Exercises, Techniques, Compensations

Maneuvers/Exercises

 
 

To close vocal cords prior to the swallow.

 

For dysphagia accompanied by reduced or late vocal cord closure or delayed pharyngeal swallow.

 

Changes timing of PES opening, duration and timing of hyoid excursion and laryngeal closure, timing of BOT movement.  Closes vocal cords earlier in the swallow, prolonging hyolaryngeal excursion before and during swallow.

 

Logemann recommends 10x/day x5 min with 5-6 swallows each time.  (Frymark et al 2009)

 

Research shows:

  • 13/15 subjects with CVA showed abnormal cardiac findings (Chaudhuri et al 2005)
  • laryngeal elevation was prolonged until postswallow exhalation was completed.  6/8 people had increased hyoid/laryngeal elevation after inhalation.  5/8 swallows with visible movement of arytenoid cartilage and vocal fold closure (Bulow et al 1999)
 
 

For early closure at the entrance to the airway.

 

Facilitates timing and extent of laryngeal closure at specific levels of the larynx.

 

For dysphagia secondary to reduced closure of the airway entrance, with increased PES relaxation pressure and duration of hyoid excursion and laryngeal movement, with decreased time between PES opening and onset of hyoid movement and BOT movement time between PES opening and the onset of vocal fold adduction and laryngeal closure (Frymark et al 2009)

 

Research shows:

  • 13/15 subjects with CVA showed abnormal cardiac findings (Chaudhuri et al 2005)
  • increased extent and duration of tongue base motion to the posterior pharyngeal wall, max laryngeal elevation and laryngeal vestibule/true vocal fold closure with increased bolus clearance (Logemann 2006)
 
 
 

To assist in laryngeal elevation.

 

 The Mendelsohn is an exercise of resistance/endurance to increase tongue-base/pharyngeal wall pressure and contact duration with increased supra hyoid constriction and PES opening.

 

The Mendelsohn can be used to:

  • increase timing of laryngeal elevation
  •  increase peak pharyngeal pressure
  •  increase PES opening duration
  •  increase duration of laryngeal elevation
  •  facilitate clearance of residue

Evidence shows:

  • sustaining laryngeal elevation for 1.5 seconds or more with increase in sub mental muscle group (anterior belly of digastric, mylohyoid and geniohyoid) (Ludlow et al 2007)
  • increased extent and duration of tongue base motion to the posterior pharyngeal wall with max laryngeal elevation and laryngeal vestibule/true VF closure with increased bolus clearance (Logemann 2006)
 

Masako Technique-Increases anterior motion of the posterior pharyngeal wall at the level of the tongue base.

 

Resistive exercise.

 

The Masako should not be used with any bolus.

 

Increases:

  • anterior motion of the posterior pharyngeal wall at the level of the tongue base
  • strength of tongue base and pharyngeal constriction
  • efferent (motor) drive of tongue base
  • pharyngeal clearance
 

Shaker

To assist in laryngeal elevation and cricopharyngeal opening.

 

Exercise of resistance/endurance to increase laryngeal anterior excursion and opening of the PES.

 

Increases efferent drive of hyolaryngeal excursion and PES opening.

 

Targets the anterior belly of the digastric, mylohyoid, geniohyoid (hyoid elevation muscles).

 

Research shows:

  • decreased post-deglutitive aspiration from decreased PES opening and enduring effect in maintaining oral nutrition (Easterling 2002)
  • significant effects to swallowing (as did traditional therapy) with reduced post swallow aspiration (Logemann et al 2009)
 

Increase strength of the overall swallow.

 

Exercises of resistance and endurance to increase tongue base retraction, lingual propulsive force, oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, duration of pharyngeal pressure and PES relaxation.

 

Can add various bolus textures to increase resistance and strengthening.

 

Research shows:

  • increased force-generating ability for swallowing muscles (Frymark et al 2009)
  • evidence of early elevation of the hyoid at initiation of the effortful swallow (Bulow et al 1999)
  • increased motoric output (activation) of submental swallowing muscles (Sapienza et al 2008)
  • heightens pre-swallow sensory input (Logemann 2006)
  • combined with NMES is resistive with increased extent of laryngeal excursion in post-stroke patients (Park et al 2012)
 

Exercise

 

Lingual exercise with resistance (tongue depressor)/Iowa Oral Performance Instrument

 Lingual exercise with resistance SwallowStrong Device (Formerly the MOST)

Research shows:

