Management

Glossectomy

Assessment, Management, Research

Glossectomy

Let’s talk total glossectomy for a minute.   I’ve actually worked with multiple partial glossectomies in my career and recently have had 2 total glossectomy patients.

It seems like a pretty difficult task, right?  Getting someone to eat and drink again with no tongue.

Taking the tongue out of the equation of swallowing makes the entire process very difficult, but not impossible.

Research

I was looking at an article recently, wanting to make sure that I’m doing right by my patient, but also limited to access to most articles.

Son, et al

An article looked at 133 patients from 2007-2012.   There was a study of swallowing ability before and after surgery.

The study found risk factors for aspiration with tongue cancer including:

  • Gender (higher incidence in males)
  • Extensive tumor resection
  • Higher node stage
  • Extensive lymph node dissection

Patients in this study were a mean age of 53.5 with 85 men and 48 women.

Patients with tongue cancer had a higher incidence of:

  • inadequate tongue control
  • inadequate chewing
  • delayed oral transit time
  • aspiration/penetration
  • vallecular residue
  • pyriform sinus residue
  • inadequate laryngeal elevation

Of the patients:

  • 16 hemiglossectomy
  • 82 wide resection
  • 23 partial glossectomy
  • 5 total glossectomy
  • 70 underwent radiation
  • 57 underwent chemotherapy
  • 74 VFSS before surgery
  • 87 VFSS after surgery

Of the patients that had VFSS before and after surgery, after surgery, there was a higher incidence of:

  • lip movement abnormality
  • tongue control
  • chewing
  • oral transit time
  • pharyngeal phase differences with aspiration/penetration in 8 patients before surgery and in 26 patients after surgery
  • 4 patients with nasal regurgitation after surgery
  • vallecular residue in 6 patients before surgery and 39 after surgery
  • pyriform sinus residue in 3 patients before surgery and 16 after surgery
  • inadequate laryngeal elevation in 1 patient before surgery and 12 patients after surgery

Furia, et al

I read an article recently about Videofluoroscopic Evaluation after Glossectomy (cited below).   The study was small, only 15 patients, 5 with partial glossectomy, 2 with subtotal glossectomy and 8 with total glossectomy.

Those patients with partial glossectomy had difficulty with bolus formation, anterior/posterior propulsion and increased oral time particularly with thicker substances.

All patients had increased oral transit time and oral/pharyngeal/esophageal stasis.

2 patients had moderate aspiration, 2/10 had persistent asymptomatic aspiration.

Compensatory strategies that were effective for patients was a head back posture, Supraglottic Swallow, Mendelsohn Maneuver and subsequent swallows following initial swallow of the bolus.   After VFSS, 8 patients had a functional swallow and 2 patients had moderate aspiraiton with residue.

Take Away

I think the biggest take away with our patients with glossectomy, no matter the degree is to not give up on them.  These patients deserve a chance at eating and drinking, even if only small amounts.

Don’t be that SLP that completes the VFSS or FEES with no compensatory strategies, no assistance with anterior/posterior propulsion and only 1-2 trials.   There is evidence to support that these patients may not have a normal swallow, but may have a functional swallow.

Push for prosthesis for your patients.  These can be functional for your patient’s speech and swallowing.  There are multiple studies regarding prosthetics for your patient listed below.   A flap can help to fill the floor of the mouth and give your patient a stronger chance of a functional swallow.

References:

Furia, C. L. B., Carrara-de Angelis, E., Martins, N. M. S., Barros, A. P. B., Carneiro, B., & Kowalski, L. P. (2000). Video fluoroscopic evaluation after glossectomy. Archives of Otolaryngology–Head & Neck Surgery, 126(3), 378-383.

Son, Y. R., Choi, K. H., & Kim, T. G. (2015). Dysphagia in tongue cancer patients. Annals of rehabilitation medicine, 39(2), 210.

Davis, J. W., Lazarus, C., Logemann, J., & Hurst, P. S. (1987). Effect of a maxillary glossectomy prosthesis on articulation and swallowing. Journal of Prosthetic Dentistry, 57(6), 715-719.

