Treatment of Dysphagia Post ABI

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). Many of these exercises, although tested within stroke or other populations, have not been tested specifically within the ABI population. 

Oral Motor Exercises

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). 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).

Range of Motion Exercises for the Pharyngeal Structures: Airway Entrance

The individual is 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.

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 is done five times. The individual is then asked to repeat “ah” five times. Again it is recommended that these exercises be repeated three times in sequence, 5 to 10 times each day for five 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).

The Shaker Exercise

For 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, and then the patient rests for one minute. The exercise is repeated three times. Following this sequence, the patient lifts their head, looks at their toes, and then lowers their head. This head up, then down sequence is repeated 30 times. It is recommended that the Shaker Exercise be completed three times per day for a period of six weeks. This exercise has been shown to have some success in improving hyolaryngeal movement (Logemann 1998; Shaker et al. 2002; Shaker et al. 1997); however, it has not been studied specifically in the ABI population.

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 early stages may lead to compliance issues with the recommended diets and possible setbacks with aspiration pneumonia. Overall, this can hinder the patient’s ability to participate in 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). Swallowing difficulties can be addressed through four maneuvers but they require the patient to follow directions, be alert, and be able to exert the physical effort it takes to do the maneuvers correctly (Kramer et al. 2007).

Supraglottic Swallow

This maneuver was meant to close the airway at the level of the true vocal folds before and during the swallow, as well as clear residue afterwards (Logemann 1998; Logemann et al. 1997). 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 cords in 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.

Super-supraglottic Swallow

This procedure is designed to close the airway entrance both before and during the swallow, increase pressure generation, as well as to clear residue afterwards (Logemann 1998). During this maneuver the patient follows the following steps: 1) take a deep breath in; 2) hold the breath in and hold it while bearing down hard; 3) swallow hard while holding this breath; 4) cough immediately after the swallow and clear throat; 5) swallow again (Logemann et al. 1997).

Effortful Swallow

Effortful swallow is designed to increase posterior movement of tongue base (Kramer et al. 2007). This technique involves asking the individual, as they swallow, to squeeze hard with all the muscles they use for swallowing (throat and neck muscles).

Mendelsohn Maneuver

The objective of this maneuver is to address decreased laryngeal movement and discoordination of the swallow. Improvements in swallowing function are achieved through increasing the extent and duration of laryngeal elevation which increases 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 two to three seconds, then complete the swallow.

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. It is reported by many patients that thickened fluids do not quench thirst in the saw way that regular thin water does; therefore, regular water is offered in combination with the recommended thickened fluids. This assists 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 the water. The Frazier Free Water protocol states that, by policy, water is allowed for any patient NPO or on a dysphasia diet (Panther 2005).

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 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). 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).

The use of a chilled laryngeal mirror applied to the anterior faucial pillars (three strokes per side) before swallowing was compared to 10 consecutive swallows of semi-solid boluses in 22 patients with dysphagia post stroke (Rosenbek et al. 1996). 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 (Rosenbek et al. 1996). This method requires further research before conclusions on it efficacy can be made.

Postural Techniques

Moving the patient in order to change the 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 that have been shown to have some success in assisting individuals improve their swallowing function (Logemann 2008).

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 do the following: remain upright for 30 minutes post meal to reduce the risk of aspiration, take controlled bites/sips, alternate solids and liquids, take multiple swallows, and clear or remove food that has pocketed in the mouth (Kramer et al. 2007).

Table: Five Postures to Improve Swallowing Function (Logemann 2008)

1. Chin Down Posture

  • Helpful for those who have tongue base retraction issues;
  • Mechanism of change widens the valleculae, allowing the valleculae to contain the bolus in event of pharyngeal delay.

2. Chin Up Posture

  • Helpful for those who have oral tongue propulsion problems;
  • May aid in gaining adequate lingual pressure to drive the food or liquid out of the mouth and into the pharynx.

3. Head Turn (left or right)

  • Involves rotating the head to the side that is damaged;
  • Bolus is then directed down the “normal” safe side.

4. Head Tilt (left or right)

  • Head is tilted toward the stronger side, to promote the flow of food and liquid to go down that side.

5. Lying Down

  • Shown effective in those with posterior pharyngeal wall contraction or reduced laryngeal elevation with resulting residue and subsequent aspiration after swallowing.
  • 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, O'Donoghue, Bartram, Lindsay, & Greenwood, 1997; Rasley et al., 1993).

Diet Modification 

The consistency of food should be chosen based on the specific nature of the problem. Although an attempt has been made to standardize dysphagic diets (McCallum 2003), there continues to be a lot of variation in their use in clinical practice and in how these diets are labelled.  The following tables illustrate two examples of diets for dysphagia.

