Intervention and Management

Strategies for Dysphagia

Linda Barboa PhD, CCC & Lisa Bell, MS, CCC
ASHA 2008
z Before beginning any program, it is understood that a complete evaluation would be
performed. The indications from your evaluation may vary. Please consult the
patient’s physician before beginning any program and on an on-going basis.

z The following compilation is just general information, not specific to any patient.
AMYOTROPHIC LATERAL SCLEROSIS
(ALS)
y Dysphagic Characteristics:
y Oral control of the bolus
y Reduced transport
y Residue
y Airway protection
y Difficulty chewing Crary & Groher, 2003
Exaggerated gag
Food rejections
Time intensive
Salivary Issues
Interventions:

◦ Use chin-tuck position

◦ Maintain liquid intake
◦ Try drinking through a straw
◦ Use double swallow

◦ Maintain liquid intake

◦ Eat calorie dense foods
◦ Increase taste, temperature (colder), and
texture sensation of liquid
Cerebral Palsy
z Characteristics
†Tongue thrust, or poor lingual function
†Prolong and exaggerated bite & gag reflex
†Tactile hypersensitivity in the oral area
†Drooling
†Poor bolus formation & transit time
…Trunk, shoulder, and head control problems.
zDelayed swallow
zReduced pharyngeal motility
zResidue
zAspiration
zPain & discomfort when swallowing
zFood refusal and behavioral problems during
feeding
 Cerebral Palsy
z Interventions
{Thicker texture foods may be indicated
zVary texture and temperature
zImprove jaw, lip, and cheek control
zSecret signals for wiping mouth and wrist bands to keep
the face dry.
zStretching, brushing, vibrating, icing, and stroking areas of
the face
zThicker textures – soft solid foods
zReduce rate of feeding
Cleft Lip and Palate
z Cleft Palate Pre-Surgery
{Feeding problems:
zPoor intake, lengthy feeding times
zNasal regurgitation
zChoking
zGagging
zExcessive air intake (

zDiscomfort with feeding

zStressful feeding interactions between infant and
caretaker
(Carlisle, 1998)
Dysphagia and Cleft Palate
Post-Surgery

{Restricted diet to promote healing

{Some discourage bottle & recommend spoon or cup
Some recommend not to use spoon or cup with spout
{Monitor nutrition & hydration for optimal healing
{Positioning: semi-upright position (head higher than
stomach-at least 60 degrees) Positioning of the nipple:
under a shelf of bone of the hard palate to provide stable
base for compression
{Pace intake/ use consistent methods:
{Burping: Expel excessive air intake during feeding
{Nasal regurgitation: Allow infant time clear the nasal
passage. May use slower flow nipple (Kummer, 2008)
Dysphagia and Cleft Palate
Modified Nipples-
Breast Feeding
{Cleft Lip only or cleft palate only
{Cleft Lip/Palate
zUsually not an option (No effective means for
positioning or compressing the nipple) (Kummer,
2008)
z Tube Feeding
{Orogastric tube or NG tube
{Gastrostomy Tube (G-tube) may be indicated if infant
has abnormal oral reflexes or poor ability to protect
airway (Kummer, 2008)
Other Craniofacial Anomalies

z Pierre Robin
{ Problems:
zSuck-swallow-breathe pattern
zPosterior position of tongue/respiratory difficulties
{ Techniques
zTube feeding if necessary
zPositioning to facilitate tongue movement
zSidelying position with special bottle
z (Kummer, 2008)
Moebius Syndrome
Characteristics:
Inability to suck
Weakness in the lips (can’t
achieve adequate seal, causes
excessive drooling)

Techniques:
Feeder assisted squeezing
Special bottle
Hemifacial Microsomia

Characteristics:
Limitation in range of motion in
jaw, lips, or tongue unilaterally

Techniques
Utilization of stronger side of
mouth
Provide stabilization to weaker
side
Special bottle/nipple
Feeding Problems and Techniques for Other
Craniofacial Anomalies

z Treacher Collins Syndrome

{Problems
zInefficient sucking
{Techniques
zSpecial bottle (Kummer, 2008)
z )
Velocardiofacial Syndrome
Problems
Dysmotility in the
pharyngoesophageal
area
Fatigue because of
cardiac involvement