  • 8 weeks of training, 3 sets, 10 reps 3x/day using IOPI, lingual strength increased, improved swallow with liquid bolus with reduced Penetration/Aspiration scores (Robbins et al 2008) (Robbins et al 2005)
  • 3 groups, 1 with no exercise, 1 with tongue depressor and 1 with IOPI.  Exercise 5 days/week for 1 month, 10 reps 5x/day for lateralization, propulsion and elevation.  Change in both exercise groups with little difference between IOPI/tongue depressor.  No change in endurance. (Lazarus et al 2003)
  •  
  • 8 weeks lingual training, isometric exercises using IOPI with increased isometric and swallowing pressure, increased airway protection.  2 subjects with increase lingual mass.  (Robbins et al 2007)
 

Mastication exercises

 

Use changes in:

texture

viscosity

temperature

sour

 

Weighted bolus

 

Add viscosity and use challenging bolus

 

 

Back of tongue exercises

 

Pull tongue straight back

Yawn and hold tongue at most retracted state

Gargle and hold tongue at most retracted state

(From Jeri Logemann’s book)

 

Oral manipulation exercises:

 

cheese cloth with bolus, toothetter, sucker, gauze (resistive to increase coordination)

 

Suck Swallow

 

Increases the speed of initiation of the pharyngeal swallow

 

May want to have the person suck a thick bolus through a straw, such as applesauce, thickened liquids, yogurt or pudding.

 
 

Postures

 

Chin Tuck

 

To assist in closing the airway by narrowing airway.  Also varies pressures in pharynx and PES during the swallow, duration of timing of swallowing events and displacement of anatomical structures during the swallowing.

 

Research shows:

  • More aspiration with chin tuck than with NTL or HTL, however more adverse affects with thickened liquids (dehydration, UTI, fever) (Robbins and Hind 2008)
  • Significant change in pharyngeal contraction pressure, duration of pharyngeal contraction pressure, larynx to hyoid bone distance, hyoid to mandible distance before the swallow with decrease in angle between mandible to posterior pharyngeal wall, angle between epiglottis to PPW of trachea, width or airway entrance, distance from epiglottis to PPW.  (Frymark et al 2009)
  • Effective in 72% of patients, but may be contraindicated in those with weak pharyngeal contraction pressure as it decreases pharyngeal contraction pressure and duration (Robbins et al 2005) (Lazarus et al 2003)
 

Head Turn

 

Closes the weak side of the swallow directing the bolus to the stronger side.  Also decreased PES resting pressure on side opposite of rotation and increased anterior/posterior opening diameter.

 

Research shows:

  • decrease in PES resistance to bolus flow and prolongation of PES opening providing bolus more time to clear from pharynx.  (Frymark et al 2009)
 

Head Back

 

Uses gravity assistance to help with lingual deficits.

 

To assist in oral phase (must have functional airway protection and functional triggering of the pharyngeal swallow).

 

Side Lying

 

To help clear pharyngeal residue by altering gravity.

 

May help to clear pharyngeal residue.

 

Before the person sits upright, have cough to clear final residue.

 

Sensory Stimulation Techniques-

 

Tactile Thermal Stimulation

 

Thermal Gustatory Treatment

 

Deep Pharyngeal Neuromuscular Stimulation.

 
 

Therapy Techniques

Pharyngocise

CTAR (Chin Tuck Against Resistance)

 

Tips to Remember in Therapy:

 

Murray, Larson and Logemann 1998 found:

 

    Lip Strength:

    It takes very little lip strength to maintain a small liquid bolus.

    Increase in muscle activation as bolus size increases.

    Simple lip contact with spoon or cup=decreased muscle activation.

    Straws=increased activation.

 
 Tongue:
 

     General tongue movement patterns for bolus transport is quite

              stereotypical.

 

      Timing of movements may vary, movement pattern remained the same.

 

      Tongue presses against the hard palate segmentally and sequentially.

 

     Timing for lingual movements for continuous swallow-differed      substantially from movement timing in discrete swallows.

 

      Full contact of the tongue with the palate not seen in all continuous swallows.

 

Laryngeal Protection:

 

     3-Tiered Protection of the airway:

         Inversion of epiglottis over laryngeal aditus.

         Closure of false vocal folds.

         Closure of true vocal folds.

3 thoughts on “Exercises, Techniques, Compensations

  1. Jacqueline says:

    Thank you for this publication. I have quite a few patients on my caseload with aspiration pneumonia. I am overwhelmed.

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