are focused on neuromuscular electrical stimulation
(Carnaby-Mann and Crary 2007; Clark et al. 2009).
Others are confined to well-defined patient populations: for example, patients suffering from neurological disorders (Ashford et al. 2009) or oncological
problems in the head and neck area (McCabe et al.
2009).
Therapists can thus turn to the existing literature
for short, systematic overviews that will help them
select therapeutic interventions when treating patients
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with oropharyngeal dysphagia. However, as many
questions remain unsolved, clinicians will have to rely
on their professional and clinical insights as well. For
example, the success of therapy in a given patient
population cannot necessarily be generalized to
another population. Furthermore, behavioural dysphagia treatment may combine many different interventions for the same patient. The question is then,
will the final outcome of therapy be equal to the sum
of each component? Or will redundancy or antagonistic factors complicate the task of determining the
actual efficacy of an individual patient’s treatment?
The literature thus has its shortcomings. But it still
provides grounds for discerning trends in therapy
success, even though methodological issues in outcome studies on oropharyngeal dysphagia remain to
be addressed.
4.1 Trends in Treatment Effects
An overview of the literature on the behavioural
treatment of oropharyngeal dysphagia shows statistically significant positive effects of therapy (Speyer
et al. 2010). However, considering the major impact
of dysphagia on a patient’s quality of life (McHorney
et al. 2003), the number of evidence-based studies is
rather small. Only effect studies that meet certain
quality criteria—notably concerning study design,
patient attrition, randomization plus allocation of
subjects to intervention groups, and blinding of outcome assessors—may provide information that is
sufficiently reliable for the study outcome to be
translated into clinical practice (Frymark et al. 2009;
Speyer et al. 2010). Besides these methodological
issues, it should be noted that the behavioural treatment of dysphagia frequently combines different
interventions (Speyer et al. 2010). Thus, even though
a combination of techniques has proven to be effective in eliminating or diminishing the symptoms, it
may be hazardous to make any firm statements about
the effectiveness of each of the separate elements.
Still, a number of well-designed effect studies have
demonstrated a positive therapy outcome of behavioural approaches in swallowing therapy. Therefore,
some general conclusions may be drawn and certain
trends may be distinguished.
One very common therapy intervention is bolus
modification. In a study of two groups of dysphagic
patients who had experienced aspiration pneumonia
prior to therapy, Groher (1987) demonstrated that
viscosity modulation (soft mechanical diet with
thickened liquids versus pureed diet with thin liquids)
could reduce the number of episodes of aspiration
pneumonia. In a later study by Groher and McKaig
(1995), the changes in dietary level in a group of
persons in residential care were described after a single evaluation by a speech and language pathologist.
On the basis of their findings, the authors concluded
that many nursing home residents may be inappropriately assigned or maintained on mechanically
altered diets. Regular reevaluation of the residents’
dietary level was strongly advised. Several other
studies have demonstrated the positive effects of
increasing bolus viscosity in dysphagic patients. Clavé
et al. (2006) found that changing the viscosity from
that of liquid to that of nectar and pudding significantly improved the efficacy and safety of swallowing
by reducing aspiration and penetration in patients with
dysphagia. However, the timing of the swallow
response and bolus kinetic energy were not affected,
whereas increasing the bolus volume significantly
impaired the efficacy and safety of swallowing. Similar effects were found in patients with unilateral vocal
fold paralysis with aspiration and/or penetration
(Bhattacharyya et al. 2003). In particular, paste bolus
consistencies were found to be safer than thin liquids,
as the paste led to much less penetration or aspiration
despite a higher prevalence of pharyngeal residue.
Increasing the bolus volume and viscosity in acute
stroke patients (Bisch et al. 1994) led to decreased
pharyngeal delay times. However, the patients exhibited very few significant effects of temperature on
swallowing disorders or swallow measures. Hamdy
et al. (2003) concluded that combined thermal (cold)
and chemical (citrus) modification of water consistently altered swallowing behaviour after cerebral
injury, resulting in slowed swallowing and reduced
swallow capacity. On the other hand, Logemann et al.
(1995) found an improved onset of the oral swallow in
response to sour boluses compared with nonsour
boluses in neurological patients. Increasing the bolus
volume increased the amount of oral residue and the
number of swallows but decreased the swallow times
(oral transit time, pharyngeal delay time, and pharyngeal transit time). In conclusion, although bolus
modification seems effective in therapy, further
research will be needed.