Techniques
Tube feeding as
necessary
Sensorimotor stimulation
Special bottles/nipples
Dementia
z Characteristics:
Loss of appetite
{Loss of understanding how to eat food.
{Inability to recognize food
{Indifferent to food
{Easily distracted
{Anxiety
{Agitation
Dementia
techniques.
z Create a quieter environment by having two dining
rooms
{Create positive dining routines
{Provide consistent cues, prompts and redirections
{Appropriate support and set-up
{Recommended diet texture
{Specific cues and prompts to assist with self-feeding
{Safe swallowing strategies
z Cleary, S., (2007).
Down Symdrome
z Down Syndrome is the most common genetic disorder caused by
genetic variations.

z Dysphagic Characteristics:.
z Dysphagic signs and symptoms (Mayo Foundation for Medical
Education and Research)
z at risk for feeding and swallowing disorders (dysphagia)
z at risk for nutritional compromise
z large tongue (macroglossia)
z underlying hypotonia (low muscle tone)
z small oral mechanism
z weak sucking or rooting reflexes

• respiratory problems, cardiac, gastro problems

(Kerwin, 1999, 2003)
Down Syndrome-
interventions

Simultaneous presentation of liked & disliked foods.

Gradually changing the type of food and/or utensil.
Progressive muscle relaxation
Systematic desensitization
Contingency management
Right CVA
z Dysphagia is typically more severe in patients with right 
CVA than left CVA.
{Characteristics: 
{Difficulty with spatial perception…
{left neglect.
{Impulsive eating
{Drooling from lip weakness: 
{Reduced range of motion the tongue
{Delayed A/P oral bolus transit
{Delayed pharyngeal bolus motility
{Delayed laryngeal elevation
Right CVA
Treatment Techniques

•Resistive exercises to strengthen and increase range

– (tongue depressors)
•Range of motion exercises.
•Optimize textures that form a cohesive bolus- (no
pudding..slides right down)
•Stimulate with cold food/stimuli.

•*Other patients may receive recommendation to feed

with large amt on spoon, but not safe with pts. with
right CVA b/c of impulsivity.
Techniques:

Counsel caregiver to feed to unimpaired side.

Increase awareness to impaired side with cold stimuli
(food and lemon swabs).
Counsel patient to be aware of impulsivity.
Promote consuming smaller bolus.
Provide finger foods
Encourage pt. to cut food into smaller pieces
Use labial resistive exercises to increase strength.
Intraoral placement to unimpaired side.
Right CVA – Pharyngeal phase.

{Effortful swallow: over exaggerates swallow,

engaging the muscles by using greater force
{Tongue base retraction exercise: promote tongue
base mvmt which assists in quickly moving bolus to
esophagus.
{Masako tongue hold – tongue is held while
swallowing w/o bolus; engages posterior pharyngeal
wall and muscles for laryngeal elevation.
{Laryngeal exercises that assist with vocal fold
adduction such as push/pull on chair, take a
breath/hold/cough.
{Compensatory strategies: chin tuck which protects
th i ith th i l tti
Laryngectomy- characteristics

zAspiration
zMuscle spasms
zStenosis- or poor bolus clearance
zDiminished sense of smell/ appetite
Laryngectomy- treatments
• Chin-tuck maneuver
• Supraglottic and Super Supra Glottic Swallow
Breath-hold followed by coughing in order to
clear residue
• Mendelsohn Maneuver
Prolonging the swallow
• Food Modification
• Effortful Swallow
Myasthenia Gravis

