Intervention and Management Strategies for Dysphagia

1
Intervention and Management Strategies for
Dysphagia

• Linda Barboa PhD, CCC Lisa Bell, MS, CCC
• ASHA 2008

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• Before beginning any program, it is understood
  that a complete evaluation would be performed.
  The indications from your evaluation may vary.
  Please consult the patients physician before
  beginning any program and on an on-going basis.
• The following compilation is just general
  information, not specific to any patient.

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AMYOTROPHIC LATERAL SCLEROSIS (ALS)

• Dysphagic Characteristics
• Oral control of the bolus
• Reduced transport
• Residue
• Airway protection
• Difficulty chewing Crary Groher, 2003
• Exaggerated gag
• Food rejections
• Time intensive
• Salivary Issues

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• Interventions
• Use chin-tuck position
• Maintain liquid intake
• Try drinking through a straw
• Use double swallow
• Maintain liquid intake
• Eat calorie dense foods
• Increase taste, temperature (colder), and texture
  sensation of liquid

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Cerebral Palsy

• Characteristics
• Tongue thrust, or poor lingual function
• Prolong and exaggerated bite gag reflex
• Tactile hypersensitivity in the oral area
• Drooling
• Poor bolus formation transit time
• Trunk, shoulder, and head control problems.
• Delayed swallow
• Reduced pharyngeal motility
• Residue
• Aspiration
• Pain discomfort when swallowing
• Food refusal and behavioral problems during
  feeding

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Cerebral Palsy

• Interventions
• Thicker texture foods may be indicated
• Vary texture and temperature
• Improve jaw, lip, and cheek control
• Secret signals for wiping mouth and wrist bands
  to keep the face dry.
• Stretching, brushing, vibrating, icing, and
  stroking areas of the face
• Thicker textures soft solid foods
• Reduce rate of feeding

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Cleft Lip and Palate

• Cleft Palate Pre-Surgery
• Feeding problems
• Poor intake, lengthy feeding times
• Nasal regurgitation
• Choking
• Gagging
• Excessive air intake (
• Discomfort with feeding
• Stressful feeding interactions between infant and
  caretaker
• (Carlisle, 1998)

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Dysphagia and Cleft PalatePost-Surgery

• Restricted diet to promote healing
• Some discourage bottle recommend spoon or cup
  Some recommend not to use spoon or cup with spout
• Monitor nutrition hydration for optimal healing
• Positioning semi-upright position (head higher
  than stomach-at least 60 degrees) Positioning of
  the nipple under a shelf of bone of the hard
  palate to provide stable base for compression
• Pace intake/ use consistent methods
• Burping Expel excessive air intake during
  feeding
• Nasal regurgitation Allow infant time clear the
  nasal passage. May use slower flow nipple
  (Kummer, 2008)

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Dysphagia and Cleft Palate

• Modified Nipples-
• Breast Feeding
• Cleft Lip only or cleft palate only
• Cleft Lip/Palate
• Usually not an option (No effective means for
  positioning or compressing the nipple) (Kummer,
  2008)
• Tube Feeding
• Orogastric tube or NG tube
• Gastrostomy Tube (G-tube) may be indicated if
  infant has abnormal oral reflexes or poor ability
  to protect airway (Kummer, 2008)

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Other Craniofacial Anomalies

• Pierre Robin
• Problems
• Suck-swallow-breathe pattern
• Posterior position of tongue/respiratory
  difficulties
• Techniques
• Tube feeding if necessary
• Positioning to facilitate tongue movement
• Sidelying position with special bottle
• (Kummer, 2008)

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Moebius Syndrome Characteristics Inability to
suck Weakness in the lips (cant achieve
adequate seal, causes excessive
drooling) Techniques Feeder assisted
squeezing Special bottle
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Hemifacial Microsomia Characteristics Limitati
on in range of motion in jaw, lips, or tongue
unilaterally Techniques Utilization of
stronger side of mouth Provide stabilization to
weaker side Special bottle/nipple
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Feeding Problems and Techniques for Other
Craniofacial Anomalies

• Treacher Collins Syndrome
• Problems
• Inefficient sucking
• Techniques
• Special bottle (Kummer, 2008)
• )

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Velocardiofacial Syndrome Problems Dysmotility in
the pharyngoesophageal area Fatigue because of
cardiac involvement Techniques Tube feeding as
necessary Sensorimotor stimulation Special
bottles/nipples
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Dementia

• Characteristics
• Loss of appetite
• Loss of understanding how to eat food.
• Inability to recognize food
• Indifferent to food
• Easily distracted
• Anxiety
• Agitation

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Dementiatechniques.