486 R. Speyer
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Rehabilitation of the swallowing process may
include an exercise programme consisting of diverse
oral motor exercises. Even though the rationale seems
obvious, a few studies have objectified the effects of
intensive oral motor training. For instance, by means
of an isometric lingual exercise programme, Robbins
et al. (2007) demonstrated that lingual exercises
enable acute and chronic dysphagic stroke patients to
increase lingual strength, with associated improvements in swallowing pressure, airway protection, and
lingual volume. Oral motor exercises such as tongue
pull-back, yawn, and gargle tasks have also been
found helpful to improve the maximum range of
posterior movement of the tongue base (Veis et al.
2000). In a study by Nagaya et al. (2000), the initia-
tion time of the swallowing reflex in dysphagic
patients with Parkinson’s disease was reduced
significantly after a single session of swallowing
training. That training consisted of tongue motion and
resistance exercises, exercises to increase the adduction of the vocal folds, the Mendelsohn manoeuvre,
and motion exercises for the neck, shoulders, and
trunk. The orofacial regulation therapy of Castillo
Morales, combining motor and sensory stimulation,
indicated long-lasting improvement in oropharyngeal
dysphagia in stroke patients, as measured by qualityof-life questionnaires, videofluoroscopy, and clinical
evaluation (Hägg and Larsson 2004). In fact, many
effect studies use oral motor exercises in combination
with a variety of other intervention techniques, such
as bolus modification, postural adjustments, and
swallow manoeuvres (Denk et al. 1997; Elmståhl
et al. 1990; Huckabee and Cannito 1999; Kiger et al.
2006; Martens et al. 1990; Masiero et al. 2007;
Neumann 1993). Overall, the effects of therapy are
positive. But because techniques are used in combination, the outcome of swallowing therapy cannot be
attributed to any single oral motor training (Speyer
et al. 2010).
A heightened sensory input may be achieved in
several ways: by changing the volume, taste, or
temperature of the bolus; by applying pressure; or
with neuromuscular electrical stimulation. Bolus
modification and management have already been
discussed. Although no effect studies have been
conducted on pressure application, considerable
attention has been given to thermal application at the
anterior faucial pillars, as studied by Rosenbek et al.
(1991, 1996, 1998) in stroke patients. They were
given intensive daily training using a chilled laryngeal
mirror for repeated strokes on the pillars. Nonetheless, after 2 weeks of thermal application alternating
with 2 weeks without it, there was no strong evidence
that their dysphagia had improved (Rosenbek et al.
1991). A later study by Rosenbek et al. (1996) used a
cross-over design to study the short-term effects of
thermal application, comparing stroke patients’
swallowing during 10 min in a treated and untreated
condition. Swallowing durations were highly variable
within an individual and across the patient group.
Still, compared with no treatment, thermal stimulation
reduced the duration of staged transition and total
swallow duration. A third study (Rosenbek et al.
1998) investigated the effects of four intensities of
tactile–thermal application combined with the effortful swallowing manoeuvre in acute stroke patients.
Patients were randomly assigned to receive 150, 300,
450, or 600 trials of tactile–thermal application per
week over a period of 2 weeks. No single treatment
intensity emerged as superior. Overall, positive
changes on an aspiration-penetration scale and
decreased duration of stage transition did not reach
clinical or statistical significance. Possibly, the
observed changes might have been due to physiological recovery.
The effect of neuromuscular electrical stimulation
on swallowing has been summarized in two recent
systematic reviews (Carnaby-Mann and Crary 2007;
Clark et al. 2009). Both indicate some small but
significantly positive treatment effects. At the same
time, they point out the need for additional research in
this area. A few publications on neuromuscular electrical stimulation have appeared since the cut-off point
for those two reviews. Some of these new studies provide cumulative evidence of the effectiveness of this
therapeutic intervention as an adjunctive modality for
treatment of swallowing disorders (Carnaby-Mann and
Crary 2008), whereas others remain conservative in
their conclusions. Ludlow et al. (2007) suggested that
low levels of sensorystimulation might be anadditional
tool for dysphagia therapy, although emphasizing the
need for further systematic studies. Others found no
significant differences between neuromuscular electrical stimulation and traditional swallowing therapy in
a group of stroke patients (Bülow et al. 2008). Future
research will provide more evidence on whether or not
neuromuscular electrical stimulation would be useful
for patients with swallowing problems.