z Dysphagia Characteristics
Difficulty chewing or swallowing
Lip incompetence
Tongue and masticatory weakness
Weakness of oropharyngeal muscles
Possible silent aspiration
Fatigue
Decreased laryngeal elevation
Decreased tongue base and elevation
Decreased epiglottic movement
Myasthenia Gravis- techniques
z Mendelsohn maneuver (lifting of larynx)
z laryngeal adduction procedures
{Supraglottic swallow
{Breath hold
{push-pull with phonation (“ahhh”)
z feeding strategies (alter bolus volume and
consistency) freq. small meals
z Compensatory strategies (tongue sweep for
pocketing)
z Try lip closure or tongue movement techniques
z positioning
Left Hemisphere
z Dysphagia Characteristics
{ Difficulty coordinating swallowing muscles due to oral apraxia
{ Sensory issues: difficulty feeling where food is during any stage
of the swallowing process: can cause spillage or aspiration
{ Paralysis of swallowing muscles on right side of neck
{ Neglecting food on right side of plate or tray due to right-sided
spatial neglect
{ Weak swallowing muscle
{ Coughing or choking
{ Wet or gurgly sounding voice
{ Extra effort or time needed to chew or swallow
{ Food or liquid leaking from or getting stuck in the mouth
{ Weight loss
{ Lees et al., 2006
Left Hemisphere
z Additional Problems Related To Swallowing
{ Inability to communicate swallowing difficulties to medical staff
due to expressive language impairments
{ Inability to understand swallowing treatment instructions due to
receptive language impairments
Left Hemisphere
z Treatment
{Strengthening, coordinating exercises & strategies
{Dietary changes:
{Electrical Stimulation/Neuromuscular stimulation
(controversial)
{ Marchese-Ragona, Giacometti, Costantini, & Zaninotto, 2006
Multiple Sclerosis

zDysphagic Characteristics
{Reduced tongue control,
{Impaired tongue base retraction
{Delayed or absence of pharyngeal swallow/pool
{Reduced pharyngeal contraction
{Upper esophageal sphincter dysfunction
{Reduced laryngeal closure, c/o choking
{Reduced pharyngeal and/or laryngeal sensation
{Hypo salivation-- drooling
Multiple Sclerosis
Treatment Approaches

z Rehabilitative treatment
{Compensatory techniques (Chin tuck, effortful
swallow)
{Indirect therapy (exercises to strengthen swallowing
muscles)
{Direct therapy (exercises to perform while swallowing)
{Reduce textures.
{Avoid “washing down food”
{Position- sit upright
{Small bites
{Reduce distractions- don’t talk while eating
z Restive, Marchese-Ragona, & Patti (2006)
Rett Syndrome
characteristics

z Weight loss/poor weight gain

z Oral motor dysfunction
z Regression in swallowing skills with age
z Chewing difficulty may increase with age
z Significant pharyngeal involvement
z Aspiration of liquids, secondary to reduced laryngeal
closure during the swallow
z Aspiration risk and incidence of pneumonia can be high
z Air swallowing
 Fetal Alcohol Syndrome
dysphagic characteristics

z Poor sucking and swallowing

z Sensory deficits
z Range of motion in jaw frequently reduced
z Functional short gut with feeding problems
z CNS problems: seizures, palate (high, cleft, submucous cleft)
z Motor coordination
z V.H. Wacha & J.E. Obrzut April 19, 2007 – review of literature on FAS
http://www.emedicine.com/ped/topic142.htm

General Treatment
•Consultation with nurse/family
•Adaptive equipment
•Nipples most consistent with sucking pattern
•Thickened liquids/formula
•Multiple feedings
•A minimum of 10-12 times/day
•Non-nutritive sucking
 General Treatment
Consultation with nurse/family
Adaptive equipment
Nipples most consistent with sucking pattern
Thickened liquids/formula
Multiple feedings
A minimum of 10-12 times/day
Non-nutritive sucking
FAS-
treatments
z Consultation with nurse/family
z Adaptive equipment
{Nipples most consistent with sucking pattern
z Thickened liquids/formula
z Multiple feedings
{A minimum of 10-12 times/day
z Non-nutritive sucking
Apraxia-
CHaracteristics

