5.9 Treatment of Dysphagia Post ABI

Of note several treatments have been found to treat dysphagia. Included among these are: “vocal fold adduction exercises, range of motion exercises for the lips, tongue, and jaw, and chewing exercises” (Logemann, 1993); however, many of these exercises although tested within the stroke or other populations have not been tested specifically within the ABI population. 

5.9.1 Oral Motor Exercises (OME)

Exercises introduced with those who have developed a swallowing disorder include various oral motor exercises such as range of motion exercises for the tongue and the pharyngeal structures (Logemann, 1998; pg. 206-210). These exercises are designed to improve strength, movement, awareness and muscle coordination when swallowing (Kramer et al., 2007).

To aid in the improvement of oral transit, exercises to assist in tongue elevation and lateralization may be implemented. Here the patient may be asked to perform very specific tongue exercises in an effort to improve speech and swallowing (Logemann, 1998). Individuals may also be asked to participate in tongue resistance exercises (pushing the tongue against a tongue blade or popsicle stick for 1 second) and bolus control exercises (to allow the patient to learn to control or manipulate items placed in the mouth) (Logemann, 1998).

5.9.1.1 Range of Motion Exercises for the Pharyngeal Structures

Airway Entrance:

Here the individual is asked placed in a seated position and asked to bear down while holding his or her breath. This exercise is not recommended for those with uncontrolled blood pressure (Logemann, 1998). It is recommended this exercise be done 5 to 10 times each day for 5 minutes.

5.9.1.2 Vocal Fold Adduction Exercises

To improve vocal quality and reduce the risk of aspiration, individuals are asked to bear down, with one hand against a chair while producing a clear voice. This exercise is performed 5 times. Following this the individual is asked to repeat “ah” 5 times. Again it is recommended that these exercises be repeated 3 times in sequence, 5 to 10 times each day for 5 minutes. If there is no significant improvement in swallowing at the end of one week, individuals may be asked to pull up on the seat of a chair, while sitting in it, and prolong phonation (Logemann, 1998). This exercise is recommended for those individuals with  vocal folds that fail to close completely (Kramer et al., 2007).

5.9.2 The Shaker Exercise

In completing the Shaker Exercise, patients are asked to lay flat on the floor or in bed and raise their heads high enough to see their toes. This position is held for one minute then the patient rests for one. The exercise is repeated three times. Following this sequence, the patient lifts their head, looks at their toes, then lowers their head. This, head up - then down, sequence is repeated 30 times. It is recommended that the Shaker Exercise be completed 3 times per day for a period of 6 weeks. This exercise has been shown to have some success in improving hyolaryngeal movement; however it has not been studied specifically in the ABI population (Logemann, 2008; Shaker et al., 1997; Shaker et al., 2002).  

In a study conducted by Shaker et al. (1997), two groups of age matched healthy adults were divided into one of two groups: those in the Shaker exercise group and those in the sham group (controls). All subjects were asked to swallow 5ml liquid barium. Results indicate that for those in the Shaker exercise group (n=19), the upper esophageal sphincter (UES) opening increased from 8.7 mm to 9.8 mm post intervention.  

5.9.3 Swallow Maneuvers

During the acute stage of recovery, patients may experience more swallowing difficulties then they do during later rehabilitation. Failing to address and treat swallowing difficulties in the acute stage may lead to compliance issues with recommended  diets for safety and possible setbacks with aspiration pneumonia.  Such infections can quicklybecome a barrier to the patient’s ability to participate fully in any formal rehabilitation. Post ABI swallowing difficulties are often the result of eating too quickly, taking large bites, cognitive impairments, and decreased swallowing sensitivity (Logemann, 1998). To address swallowing difficulties, 4 specific maneuvers have been developed, each addressing a specific dysphagia presentation. For patients to be successful with each of these maneuvers they must have the ability to follow direction, they must be alert and be able to exert the physical effort it takes to do the maneuvers correctly (Kramer et al., 2007).

5.9.3.1 Supraglottic Swallow

This maneuver was “designed to close the airway at the level of the true vocal folds before and during the swallow” (Logemann, 1998; Logemann et al.,1997).  In this maneuver individuals are asked to hold their breath while swallowing and then to cough immediately after the swallow. This maneuver encourages closure of the true  vocal cordsin an effort to address reduced or delayed vocal fold closure or delayed pharyngeal swallow. The cough portion of this maneuver is meant to eject  any objects or residue caught in the laryngeal vestibule.