• Create a quieter environment by having two dining
  rooms
• Create positive dining routines
• Provide consistent cues, prompts and redirections
• Appropriate support and set-up
• Recommended diet texture
• Specific cues and prompts to assist with
  self-feeding
• Safe swallowing strategies
• Cleary, S., (2007).

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Down Symdrome

• Down Syndrome is the most common genetic disorder
  caused by genetic variations.
• Dysphagic Characteristics.
• Dysphagic signs and symptoms (Mayo Foundation for
  Medical Education and Research)
• at risk for feeding and swallowing disorders
  (dysphagia)
• at risk for nutritional compromise
• large tongue (macroglossia)
• underlying hypotonia (low muscle tone)
• small oral mechanism
• weak sucking or rooting reflexes
• respiratory problems, cardiac, gastro problems
• (Kerwin, 1999, 2003)

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Down Syndrome- interventions
Simultaneous presentation of liked disliked
foods. Gradually changing the type of food and/or
utensil. Progressive muscle relaxation Systematic
desensitization Contingency management
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Right CVA

• Dysphagia is typically more severe in patients
  with right CVA than left CVA.
• Characteristics
• Difficulty with spatial perception
• left neglect.
• Impulsive eating
• Drooling from lip weakness
• Reduced range of motion the tongue
• Delayed A/P oral bolus transit
• Delayed pharyngeal bolus motility
• Delayed laryngeal elevation

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Right CVA Treatment Techniques

• Resistive exercises to strengthen and increase
  range (tongue depressors)
• Range of motion exercises.
• Optimize textures that form a cohesive bolus- (no
  pudding..slides right down)
• Stimulate with cold food/stimuli.
• Other patients may receive recommendation to
  feed with large amt on spoon, but not safe with
  pts. with right CVA b/c of impulsivity.

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Techniques
Counsel caregiver to feed to unimpaired
side. Increase awareness to impaired side with
cold stimuli (food and lemon swabs). Counsel
patient to be aware of impulsivity. Promote
consuming smaller bolus. Provide finger
foods Encourage pt. to cut food into smaller
pieces Use labial resistive exercises to increase
strength. Intraoral placement to unimpaired side.
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Right CVA Pharyngeal phase.

• Effortful swallow over exaggerates swallow,
  engaging the muscles by using greater force
• Tongue base retraction exercise promote tongue
  base mvmt which assists in quickly moving bolus
  to esophagus.
• Masako tongue hold tongue is held while
  swallowing w/o bolus engages posterior
  pharyngeal wall and muscles for laryngeal
  elevation.
• Laryngeal exercises that assist with vocal fold
  adduction such as push/pull on chair, take a
  breath/hold/cough.
• Compensatory strategies chin tuck which protects
  the airway with the epiglottis.

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Laryngectomy- characteristics

• Aspiration
• Muscle spasms
• Stenosis- or poor bolus clearance
• Diminished sense of smell/ appetite

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Laryngectomy- treatments

• Chin-tuck maneuver
• Supraglottic and Super Supra Glottic Swallow
• Breath-hold followed by coughing in order to
  clear residue
• Mendelsohn Maneuver
• Prolonging the swallow
• Food Modification
• Effortful Swallow

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Myasthenia Gravis

• Dysphagia Characteristics
• Difficulty chewing or swallowing
• Lip incompetence
• Tongue and masticatory weakness
• Weakness of oropharyngeal muscles
• Possible silent aspiration
• Fatigue
• Decreased laryngeal elevation
• Decreased tongue base and elevation
• Decreased epiglottic movement

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Myasthenia Gravis- techniques

• Mendelsohn maneuver (lifting of larynx)
• laryngeal adduction procedures
• Supraglottic swallow
• Breath hold
• push-pull with phonation (ahhh)
• feeding strategies (alter bolus volume and
  consistency) freq. small meals
• Compensatory strategies (tongue sweep for
  pocketing)
• Try lip closure or tongue movement techniques
• positioning

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Left Hemisphere

• Dysphagia Characteristics
• Difficulty coordinating swallowing muscles due to
  oral apraxia
• Sensory issues difficulty feeling where food is
  during any stage of the swallowing process can
  cause spillage or aspiration
• Paralysis of swallowing muscles on right side of
  neck
• Neglecting food on right side of plate or tray
  due to right-sided spatial neglect
• Weak swallowing muscle
• Coughing or choking
• Wet or gurgly sounding voice
• Extra effort or time needed to chew or swallow
• Food or liquid leaking from or getting stuck in
  the mouth
• Weight loss
• Lees et al., 2006

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Left Hemisphere

• Additional Problems Related To Swallowing
• Inability to communicate swallowing difficulties
  to medical staff due to expressive language
  impairments
• Inability to understand swallowing treatment
  instructions due to receptive language
  impairments