Donaldson, R. C., Skelly, M., & Paletta, F. X. (1968). Total glossectomy for cancer. The American Journal of Surgery, 116(4), 585-590.

Hirano, M., Matsuoka, H., Kuroiwa, Y., Sato, K., Tanaka, S., & Yoshida, T. (1992). Dysphagia following various degrees of surgical resection for oral cancer. Annals of Otology, Rhinology & Laryngology, 101(2), 138-141.

Kothary, P. M., & DeSouza, L. J. (1973). Swallowing without tongue. Bombay Hosp J, 15, 58-60.

Frazell, E. L., & Lucas Jr, J. C. (1962). Cancer of the tongue. Report of the management of 1,554 patients. Cancer, 15(6), 1085-1099.

Standardizing Dysphagia Assessment and Treatment

Management

Sometimes in our professional career we see, read or hear something that goes against everything we’ve learned where everything we think we know. I recently wrote a blog post about three things we need to stop doing and dysphagia assessment and treatment. That post was a challenge.

Sometimes we have to step out of our comfort zone and realize that what we’re doing needs an upgrade. Research and dysphagia is constantly evolving and showing us what we should and should not be doing.

There is no all or nothing and there is no cookbook recipe to assessing or treating dysphagia. What we need to become competent in is reading the research articles. These articles are not all or nothing. We may have a patient that the Mendelsohn maneuver is a perfect contribution to their therapy program however have 10 other patients for whom the Mendelsohn maneuver is not an option.

Research gives us a guide to help us develop an appropriate program for each patient.

When we sit in the dining room day after day and watch patients eat it downplays our role as a pathologist.  We become an aid or a waitress to many of the patients in the dining room.  Now that’s not to say that there aren’t appropriate times to assess the patient in the dining room.  What better way to assess the patient at mealtime? It is however not a skilled treatment when we sit in the dining room day after day assessing or monitoring patient tolerance.

What we need to do as a profession is to become skilled at prescribing an appropriate therapy program for dysphagia. There is an article by Dr. Gisele Carnaby called usual care and dysphagia therapy that was very eye-opening.  Dr. Carnaby and colleagues found that given one scenario they were provided with over 90 treatment plans and no two treatment plans were the same.

When we keep up with the research and new developments in our field we know that we can begin to standardized our assessment and treatment with programs such as:

  • The Modified Barium Swallow Impairment Profile- A standardized protocol to completing and analyzing the MBSS (modified barium swallow study).
  • The McNeil Dysphagia Therapy Program- A systematic, exercise based therapy program using food as resistance.
  • Pharyngocize- A protocol developed for patients with head and neck cancer.
  • Expiratory Muscle Strength Training- A program developed to increase respiratory muscle strength for increased cough response and swallowing ability.

Let me know your favorite evidence-based protocol.

Carnaby, G. D., & Harenberg, L. (2013). What is “usual care” in dysphagia rehabilitation: A survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567-574.

Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: establishing a standard. Dysphagia, 23(4), 392-405.

Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: a case-control study. Archives of physical medicine and rehabilitation, 91(5), 743-749.

Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. Archives of physical medicine and rehabilitation, 93(7), 1173-1178.

Lan, Y., Ohkubo, M., Berretin-Felix, G., Sia, I., Carnaby-Mann, G. D., & Crary, M. A. (2012). Normalization of temporal aspects of swallowing physiology after the McNeill dysphagia therapy program. Annals of Otology Rhinology and Laryngology-Including Supplements, 121(8), 525.

Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). “Pharyngocise”: randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy. International Journal of Radiation Oncology* Biology* Physics, 83(1), 210-219.

Kim, J., Davenport, P., & Sapienza, C. (2009). Effect of expiratory muscle strength training on elderly cough function. Archives of gerontology and geriatrics, 48(3), 361-366.

Pitts, T., Bolser, D., Rosenbek, J., Troche, M., Okun, M. S., & Sapienza, C. (2009). Impact of expiratory muscle strength training on voluntary cough and swallow function in Parkinson disease. Chest Journal, 135(5), 1301-1308.

