A big shout-out to Tanya for the inspiration for this blog!!!
Education is such an important part of not only the dysphagia eval, but also throughout therapy. More than likely the patient/family will have no clue what dysphagia is or that such a condition even exists. Swallowing is an event that you don’t think about. Nobody swallows and analyzes their own swallow function (unless you’re an SLP of course).
My first session with a patient is a large portion of education. Whether I’m doing a swallow eval or a Modified Barium Swallow Study I’m continually educating. I find that one of the easiest ways for me to educated patients/families is to explain each part of the eval and how it relates to swallowing. If I’m checking for labial seal/strength I explain to the patient the purpose of the lips. My new explanation for the tongue is that it’s like the quarterback of the team. The tongue is the one that starts the play and makes it happen. (The Colts have been doing well so everyone in Indiana loves football now.) I not only educate on the structures and the means by which they function, I show pictures and try to demonstrate as best I can.
Back to the Basics
When the patient understands the basics of such a complex and intricate system, they begin to understand how it could falter. I always make sure that the patient understands that the swallow is something that we do so frequently we don’t even think about it. I also let them know that the swallow involves a variety of closures, muscles, nerves and actions that all occur in 3-5 seconds.
I typically have information available for the patient to take home with them. I have brochures describing how speech therapy rehabs the swallow, information regarding swallowing and a self-assessment for dysphagia.
The Swallowing System
So, for all those that may read this and not understand dysphagia or know anything about the swallowing system:
The lips are the first part of the swallowing system. They have to close, and stay closed to help keep the food (the bolus) inside the mouth (the oral cavity). The lip seal also helps create a pressure which helps to push the food (bolus) back and down the throat (the pharynx). The tongue is the main player in the swallow. The tongue is like the quarterback. It is the first player to really receive the ball (the bolus), moves it around, getting it ready to “throw” down the line (the pharynx). When the ball (bolus) is ready, the tongue takes it, throws it back (posterior propulsion) and launches the ball (bolus) down the pharynx. Once the bolus starts down the pharynx, the airway has to move up and forward to close it off and you hold your breathe until the swallow is completed. (I usually have the person swallow and feel their Adam’s Apple move up when they swallow. If they can’t/don’t feel the laryngeal elevation, have them feel your throat.) When the airway is closed, the food tube (esophagus) and lets the food go down.
When we are not swallowing, our airway is open, allowing us to breathe and the esophagus is closed. It switches for a split second when we swallow. If any of these “tasks” don’t happen during the swallow or if they happen at the wrong time, that causes a problem with the swallow.
Deficits with Swallowing
Some of the problems that commonly occur with swallowing are lingual (tongue) weakness causing difficulty moving the bolus back in the mouth towards the pharynx (posterior propulsion), poor labial seal with food/drink falling out of the front of the mouth. Pocketing is when food sticks in the mouth, usually between the cheeks and the gums. If the airway doesn’t close off completely then food/liquids can start to go into the airway or go completely into the airway. When the food/liquid goes into the airway, that is called aspiration and can lead to respiratory difficulties such as breathing difficulties, bronchitis, pneumonia or even death.
Another problem that can occur in the pharynx is residue. There are two pockets in your throat, one is called the valleculae and is located just above your airway. The other is called the pyriform sinus and is above the esophagus. If there is not enough pressure or force from the back of the tongue pushing the bolus down the throat and against the wall of the throat (posterior pharyngeal wall), the food can stick in these pockets after the swallow. When food/drinks remain in the pharynx, the person may aspirate (the food/drink goes into the lungs) the residue once they breathe again.
Another major part of the swallow that can “go wrong” is that the esophagus doesn’t open, or doesn’t open enough for the entire bolus to enter the esophagus. The esophagus (upper esophageal sphincter-UES) is opened by the upward and forward movement of the airway (hyoid/larynx) and the pressure of the bolus. Typically when the UES opening is compromised, the person will have pyriform residue, which may then be aspirated.
There can also be a dysfunction of skill. The timing of the swallow may be wrong. There can be timing and swallowing dysfunction that is not caused by weakness.
How Can the SLP Help?
There are many techniques/therapies to aid in rehabilitating the swallow mechanism. Most commonly, people are placed on altered diets, or taught compensations such as chin tuck or head turn to stop aspiration/residue. These alterations/compensations DO NOT improve the swallow, but may serve to eliminate the aspiration or risk of aspiration. They may also help to increase the skill of the swallow until the SLP can work with the patient on rehabilitation.
Swallowing is a muscle based system, powered by 6 cranial nerves and skill level. We have to take an exercise physiology approach to rehabilitate dysphagia that is caused by a weakness to the any part of the swallow. We can learn much from our physical and occupational therapy counterparts.
To train a person to walk, they have the person walk. They may have them use a walker, but the ultimate goal is to have them walk without the walker or with independence. The walker makes the person safe at the time, but does not “fix” the problem. By the same token, we may put a person on an altered diet, or say, honey thick liquids. This makes the person safe at the time, but does not “fix” the problem. We work on strengthening those swallowing muscles to allow the person the opportunity to swallow with independence and to again swallow thin liquids. Just as the physical therapist will work with the person walking without the walker in therapy, although outside of therapy the patient will probably still need to use the walker, we need to work with our dysphagia patient on swallowing thin liquids in therapy. This may be a teaspoon of the liquid at a time. By using the thin liquid, a little at a time, you are training the person to swallow. You may use techniques such as the Mendelsohn or the effortful swallow to strengthen the muscles through resistance.
A session focusing on swallowing may look completely different for every patient. You may work on the actual skill of the swallow through a program such as MDTP (McNeill Dysphagia Therapy Program) or through use of sEMG (Surface Electromyography).
Home Exercise Program
I always give a Home Exercise Program (HEP) which will typically include no more than 2-3 exercises and often, those exercises, or at least 1 involves swallowing food, liquid or ice chips. Increasing sensory input to the swallow through a bolus swallow is vital to rehabilitation. We always need to use those principles of neuroplasticity when creating any program.
You are going to need an instrumental evaluation such as FEES or MBSS to determine the actual dysfunction of the pharynx to determine the appropriate exercises.
When choosing 2-3 exercises, you want these exercises to target the exact dysfunction of the swallow. Many times, my patients are given exercises such as saying “k” and “g” words and many different and interesting movements of the neck.
Exercises chosen may also be dependent on etiology of the swallow. A list of exercises for a patient with head and neck cancer may look completely different from a patient with a CVA.
When limiting the amount of exercises you give the patient, you are not only increasing compliance, think about it, YOU would be much more apt to complete 2 exercises vs. 53 exercises. It’s also easier to fully describe 2-3 exercises to that your patient understands the exercises.
Your session can focus on swallowing. You should have your patient swallow, something, in every session. It may be the tiniest amount of water, it may be an ice chip.
Interested in reading more about treatment strategies?