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Various outcome studies have described the effects
of postural changes, mainly head postural adjustments, which may affect the direction and speed of
the bolus transport through the oropharynx. Overall,
evaluations of therapy outcome, mainly in singlesession study designs, have noted significant
improvement from postural changes. For example, the
use of head flexion or chin tuck in a group of aspirating patients with oesophagectomy (Lewin et al.
2001) and in a patient population with diverse neu-
rological diseases (Shanahan et al. 1993) significantly
reduced the number of patients who were aspirating.
In a group of patients with unilateral dysphagia, head
rotation towards the paretic side increased the fraction
of the bolus swallowed and the opening diameter of
the upper oesophageal sphincter (Logemann et al.
1989). However, studies on head tilt or general
postural adjustments are rare and may be limited to
single-case studies (Drake et al. 1997).
Behavioural swallow therapy may include diverse
manoeuvres, such as the supraglottic swallow and the
super supraglottic swallow. However, to determine
the isolated effect of a single manoeuvre, studies must
restrict the intervention protocol to one specific
swallow manoeuvre. This would entail providing
outcome data before and after this intervention,
without introducing other treatment techniques during
the same therapy period. In general, the treatment
outcomes reported in the literature have been positive.
Logemann et al. (1994b) described an improved
oral intake in patients after supraglottic laryngectomy
when using the supraglottic swallow. When the super
supraglottic swallow was applied in a group of
patients with head and neck cancer (Logemann et al.
1997), fewer motility disorders were observed.
Furthermore, the manoeuvre eliminated or reduced
aspiration in some of the patients. With use of electromyographic biofeedback (surface electromyography) during the Mendelsohn manoeuvre in stroke
patients and patients with head and neck cancer, the
oral intake was improved and reflected a trend
towards statistical significance (Crary et al. 2004).
Evidence for the benefit of the effortful swallow is
limited. For example, in two case studies by Lazarus
et al. (2002) describing two patients with dysphagia as
a result of oncological problems, using the effortful
swallow seemed to help them attain near-normal
swallowing pressures and an improved oropharyngeal
clearing efficiency. The literature also provides little
evidence for the benefit of the Masako manoeuvre,
although the rationale has been well described (Fujiu
et al. 1995; Fujiu and Logemann 1996). The Shaker or
head-raising exercise was studied in a randomized
controlled trial by Shaker et al. (2002) in a group of
patients with dysphagia from diverse causes and
an abnormal upper oesophageal sphincter opening.
After a head-raising exercise programme, significant
therapy effects were found. These included an
improvement in the anteroposterior diameter of the
sphincter opening and the anterior laryngeal excursion, a decrease in the amount of postdeglutitive
residue, and the resolution of aspiration.
Several studies have been published on adjunctive
biofeedback in dysphagia treatment with promising
results. Denk and Kaider (1997) studied the use of
videoendoscopic biofeedback in conventional therapy
for patients with dysphagia associated with oncological disorders. Their main conclusion was that the
functional rehabilitation period was shorter than in
conventional therapy without adjunct biofeedback. In
a study of tube-dependent stroke patients who had
previously been treated by speech therapists without
success, Bogaardt et al. (2009) demonstrated that
using surface electromyography as biofeedback to
standard exercises could result in a significantly
positive change in oral intake. Some of these patients
could have the percutaneous enteral gastrostomy
tubes removed after therapy. In a study by Crary et al.
(2004), the positive effects of electromyographic
biofeedback on the functional oral intake in stroke
patients and patients following treatment for head and
neck cancer also showed a trend towards statistical
significance. The findings of both studies are in line
with the study outcome reported by Huckabee and
Cannito (1999). In a population of chronic dysphagic
patients with brainstem injury, they studied the
effects of electromyographic biofeedback and cervical auscultation biofeedback in combination with
traditional swallowing therapy, including swallow
manoeuvres, oral motor exercises, and compensatory
mechanisms. After therapy, significant improvements
were observed in swallowing function as measured by
severity ratings of videofluoroscopic swallowing
studies, diet level, and pulmonary status.
Many more evidence-based studies have been
published on issues related to outcomes in swallowing
therapy using a combination of diverse intervention
techniques (see the review by Speyer et al. 2010).
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