Kim, J., & Sapienza, C. M. (2005). Implications of expiratory muscle strength training for rehabilitation of the elderly: Tutorial. Journal of rehabilitation research and development, 42(2), 211.

Carbonated Beverages

Management

Not Nectar Thick

When patients have dysphagia, often sensory techniques, including carbonation can help increase aspects of the swallow.  For some reason, at one point in time, the research was translated to substitution of carbonated beverages, including soda to replace nectar thick liquids.

 

carbonated

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The Patient Exercising Their Right to Choose (Formerly The Non Compliant Patient)

Management

 

EDIT 1/4/17.  Due to a recent Facebook post, I wanted to change some wording on this post.  As with all areas of dysphagia, I continue to grow, learn and change my beliefs, mainly because of the patients I serve.

Although my belief stands that those patients who do not follow my recommendation continue to require SLP services, maybe we should look at these patients not as “non-compliant” but as “exercising their right to choose.”  

There was post recently on the Special Interest Group (SIG) 13 email blast.  An SLP was asking what to do with a noncompliant patient.

When I was first beginning of the ever-changing world of speech pathology, I first learned that if a patient is noncompliant then they are discharged.  The rationale was, a doctor would release a patient for noncompliance and our license is always at stake.

My belief system is not the same, fortunately for my patients!

First, think about this.  Aren’t the noncompliant patients who choose to not follow the SLP’s recommends the ones we should be the most concerned about?  The patients that are compliant are on a modified diet that has been determined to be the safest diet consistency for them, although there is always some risk with every recommendation we make.  They may be regulated by caregivers or a facility, but if they are following all instructions and diet recommendations, they should be safe.  The noncompliant patient who aspirates thin liquids, but continues to drink them is the one you should be the most concerned for their safety.  That is the patient that may be most at risk for aspiration pneumonia.

In my experience, patients are not compliant unless they are forced to be. I have worked with patients that will sneak a drink, sneak a bite whenever they have the opportunity.  I have had patients that were supposed to be on thickened liquids, went home, told me they were continuing the thickened liquids but were actually drinking all thin liquids.

The best thing we can do for our noncompliant patients is to educate and rehabilitate.  Why not make them safer with the consistency they choose?

The first thing I do with every patient that is cognitively able is teach them and/or their caregivers about oral care.  If you read anything about oral care and aspiration pneumonia, the take-home message should be that pneumonia is a result of the bacteria from the oral cavity traveling to the lungs through saliva or a liquid/food swallow.  I recently wrote a post about oral care which you can find here.

It’s important to remember that we want the patient to succeed with the diet they choose to consume.  We can recommend a safe diet and we can advise but we have to focus on the rehabilitation.  Just remember, not everybody that aspirates develops aspiration pneumonia.  There are functional aspirators.

You may have a patient that aspirates everything on the Modified Barium Swallow Study (MBSS), goes home and consumes a regular diet without ever having an aspiration event or a pneumonia.  Just because that patient does not choose the diet you recommend does not mean you give up on them.  If they are willing to put in the work and give you some time (they will have to buy-in to your program)  THOSE are absolutely  patients with whom we should work.

To Tuck or Not to Tuck

Management

chin tuck

The chin tuck.  I’m not talking about Chin Tuck Against Resistance (CTAR), I’m talking about the compensatory strategy.  That strategy that we’ve taught so well that nurses, respiratory therapists and doctors all tell patients, if you’re having trouble swallowing, just tuck your chin.  Somewhere down the road, we’ve made the chin tuck the end-all be-all in therapy, just after thickening liquids and diet modification.

We use the chin tuck with patients for a variety of reasons.  We have patients use a chin tuck to widen the valleculae, push the tongue base back placing the epiglottis more posterior and to narrow the airway, according to the research.

We often have patient tuck their chin to eliminate vallecular residue and to help in the prevention of laryngeal penetration or aspiration.

One study (Robbins and Hind 2008) compared using a chin tuck with thin liquids vs. nectar thick liquids and honey thick liquids.  The study found more aspiration with the chin tuck group than with the thickened liquid group, however there were more adverse effects with the group on thickened liquids (dehydration, UTI, fever).

