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.
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-test for dysphagia. The self-test I use is found at http://americandysphagianetwork.org.
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.
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 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. Swallowing is a muscle based system, powered by 6 cranial nerves. We have to take an exercise physiology approach to rehabilitate dysphagia. 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.
I use VitalStim or neuromuscular electrical stimulation during swallowing therapy. I place the electrodes so that they stimulate the impaired muscles during swallowing therapy. If the person has decreased laryngeal elevation or the airway doesn’t close during the swallow, then I target the muscles that elevate the larynx. The tongue is attached, via muscles, to the hyoid bone, which is part of laryngeal elevation. So take the patient with decreased laryngeal elevation. This person has aspiration with thin liquids but is safe with nectar thick liquids. When using the Mendelsohn maneuver, the patient was able to safely swallow 5 ml of thin liquids.
My therapy session would look like this:
At home, the person is drinking nectar thick liquids. In therapy, I’m going to place the VitalStim electrodes on the laryngeal excursion muscles. I like circuit therapy, I say it’s like Curves but for swallowing. The patient will complete all exercises/swallows while the VitalStim is on. We do lingual strengthening exercises using a tongue depressor (the patient pushes their tongue out, up and side to side against the tongue depressor), practice the Mendelsohn maneuver using dry swallows, when they are able to complete the Mendelsohn I would have them start using the Mendelsohn with 1ml water, working up to 5ml of water. Therapy should always have many opportunities for swallowing (you can only exercise the swallowing system by swallowing).
Vitalstim electrodes are attached to patient and VitalStim is turned on to a therapeutic level.
5 minutes of dry swallows using the Mendelsohn
4 minutes push your tongue out against the tongue depressor
5 minutes suck pudding through a straw (my FAVORITE exercise)
4 minutes push your tongue up against the tongue depressor
5 minutes pull your tongue back as far as it will go in your mouth, hold 5 seconds
4 minutes push your tongue to the right against the tongue depressor
5 minutes dry swallow using an effortful swallow
4 minutes push your tongue to the left against the tongue depressor
5 minutes pudding through the straw
5 minutes pretend to yawn and hold tongue back for a count to 5
5 minutes swallow pudding using an effortful swallow
Now, keep in mind, the tongue is the quarterback of the swallow. It is attached to the hyoid via muscles. The person needs their larynx to elevate so I’m going to work on strengthening the tongue, to strengthen the hyolaryngeal excursion. The Mendelsohn provides hyolaryngeal excursion through resistance of gravity. The effortful swallow has been found to strengthen the overall swallow. Tongue base retraction is part of the tongue which is going to aid in the hyolaryngeal excursion. I like the pudding through the straw (I start with a regular straw and work to a coffee stirrer, my way of adding “weight” to the exercise) because it strengthens labial seal, the buccal (cheek) muscles, works on tongue base retraction, the person has a bolus to manipulate and then they have to swallow. The pudding through a straw offers resistance to the oral phase of the swallow, by adding an effortful swallow, you add resistance to the pharyngeal phase as well.
Keeping in mind the basic anatomy and physiology of the swallow, it just makes sense that exercise should offer resistance, making the task more difficult or require more effort. Just as if you are trying to build up your arms to look good in your tank tops, you don’t start at 5 pounds and stay there. You eventually add weight and keep working up. Swallowing therapy should offer resistance, strengthening and endurance because you are working to improve the timing, speed and strength of the swallowing mechanism.