 It should be noted that restrictions to diet and specific consistencies of food should be the last strategy examined (Logemann 1997). Restrictions to diets and consistencies, especially thin fluids, can be very challenging for individuals (Logemann 1997). Often patients 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.

Table: A Description of Four Levels of Diets

Level 1

Soft textured foods – may be pureed or mashed foods. Pudding may also be given.

Level 2

Minced and Moist – foods are soft, minced.  This may include cooked cereals, yogurts, curds.

Level 3

Smooth pureed – foods may include soft bananas, ground meats and fish, cream soups, ice-cream etc.

Level 4

Foods are finely chopped.

 

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

Dysphagia Diet Fluids

Thin Fluids

All fluids that are thin at room temperature: water/ice chips/juices/ tea/liquid nutritional supplements/ regular or strained soups/ice cream/jello.

Honey Thick Fluids

Thin fluids that are thickened to the consistency of liquid honey but can be sipped from a cup: honey thick juices, mild, water, soup.

 Honey Thick/Thin Fluids

Honey thickened fluids with the addition of thin fluids as determined in consultation with the patients/ resident/SDM and the SLP/RD.

Honey Thick Clear Fluids

Only honey thickened CLEAR fluids are allowed (no textures): honey thick apple/orange/cranberry juice and honey thick water.

Honey Thick Full Fluids

Only honey thickened FULL fluids are allowed (no textures): honey thick juices/water/mild/soup/hot cereals/custard/pudding/smooth yogurt.

Pudding Thick Fluids

Thin Fluids that are thickened to the consistency of pudding and are eaten with a spoon: pudding thick juices/mild/water/soup/custards, high energy puddings/smooth yogurt.

Pudding Thick/Thin Fluids

Pudding thickened fluids with the addition of thin fluids as determined in consultation with the patient/resident/SDM/and the SLP/RD.

Pudding Thick Clear Fluids

Only pudding thickened CLEAR fluids are allowed (no textures): pudding thick/apple/cranberry juices and pudding thick water.

Pudding Thick Full Fluids

Only pudding thickened FULL fluids are allowed (no textures): pudding thick juices/water/mild/soups: hot cereals, custard, pudding, smooth yogurt.

Dysphagia Diet Textures

Regular

All items are served unmodified.

Ready

Same as regular but roast meats are diced.

Diced Meat/Modified Vegetable

Most meats are diced/soft proteins are allowed whole (meatloaf); also allowed: bananas, watermelon, strawberries etc); not allowed: raw vegetables, brussel sprouts, large pieces of cauliflower, whole corn.

Minced meat/Modified Vegetable

Most meats are minced, soft protein items are allowed, nothing on a bun, no brussel sprouts, florets of cauliflower or broccoli, no stir fry (mince before serving); allowed: mashed potatoes, macaroni salads, bananas, sliced strawberries and seedless watermelon.

Minced

Minced meats, vegetables, mashed potatoes, potato puffs, scalloped potatoes, cheese, peanut butter sandwiches, fresh bananas, minced strawberries, seedless watermelon.

Minced/Pureed

Minced mead and vegetables, mashed potatoes (not rice), soft casseroles, scrambled eggs, pureed fruits, strained soups, oatmeal or cream of wheat.

Pureed Entrée/Modified Bread

Same as above; can add crustless bread toast, moist cakes.

Pureed with oatmeal

Oatmeal, foods with a pudding type consistency, all entree must be pureed.

Pureed

All foods with a pudding type consistency, all entrees to be pureed, bread with diet syrup. No bananas, cottage cheese, oatmeal, old cereal, peanut butter.

Dysphagia Diet Guidelines, Parkwood Institute, St. Joseph’s Health Care London, London, Ontario

Passy-Muir Speaking Valve (PMV) 

Passy-Muir (Positive Closure) Speaking Valves (PMV) operated in the closed position can improve voice quality and speech production while, at the same time, improving swallowing and reducing aspiration (Passy-Muir Incorporated 2004). 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 PMV, reduces the potential for aspiration.

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 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. This ease of communication is very beneficial to the patient’s ability to direct their own care which is important in feeding and swallowing safety.

Within the literature, the benefits of the PMV have been supported. Manzano et al. (1993) found that patients experienced a decrease in secretions and showed improvement in ability to cough with the PMV in place; however, the volume of secretions appears to increase when the PMV is removed (Lichtman et al. 1995; Passy et al. 1993). The use of a PMV has also been shown to significantly improve the degree of aspiration (Elpern et al. 2000; Stachler et al. 1996), provide the ability to safely take thin liquids (Suiter et al. 2003), improve oxygenation, decrease oral and nasal secretions, improve sense of smell, enhance airway clearance, and improved swallowing (Bell 1996). To determine its effectiveness specifically within the ABI population more research is recommended.

 

Although there are several possible interventions to treat dysphagia, there is no clinical evidence to support their efficacy specifically within an ABI population. More research is needed.