Studies (Robbins et al 2005, Shaker et al 2002) found the chin tuck to be effective in 72% of the patients studied.  They found it may be contraindicated in patients with weak pharyngeal contraction pressure as it decreased pharyngeal contraction pressure and duration.

In my own practice, I have seen the chin tuck as both effective and ineffective.  It has been effective at times in prevention of laryngeal penetration or aspiration.  I have also seen exactly the opposite where patients tried the chin tuck to eliminate vallecular residue.  The patients had no penetration or aspiration until a chin tuck was introduced, which was when the patient aspirated.

The moral to the story:  Don’t assume the chin tuck will always work because it won’t.  Make sure to observe multiple trials of the chin tuck under fluoro to ensure that it is effective in your patient.  Not all patients will benefit from a chin tuck.  Just because Tom does well with the chin tuck and it is very effective for him, does not mean it will be the same for Rick.

The Swallow in Detail

Assessment, Management

The Swallow in Detail

 

Taken from: *Dysphagia Foundation, Theory and Practice by Julie Cicheroand Bruce Murdoch*

 

Hunger

Smell of food, empty stomach or electrolyte imbalance informs hypothalamus of the need to eat.

Brainstemactivates nucleii of CN VII and IX to promote secretion of salivary gland juices to prep for bolus

 

Chewing 

Bolus in mouth.  CN VII ensures good lip seal (orbicularisoris) while CN V relays sensory info to brainstem to constantly modify the fine motor control of bolus prep.

Motor activity to CN V, VII, IX, X, XII to create an enclosed environment within the mouth to prepare the bolus.

Cheeksprovide tone (buccinator CN VII).

Soft palate tense and drawn down towards tongue (tensor velipalatini CN V and palatopharyngeusCN IX)

Tongue is drawn up towards the soft palate (palatopharyngeusCN X, styloglossus CN XII).

Hyoidbone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow movement of the mandible).

Bolus prepared by closing (temporalis, masseter, meial pterygoid,lateral pterygoid, CNV) and opening (mylohyoid and anterior belly of digastric CNV, geniohyoid CNXII &C1-C3.)

Bolus pushed around the mouth by actions of the tongue to create a consistent, homogenous texture (hypoglossus, genioglossus,styloglossus and 4 groups of intrinsic muscles of the tongue CN XII). Taste sensations (CN VII and IX) provide info to cortex to stimulate areas of brain required to coordinate the swallow (insulaand cingulatecortex).

 

Voluntary initiation

Once bolus is adequately prepared.

Soft palate elevates slightly (levator veli palatini and palatopharyngeusCN X).

Slight elevation of hyoid bone (suprahyoid muscles contracting on rigid mandible with slight relaxation of infrahyoid muscles.

Pharyngeal tube is elevated (stylopharyngeus CN IX, palatopharyngeusand salpingopharyngeus CN X).

Tongue delivers bolus to force bolus distally towards posterior wall of the pharynx in a “piston-like” manner using hard palate for resistance. Sensation by CN XI and by CN X (pharyngeal plexus).

 

Larngeal elevation

1st motion for tongue to propel bolus into oropharynx is elevated anterior direction toward roof of mouth (mylohyoid and anterior belly of digastric, CNV; stylohyoid and posterior belly of digastric CNVII; palatoplossusCN X; genioglossus, hyoglossus and styloglossusCN XII; geniohyoid CN XII and C1-C3) affects hyoid elevation in an anterior direction.

Soft palate seals off nasopharynx.

Superior constrictors begin medialization of the lateral walls.

Larynx elevated and moved anteriorly in relation to hyoid bone by thyrohyoid CNX.

 

Laryngeal closure

During laryngeal elevation-vestibule closes and rises relative to thyroid cartilage (cricothyroid and intrinsic laryngeal muscles CN X).

Opposition and elevation of arytenoid cartilages provide “medial curtains” of pyriform recesses (aryeppiglottic folds).

Pressure exerted on base of epiglottis causing it to tip and cover the laryngeal vestibule.

Medial constrictors (CN X) “strip” the pharynx by medialization following on from superior constrictors.