5.9.3.2 Super-supraglottic Swallow

During this maneuver, individuals are asked to take a breath in and hold it while bearing down hard, swallow while holding this breath and bearing down, then cough immediately after the swallow (Logemann et al., 1997). This procedure is designed “to close the airway entrance before and during the swallow” (Logemann, 1998). The Supraglottic Swallow maneuver is used to address reduced closure of the airway entrance (Perlman & Schulze-Delrieu, 1997).

5.9.3.3 Effortful Swallow

This technique was designed to “increase posterior movement of tongue base” (Kramer et al., 2007). As the individual swallows they are asked to squeeze hard with all the muscles (throat and neck muscles) they use for swallowing. The maneuver is intended to address reduced posterior movement of the tongue base

5.9.3.4 Mendelsohn Maneuver

The objective of this maneuver is to address decreased laryngeal movement and discoordination of the swallow (Perlman & Schulze-Delrieu, 1997) Improvements in swallowing function are achieved through  “increasing the extent and duration of laryngeal elevation, thus increasing the duration and width of the cricopharyngeal opening” (Logemann, 1998). Typically, patients are asked to swallow, but as they do so, to hold their Adam’s apple up, for 2-3 seconds then complete the swallow.  This exercise may be recommended to e performed several times a day.

5.9.4 Frazier Free Water protocol

To increase fluid consumption and decrease the risk of dehydration, the Frazier Water Protocol, allows patients, who are receiving thickened liquids, to be given regular, thin water between meals. This practice (and later protocol) arose out of complaints from patients that thickened fluids did not quench thirst in the same way regular thin water does.  The regular water, in combination with the recommended thickened fluids, works to assist some patients in better meeting their daily hydration needs.  Patients who are NPO are often permitted to have water (following screening) and those who have found success using various postural changes are asked to use these postural maneuvers when drinking water. The Frazier Free Water protocol states that “by policy any patient NPO or on a dysphasic diet may have water” (Panther, 2005).  

5.9.5 Thermal-tactile Stimulation

Thermal stimulation or thermal-tactile stimulation was developed to stimulate the swallowing reflex of patients who are neurologically impaired (Lazzara et al., 1986). The procedure for thermal-tactile stimulation involves having the patient open their mouth and applying a cold laryngeal mirror at the base of the faucial arches. The mirror, while being in contact with the arch, is then rubbed up and down five times.  For those patients who have sustained a “trauma” contact will be made on the normal (non-injured) side of the mouth (Logemann, 1998; p212). Pharyngeal swallow is not triggered at the time of stimulation, but its purpose is to heighten the sensitivity for swallowing in the central nervous system.  It is hoped that once a patient attempts to swallow the pharyngeal swallow will be triggered more quickly (Logemann,1998).

In one study 22 patients who had been diagnosed with dysphagia post stroke, were assigned to either the untreated group or the treated group. Those in the untreated groups were asked to swallow 10 consecutive semisolid boluses, while those in the treated group had a chilled laryngeal mirror applied to the anterior faucial pillars before they swallowed (Rosenbek et al.,1996). Three strokes were applied to the right and left side of the pillars, then the procedure was reversed. An attempt to keep the probe as cold as possible was made.  Following the stimulation, patients were asked to swallow a bolus. Results indicated that the duration of stage transition and total swallow duration was reduced following thermal stimulation. These findings suggest that thermal stimulation using a cold probe may modify swallowing duration (Rosenbek et al., 1996). Although this method appears to be effective, no research on its effectiveness or its efficacy within the ABI population appears to have been conducted. Further research is recommended.

5.9.6 Postural Techniques

Moving the patient, changing position of the head, neck and/or body may assist in changing the direction of the bolus flow, thereby reducing the risk of aspiration. There are five postures, chin-up, chin-down, head turn (left or right), head tilted (left or right) and lying down, that have been shown to have some success in assisting individuals improve their swallowing function (Logemann, 2008).