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Left Hemisphere

• Treatment
• Strengthening, coordinating exercises
  strategies
• Dietary changes
• Electrical Stimulation/Neuromuscular stimulation
  (controversial)
• Marchese-Ragona, Giacometti, Costantini,
  Zaninotto, 2006

30
Multiple Sclerosis

• Dysphagic Characteristics
• Reduced tongue control,
• Impaired tongue base retraction
• Delayed or absence of pharyngeal swallow/pool
• Reduced pharyngeal contraction
• Upper esophageal sphincter dysfunction
• Reduced laryngeal closure, c/o choking
• Reduced pharyngeal and/or laryngeal sensation
• Hypo salivation-- drooling

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Multiple Sclerosis Treatment Approaches

• Rehabilitative treatment
• Compensatory techniques (Chin tuck, effortful
  swallow)
• Indirect therapy (exercises to strengthen
  swallowing muscles)
• Direct therapy (exercises to perform while
  swallowing)
• Reduce textures.
• Avoid washing down food
• Position- sit upright
• Small bites
• Reduce distractions- dont talk while eating
• Restive, Marchese-Ragona, Patti (2006)

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Rett Syndromecharacteristics

• Weight loss/poor weight gain
• Oral motor dysfunction
• Regression in swallowing skills with age
• Chewing difficulty may increase with age
• Significant pharyngeal involvement
• Aspiration of liquids, secondary to reduced
  laryngeal closure during the swallow
• Aspiration risk and incidence of pneumonia can be
  high
• Air swallowing

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Fetal Alcohol Syndromedysphagic characteristics

• Poor sucking and swallowing
• Sensory deficits
• Range of motion in jaw frequently reduced
• Functional short gut with feeding problems
• CNS problems seizures, palate (high, cleft,
  submucous cleft)
• Motor coordination
• V.H. Wacha J.E. Obrzut April 19, 2007 review
  of literature on FAS http//www.emedicine.com/ped/
  topic142.htm

• General Treatment
• Consultation with nurse/family
• Adaptive equipment
• Nipples most consistent with sucking pattern
• Thickened liquids/formula
• Multiple feedings
• A minimum of 10-12 times/day
• Non-nutritive sucking

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General Treatment Consultation with nurse/family
Adaptive equipment Nipples most consistent with
sucking pattern Thickened liquids/formula Multiple
feedings A minimum of 10-12 times/day
Non-nutritive sucking
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FAS-treatments

• Consultation with nurse/family
• Adaptive equipment
• Nipples most consistent with sucking pattern
• Thickened liquids/formula
• Multiple feedings
• A minimum of 10-12 times/day
• Non-nutritive sucking

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Apraxia-CHaracteristics

• Dysphagia in developmental apraxia of speech
• Weight loss
• Excessive drooling
• Weak suck
• Difficulty initiating the swallow
• Difficulty coordinating and timing muscle
  movements involving swallowing

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HIV or AIDS

• HIV (human immunodeficiency virus)
• AIDS (acquired immunodeficiency syndrome)
• chronic, life-threatening condition caused by
  HIV.
• the later stages of an HIV infection
• U.S. Department of Health Human Services (2007)

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HIV/AIDS-dysphagic characteristics
quick weight loss nausea vomiting Decreased
laryngeal elevation Decreased tongue base and
retraction sore throat (dry cough)/ painful
swallow Decreased pharyngeal wall
contraction. Painful swallow c/o lump in throat

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HIV/AIDS treatment

• Determine whether the patient is able to swallow
  pills before giving oral medications. If pills
  are not tolerated, the patient may need liquids
  or troches.
• Diet modifications
• Compensatory strategies
• Exer. Prog pharyngeal, laryngeal, tongue base/
• Med management.
• Important patients maintain adequate caloric
  intake, preferably with foods and liquids that
  can be swallowed easily. Nutritional supplements
  along with soft, bland, high-protein foods are
  recommended. Refer to nutritionist as needed.
• United States Department of Veterans Affairs
  (2007)
• Great Resource for coping with discomforts
  http//www.metroplexhealth.com/hiv.htm

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Head Injurydysphagic characteristics

• Abnormal oral reflexes
• Laborious tongue movements
• Poor lip closure
• Poor mouth opening delayed initiation
• Slow motor movements
• Reduced range of pharyngeal, and laryngeal
• Abnormal chewing

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Parkinsonscharacteristics

• Reduced tongue base movement
• Reduced lip closure
• Tongue pumping
• Delayed initiation of swallow
• Silent aspiration
• Lack of volitional cough
• Anterior chew
• Drooling
• Tremors in oral musculature