Palatedescends (palatopharyngeus CN X), constrictors “strip” and tongue moves posteriorly (styloglossus CN XII) to close oropharynx.

Once the bolus has reached pharyngeal areas innervated by the internal branch of the superior laryngeal nerve swallow reflexive and cannot be stopped.

Anterior and elevated movement of larynx allows cricopharyngeus to be stretched (UES) and opened.

Inferior constrictor finishes medialization and bolus in esophagus.

 
 

Resting state

CNX

Cricopharyngeus resumes tonic state.

Glotticopens and larynx lowers.

Ifbolus present should cough.

Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and the pharyngeal phase with all consistencies should take 1 second.**The ability to contain a bolus is prognostic.**The swallow is a positive pressure phenomena where the pressure is always on the tail of the bolus.

 
 

Triggering the pharyngeal swallow response:

 

        The bolus stimulates CN IX, X, XI in the medullary reticular formation

        (nucleus tractus solitarius) (NTS).

 

        Incoporates (NTS) input from V, VII, XII

 

        NTS signals motor nuclei in teh nucleus ambiguus to help fire IX, X,

        XI.

 

        Nucleus ambiguus innervates muscles of the velum, pharynx, larynx,

        and upper esophagus (IX, X, XI) producing the pharyngeal swallow

        response.

 

       Strongest ties to the NTS=anterior faucial arches, posterior tongue at

       the lower edge of the mandible, valleculae, pyriform sinuses and

       laryngeal aditus.

 

       The anterior faucial arches have a strong connection between the

       sensory receptors and NTS via afferent fibers of the glossopharyngeal

       nerve (IX) creating a trigger point for younger adults.  (Swallows in

       older adults may trigger lower.)

The Dysphagia Buy-In: Selling Your Services

Management

My colleague Jonathon Waller, over at the Dysphagia Cafe posted recently. I LOVE his post. If you haven’t read it yet, you definitely need to. Dysphagia Therapy: More Rehabilitation and Less Compensation.

I think the reason I love this post, and asked him if he minded if I expanded on it, was because THIS IS MY LIFE!

I have definitely had the buy-in aspect. I live and work in Smalltown, Nowhere. People typically have not heard about this “dis-fay-gee-ah” thing.

I go into a room to work with a patient or they come to see me as an outpatient and they have NO idea why they’re there. They swallow just fine and have no problem speaking. Even though they cough and choke with every sip of water.

I find the majority of my evaluation is getting the person to “buy-in” to therapy. They’re not going to continue to come in for therapy if they don’t know what I’m doing.

Let’s face it, we’ve given ourselves a bad name at times. Have you ever had that patient that actually comes to you from another SLP with a 10 page list of exercises that they need to complete 10 times each, 3 times a day, including, but not limited to: stick your tongue out, up, side to side, say every /k/ and /g/ word known to man, stick out your jaw and hold it tensed for 5 hours……you get the picture. Now ask these people why they do these exercises and they have no idea.

I explain the swallowing system to the patient. These are muscles that we work with and when we don’t use those muscles or don’t use them as we’re supposed to, we lose the ability for those muscles to perform the way they are meant.

I often teach my patients, it’s like when you hurt your leg or ankle and limp for several days. You then create other problems because you are walking in a manner you were not meant.

I then teach them how I’m going to help. There’s homework. You don’t do your homework, you may not get better. There’s work to be done in my room. However, I can’t fix this in one session. Much like you can’t expect to go to the gym and after one day of lifting weights look like Arnold Schwarzenegger from the 80’s.

I ask them to give me 4-8 weeks along with the home-exercise program.

We use NO compensation in the therapy room. By using those compensations 100% of the time, we’re not teaching them to swallow without and building pathways FOR those compensations. (After all, who wants to tuck their chin, stand on their head and count to 25 when they swallow).

My patients EAT and DRINK in my therapy room. They don’t stick out their tongue at me or say “cook” with an emphasized /k/ sound. They SWALLOW.

Happy Swallowing Rehabilitation. P.S. I’m all for Swallow Pathologists, Dysphagiologists, anything that distinguishes us by what we do!! Maybe Dysphagia Rehabologists?? I say we put it to a vote!