• Dysphagia in developmental apraxia of speech

• Weight loss
• Excessive drooling
• Weak suck
• Difficulty initiating the swallow
• Difficulty coordinating and timing muscle
movements involving swallowing
HIV or AIDS
zHIV (human immunodeficiency
virus)
zAIDS (acquired immunodeficiency
syndrome)
{chronic, life-threatening condition caused by HIV.
{the later stages of an HIV infection
U.S. Department of Health & Human Services (2007)
HIV/AIDS-
dysphagic characteristics
quick weight loss
nausea
vomiting
Decreased laryngeal elevation
Decreased tongue base and retraction
sore throat (dry cough)/ painful swallow
Decreased pharyngeal wall contraction.
Painful swallow
c/o “lump in throat”
HIV/AIDS
treatment:
{Determine whether the patient is able to swallow pills
before giving oral medications. If pills are not tolerated,
the patient may need liquids or troches.
{Diet modifications
{Compensatory strategies
{Exer. Prog= pharyngeal, laryngeal, tongue base/
{Med management.
{Important: patients maintain adequate caloric intake,
preferably with foods and liquids that can be swallowed
easily. Nutritional supplements along with soft, bland,
high-protein foods are recommended. Refer to
nutritionist as needed.
United States Department of Veterans Affairs (2007)
*Great Resource for coping with discomforts: http://www.metroplexhealth.com/hiv.htm
Head Injury
dysphagic characteristics
z Abnormal oral reflexes
z Laborious tongue movements
z Poor lip closure
z Poor mouth opening – delayed initiation
z Slow motor movements
z Reduced range of pharyngeal, and laryngeal
z Abnormal chewing
Parkinson’s
characteristics
z Reduced tongue base movement
z Reduced lip closure
z Tongue pumping
z Delayed initiation of swallow
z Silent aspiration
z Lack of volitional cough
z Anterior chew
z Drooling
z Tremors in oral musculature
Parkinson
treatments

zAROM at strength peaks

zThickened liquids
zChewing exercises
 References
z “Coping with discomforts.” (2003). Metroplex Health and Nutrition Services, Inc. Retrieved October 22,
2007 from http://www.metroplexhealth.com/hiv.htm

y Bladon, K. & Ross, E. (2007). Swallowing difficulties reported by adults infected with HIV/AIDS attending
a hospital outpatient clinic in Gauten, South Africa. Folia Phoniatrica et Logopaedica. 59, 39-
52.

z “National HIV/AIDS program.” (2007). United States Department of Veterans Affairs. Retrieved October
22, 2007 from http://www.hiv.va.gov/vahiv?page=cm-404_esoph&pf=vahiv-aetc-pf&pp=pf

z “Basic HIV/AIDS information.” (2007). U.S. Department of Health & Human Services. Retrieved October
22, 2007 from http://www.aids.gov/

y Shaw, MD, G.; Sechtem, MS, P.; Searl, Ph.D., J.; Keller, MS, K.; Rawi, MS, R.; and Dowdy, E. (2007).
Transcutaneous neuromuscular electrical stimulation (VitalStime) curative therapy for severe
dysphagia: Myth or reality? Annals of Otology, Rhinology & Laryngology, 116, 1. 36-44.

z “Women and HIV/AIDS.” (2006). U.S. Department of Health & Human Services. Retrieved October 22,
2007 from http://www.4women.gov/hiv/what/
 References
z “Coping with discomforts.” (2003). Metroplex Health and Nutrition Services, Inc. Retrieved October 22,
2007 from http://www.metroplexhealth.com/hiv.htm

y Bladon, K. & Ross, E. (2007). Swallowing difficulties reported by adults infected with HIV/AIDS attending
a hospital outpatient clinic in Gauten, South Africa. Folia Phoniatrica et Logopaedica. 59, 39-
52.

z “National HIV/AIDS program.” (2007). United States Department of Veterans Affairs. Retrieved October
22, 2007 from http://www.hiv.va.gov/vahiv?page=cm-404_esoph&pf=vahiv-aetc-pf&pp=pf

z “Basic HIV/AIDS information.” (2007). U.S. Department of Health & Human Services. Retrieved October
22, 2007 from http://www.aids.gov/

y Shaw, MD, G.; Sechtem, MS, P.; Searl, Ph.D., J.; Keller, MS, K.; Rawi, MS, R.; and Dowdy, E. (2007).
Transcutaneous neuromuscular electrical stimulation (VitalStime) curative therapy for severe
dysphagia: Myth or reality? Annals of Otology, Rhinology & Laryngology, 116, 1. 36-44.