1. Chin down posture:
   1. Helpful for those who have tongue base retraction issues;
   2. Mechanism of change widens the valleculae, allowing the valleculae to contain the bolus in event of pharyngeal delay.
2. Chin up posture:
   1. Helpful for those who have oral tongue propulsion problems;
   2. Aids in gaining adequate lingual pressure to drive the food or liquid out of the mouth and into the pharynx.
3. Head turn:
   1. Involves rotating the head to the side that is damaged;
   2. Bolus is then directed down the “normal” safe side.
4. Head tilt:
   1. Head is tilted toward the stronger side, to promote the flow of food and liquid to go down that side.
5. Lying down:
   1. Shown effective in those with posterior pharyngeal wall contraction or reduced laryngeal elevation with resulting residue and subsequent aspiration after swallowing.
   2. Residual or pooling of food or liquid in the pharynx is kept from falling into the airway as gravity pulls the bolus towards the posterior pharyngeal wall and in this way bolus may be more easily moved into the esophagus (Drake et al., 1997; Rasley et al., 1993).                   

For individuals who have significant cognitive deficits post injury, having the patient engage in any one of these techniques may be challenging.  It has been suggested that patients with “oral and pharyngeal deficits remain upright for 30 minutes post-meal to reduce the risk of aspirating, take controled bites and sips, alternate solids and liquids, cue the patient to take multiple swallows and train the patient to clear or remove fool that is pocketed in the mouth” (Kramer et al., 2007).

5.9.7 Diet Modification

To date they has not been a "typical" dysphagia diet developed (Logemann, 1989). The consistency of food should be chosen based on the specific nature of the problem. It should also be noted that restrictions to diet and specific consistencies of food should be the last strategy examined (Perlman & Schulze-Delrieu, 1997). Restrictions to diets and consistencies, especially thin fluids, can be very challenging for individuals (Perlman & Schulze-Delrieu, 1997).  That said, diets for those who have been diagnosed with dysphagia not remedial to other compensatory strategies are generally determined by speech language pathologists or others trained in dysphagia management. These patients may begin with a very restrictive diet (liquids of various consistencies – purees) and  move to less  restrictive diets (diced to regular foods) at a pace that has been deemed safe for that individual (Kramer et al., 2007). Asking the patient to limit the amount of food they attempt to swallow (taking smaller bites) will also help reduce difficulties with swallowing.

In practice, there is a great deal of variation in the dysphagic diets available at various hospital/centres/facilities as well as great variation in the names they are given.  Although an attempt has been made (McCallum 2003) to standardize dysphagic diets, there continues to be much variation in practice, setting to setting.  The following tables illustrate two examples of dysphagia diets (tables 5.16 and 5.17).

Table 5.16 A Description of Four Levels of Diets

Table 5.17 Diet Levels as Defined by a Canadian Hospital (Parkwood Hospital-SJHC)

The above information is extracted from the Dyspahgia Diet Guidelines, Parkwood Hospital-SJHC, London ON

Due to the variability, clinicians working in the area of dysphagia would benefit from familiarizing themselves with the specific titles and descriptions of diets used in their facility.

5.9.8 Passy-Muir Speaking Valve (PMV)

Aspiration is often problematic in patients who have a tracheostomy. These patients are essentially unable to achieve the apneic interval necessary for an efficient swallow.  It is thought that, normalization of subglottic air pressure, achieved through placement of a Passy Muir Speaking Valve (PMV) reduces the potential for aspiration. In fact, in a study by Gross et al. (1994) they found a “tenfold in subglottic pressure with the speaking valve in place”.  

Many of these patients have been shown to benefit from the PMV,  designed by Victor Passy.  The valve may be  attached to the 15mm connector found on most adult tracheostomy tubes (Dettelbach et al., 1995; Passy et al., 1993). With the PMV is in place, a noticeable decrease in the amount aspirated has been observed.  While wearing the valve, patients also have the opportunity to more easily express themselves verbally (Bell, 1996). Passy et al. (1993) found that patients began speaking almost immediately and their speech improved making it easier for them to communicate with hospital staff, doctors and family. 

The volume of secretions appears to increase when the PMV is removed (Passy et al., 1993; Lichtman et al., 1995). Manzano et al. (1993), found that patients experienced a decrease in secretions and showed improvement in ability to cough with the PMV in place. In studies conducted by Stachler et al. (1996) and Elpern et al. (2000), both noted that patients with the PMV showed significant improvement in degree of aspiration. Suiter et al. (2003) noted that individuals, once the valve was in place, were able to safely take thin liquids. Benefits of the PMV include: improved oxygenation, decreased oral and nasal secretions, improved sense of smell, enhanced airway clearance, and improved swallowing (Bell, 1996). To determine it effectiveness specifically within the ABI population more research is recommended.