Ampcare………A new name for NMES

Management

I love the ASHA convention.  Why?  It gives me an opportunity to not only see all the new products and offerings in the world of Speech Pathology, but a chance to sit down with the company reps to ask my questions and to actually try the product.  NMES or E-Stim has been dominated in  the world of dysphagia by VitalStim.

Ampcare is not new in the sense that they just started the company.  Ampcare has actually been around and researching NMES (Neuromuscular Electrical Stimulation) for swallowing rehabilitation since 1993.

I actually touched on Ampcare in a previous post regarding electrodes for NMES, however at that time, they were working on FDA approval of the device, so there was little information available.  I had received an email from Ampcare discussing their product, however it was very nice to sit down with Russ and Rick and to have them explain why they are superior in the NMES market.

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NSOMES-To Use Them or Not to Use Them…..That is the Debate

Management

This topic may seem a little off the dysphagia path, but it’s not, trust me.  I have actually thought a lot about NSOMES in my therapy as of late.  Not only does NSOME, at least in my eyes, stand for Non-Speech Oral Motor Exercises, I also use the term for Non SWALLOWING Oral Motor Exercises.  This was the March topic for the SLP Chat, which was a very interesting conversation.  I also went to a session on NSOME’s at our state convention, which actually turned into an artic course using core vocabulary which upset me immensely since I was hoping to learn a little more about NSOME’s.

 

 

First, let’s start with these exercises.  What are they?  Non-speech (swallowing) imply that these are movements that are not concurrent with producing sounds or swallows.  These are the typical stick out your tongue 10 times, move your tongue from corner to corner of your mouth.  These are actions that we use to “strengthen” the speech/swallowing mechanism by having our patients move the articulators.

 Now I’m switching to all swallowing-hey that’s what my blog is about.  It’s my blog!!  So, anyway, who hasn’t been to a facility and observed the SLP there.  What do they usually do for swallowing exercises.  Stick out your tongue, try to touch your nose with your tongue, move your tongue from corner to corner of your mouth, stick out your jaw…….all of these 10 times, 3 times a day.  So, 30 times total.  How many of these patients truly get better with only these exercises??  In my experience, very few.

 Robbins, et al wrote a very good article about neural plasticity in swallowing.  I actually reviewed that article in an earlier blog.  One principle is that plasticity is experience specific, or that to make neural changes (i.e. to the swallowing mechanism) the experience has to be specific to the actual movement.  So, to improve the swallowing mechanism, you have to practice swallowing.  To make neural changes to the swallowing system, the patient has to SWALLOW!  What a novel idea.

 Dysphagia therapy is quickly moving to a very exercise-based therapy.  No, not the typical stick out your tongue exercises.  When you exercise the swallowing system, there are very few researched techniques, however they do exist.  With all the changes in therapy and in insurance, healthcare, now is most definitely the time to move to evidence-based practice, if you haven’t already jumped on board.  I have my list of exercises that I use that are swallowing-specific and have evidence to support them.

 Tongue exercises using resistance, i.e. tongue depressor or IOPI.  Robbins et al looked at the IOPI 10x/3xday against the tongue tip, blade and dorsum with improvement with swallowing.  (Robbins, J.A., Gangnon, R.E., Theis, S.M., Kays, S.A., Hewitt, A.L., & Hind, J.A. (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatric Society, 53, 1483-1489.)  Lazarus, et al looked at the IOPI vs. a tongue depressor and found that the tongue depressor exercises worked just as well as the IOPI exercises.  (Lazarus, C. Logemann, J.A., Huang, C.F., and Rademaker, A.W. (2003). Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatrica et Logopaedica, 55, 199-205.)  So, I have my patients use a tongue depressor and push their tongue against it using protraction, elevation, depression and lateralization, 10x each, 5x/day, 5 days/week.

 

 

 

 Mendelsohn Maneuver uses resistance with swallowing.  You can continually add resistance if you have the capability to use sEMG with your patients, which unfortunately I do not have at this time.  With the Mendelsohn, you not only have resistance, but the entire exercise involves the act of swallowing, therefore it is a relevant exercise to improve the swallow.  (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence.   Journal of Speech, Language, and Hearing Research, 51, S276-300.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.) 