z “Women and HIV/AIDS.” (2006). U.S. Department of Health & Human Services. Retrieved October 22,
2007 from http://www.4women.gov/hiv/what/
 References
z “Coping with discomforts.” (2003). Metroplex Health and Nutrition Services, Inc. Retrieved October 22,
2007 from http://www.metroplexhealth.com/hiv.htm

y Bladon, K. & Ross, E. (2007). Swallowing difficulties reported by adults infected with HIV/AIDS attending
a hospital outpatient clinic in Gauten, South Africa. Folia Phoniatrica et Logopaedica. 59, 39-
52.

z “National HIV/AIDS program.” (2007). United States Department of Veterans Affairs. Retrieved October
22, 2007 from http://www.hiv.va.gov/vahiv?page=cm-404_esoph&pf=vahiv-aetc-pf&pp=pf

z “Basic HIV/AIDS information.” (2007). U.S. Department of Health & Human Services. Retrieved October
22, 2007 from http://www.aids.gov/

y Shaw, MD, G.; Sechtem, MS, P.; Searl, Ph.D., J.; Keller, MS, K.; Rawi, MS, R.; and Dowdy, E. (2007).
Transcutaneous neuromuscular electrical stimulation (VitalStime) curative therapy for severe
dysphagia: Myth or reality? Annals of Otology, Rhinology & Laryngology, 116, 1. 36-44.

z “Women and HIV/AIDS.” (2006). U.S. Department of Health & Human Services. Retrieved October 22,
2007 from http://www.4women.gov/hiv/what/
References
z Arvedson, J.C. & Brodsky, L. (2002). Pediatric Swallowing and Feeding. Albany, NY: Singular Publishing Group.
z Calcano, P., Ruoppolo G., Grasso, MG., De Vincentiis, M. & Paolucci, S. (2002) Dysphagia in multiple sclerosis–
prevalence and prognostic factors. Acta Neurol Scand, 105, 40-43.
z Carlisle, D. (1998). Feeding babies with cleft lip and palate. Nursing Times, 94(4), 59-60.
z Clarren, S. K., Anderson, B., Wolf, L. S. (1987). Feeding infants with cleft lip, cleft palate, or cleft lip and palate.
Cleft Palate Journal, 24 (3), 244-249.
z Cleary, S. (2007). Current approaches to managing feeding and swallowing disorders for residents with dementia.
Canadian Nursing Home.18. 11-16.
z Crary, M.A. & Groher, M.E. (2003). Introduction to adult swallowing disorders. Philadelphia, PA: Elsevier Science.
z DiBartolo, M., C. (2006). Careful hand feeding: A reasonable alternative to PEG tube placement in individuals with
dementia. Journal of Gerontological Nursing. 25-35.
z Humbert, I. & Ludlow, C. (2004, March 16). Electrical Stimulation Aids Dysphagia. The ASHA Leader, pp. 1, 23.
z Kummer, A. (2008). Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance. Clifton Park,
NY: Thomson Delmar Learning.
z Lees et al. (2006). Nurse-Led Dysphagia Screening in Acute Stroke Patients. Nursing Standard, 21 (6), 35-42.
z Masiero, S., Briani, C., Marchese-Ragona, R., Giacometti, P., Costantini, M., & Zaninotto, G. (2006).
Successful Treatment of Long-Standing Post-Stroke Dysphagia With Botulinum Toxin and Rehabilitation. Journal
of Rehabilitation Medicine, 38, 201-203.
z National Institute of Neurological Disorders and Stroke Amyotrophic Lateral Sclerosis Fact Sheet
http://www.ninds.nih.gov/disorders/amyotrophiclateralsclerosis/detail_amyotrophiclateralsclerosis.
htm
z Prosser-Loose, E. & Patterson, P. (2006). The FOOD Trial Collaboration: Nutritional Supplementation Strategies
and Acute Stroke Outcome. Nutrition Reviews, 64 (6), 289-294.
z Restivo, D.A., Marchese-Ragona,R., & Patti, F., (2006). Management of swallowing disorders in multiple sclerosis.
Neurol Sci, 27, S338-S340.
z Steele, C. (2004). Treating Dysphagia with sEMG Biofeedback. The ASHA Leader, pp. 2, 23.