The Masako technique is a little bit questionable with therapy.  Yes, it does involve a swallow, however, how often do you swallow with your tongue sticking out???  This exercise should be used with caution, and should never be the only exercise you use, but may be a good exercise paired with another exercise to improve tongue base retraction.  So, possibly have the patient use the Masako and then the Mendelsohn??   (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence.   Journal of Speech, Language, and Hearing Research, 51, S276-300.)

 The Shaker exercise offers not only resistance using the head as weight, but repetition of the exercise.  Logemann and Eastering both have research for the Shaker exercise available, however use caution with this exercise, particularly for cardiac patients.  I have been to a conference where I learned the Neckline Slimmer (https://www.buynecklineslimmer.com/) using the highest resistance spring can do the same as the Shaker without the strain on the patient.  However, be careful with this as there is no research out there to support this.  The Slimmer can be purchased at many stores including Walgreens and Bed Bath and Beyond.

 The effortful swallow uses an actual swallow with the added resistance by producing force with the swallow.  You have to have the patient not only “swallow hard” but an important component of the effortful swallow is to forcefully push the tongue against the palate, therefore creating pressure for the swallow.  (Bulow, M., Olsson, R. & Ekberg, O. (1999). Videomanometric analysis of suprglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia, 14, 67-72.)  (Robbins, J.A., Butler, S.G., Daniels S.K., Diez Gross, R., Langmore, S., Lazarus, C.L., et al. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence.   Journal of Speech, Language, and Hearing Research, 51, S276-300.) (Frymark T, Schooling T., Mullen R., Wheeler-Hegland K., Ashford J., McCabe D., Musson N., Hammond C.S. (2009).  Evidence-based systematic review:  Oropharyngeal dysphagia behavioral treatments.  Parts I-V.  JRRD, 46, 175-222.)

 There are also exercises that I use that are “swallowing-based” such as changing the consistency, texture, weight of the bolus, one of my favorite exercises (you’d know this if you read my previous blog posts) is having the patient suck pudding through a straw and then change to a smaller straw as the patient progress.  This not only has the person swallow but strengthens the oral phase of the swallow through sucking, which is a natural motion of swallowing (we all use a straw at some point).  Mastication exercises are good, if the patient is not appropriate for an actual bolus, I use a mesh baby feeder or cheese cloth.  Any exercise you can have the patient complete that adds resistance or complication to their natural swallow is what we need.  Remember, evidence-based can also be what YOU trial, track and possibly research.  

 Now, there are times that I do use NSOME’s, I know, right, gasp.  I find that STRETCHING the articulators/swallowing mechanism is quite good for patients that have been through radiation therapy, for example.  If they are unable to move the articulators to the maximum benefit, yes, I will combine oral stretches/massage/myofascial release to the mix (above exercises) for maximum benefit.

 

 Will tongue exercises, jaw exercises, etc work outside of the context of swallowing/speech, I really don’t think they will.  You have to train the muscles to do what they’re supposed to do for function.  To do that, you HAVE to combine exercise/therapy with the intended movement.  You cannot rehabilitate speech without using speech and you cannot rehabilitate swallowing without having your patient swallow, even if it is only their own secretions.  Make certain that what you are doing is working for your patient, if the tongue exercises don’t seem to be changing anything, by the data you track, change what you are doing!  We are therapists adn are trained to use a variety of techniques.  If you are uncertain about where to go next, ask.  Don’t be afraid to ask questions.  

 When having your patients exercise, whether it be the speech or swallowing system, look to your physical therapist for ideas.  They exercise their patients, however they relate the exercise to the actual act (i.e. walking) and combine the exercises with the act of walking.  They don’t have their patients do leg exercises and send them home expecting them to walk with more efficiency.  They also exercise their patients with walking and make it more difficult (without the walker).  

 Remember when using Swallowing Oral Motor Exercises, use plenty of repetition, add resistance and make it worth your and your patient’s time!