42
Parkinson treatments

• AROM at strength peaks
• Thickened liquids
• Chewing exercises

43
References

• Coping with discomforts. (2003). Metroplex
  Health and Nutrition Services, Inc. Retrieved
  October 22, 2007 from http//www.metroplexhealth.
  com/hiv.htm
• Bladon, K. Ross, E. (2007). Swallowing
  difficulties reported by adults infected with
  HIV/AIDS attending a hospital outpatient clinic
  in Gauten, South Africa. Folia Phoniatrica et
  Logopaedica. 59, 39-52.
• National HIV/AIDS program. (2007). United
  States Department of Veterans Affairs. Retrieved
  October 22, 2007 from http//www.hiv.va.gov/vahiv
  ?pagecm-404_esophpfvahiv-aetc-pfpppf
• Basic HIV/AIDS information. (2007). U.S.
  Department of Health Human Services. Retrieved
  October 22, 2007 from http//www.aids.gov/
• Shaw, MD, G. Sechtem, MS, P. Searl, Ph.D., J.
  Keller, MS, K. Rawi, MS, R. and Dowdy, E.
  (2007). Transcutaneous neuromuscular
  electrical stimulation (VitalStime) curative
  therapy for severe dysphagia Myth or reality?
  Annals of Otology, Rhinology Laryngology, 116,
  1. 36-44.
• Women and HIV/AIDS. (2006). U.S. Department of
  Health Human Services. Retrieved October 22,
  2007 from http//www.4women.gov/hiv/what/

44
References

• Coping with discomforts. (2003). Metroplex
  Health and Nutrition Services, Inc. Retrieved
  October 22, 2007 from http//www.metroplexhealth.
  com/hiv.htm
• Bladon, K. Ross, E. (2007). Swallowing
  difficulties reported by adults infected with
  HIV/AIDS attending a hospital outpatient clinic
  in Gauten, South Africa. Folia Phoniatrica et
  Logopaedica. 59, 39-52.
• National HIV/AIDS program. (2007). United
  States Department of Veterans Affairs. Retrieved
  October 22, 2007 from http//www.hiv.va.gov/vahiv
  ?pagecm-404_esophpfvahiv-aetc-pfpppf
• Basic HIV/AIDS information. (2007). U.S.
  Department of Health Human Services. Retrieved
  October 22, 2007 from http//www.aids.gov/
• Shaw, MD, G. Sechtem, MS, P. Searl, Ph.D., J.
  Keller, MS, K. Rawi, MS, R. and Dowdy, E.
  (2007). Transcutaneous neuromuscular
  electrical stimulation (VitalStime) curative
  therapy for severe dysphagia Myth or reality?
  Annals of Otology, Rhinology Laryngology, 116,
  1. 36-44.
• Women and HIV/AIDS. (2006). U.S. Department of
  Health Human Services. Retrieved October 22,
  2007 from http//www.4women.gov/hiv/what/

45
References

• Coping with discomforts. (2003). Metroplex
  Health and Nutrition Services, Inc. Retrieved
  October 22, 2007 from http//www.metroplexhealth.
  com/hiv.htm
• Bladon, K. Ross, E. (2007). Swallowing
  difficulties reported by adults infected with
  HIV/AIDS attending a hospital outpatient clinic
  in Gauten, South Africa. Folia Phoniatrica et
  Logopaedica. 59, 39-52.
• National HIV/AIDS program. (2007). United
  States Department of Veterans Affairs. Retrieved
  October 22, 2007 from http//www.hiv.va.gov/vahiv
  ?pagecm-404_esophpfvahiv-aetc-pfpppf
• Basic HIV/AIDS information. (2007). U.S.
  Department of Health Human Services. Retrieved
  October 22, 2007 from http//www.aids.gov/
• Shaw, MD, G. Sechtem, MS, P. Searl, Ph.D., J.
  Keller, MS, K. Rawi, MS, R. and Dowdy, E.
  (2007). Transcutaneous neuromuscular
  electrical stimulation (VitalStime) curative
  therapy for severe dysphagia Myth or reality?
  Annals of Otology, Rhinology Laryngology, 116,
  1. 36-44.
• Women and HIV/AIDS. (2006). U.S. Department of
  Health Human Services. Retrieved October 22,
  2007 from http//www.4women.gov/hiv/what/

46
References

• Arvedson, J.C. Brodsky, L. (2002). Pediatric
  Swallowing and Feeding. Albany, NY Singular
  Publishing Group.
• Calcano, P., Ruoppolo G., Grasso, MG., De
  Vincentiis, M. Paolucci, S. (2002) Dysphagia in
  multiple sclerosis prevalence and prognostic
  factors. Acta Neurol Scand, 105, 40-43.
• Carlisle, D. (1998). Feeding babies with cleft
  lip and palate. Nursing Times, 94(4), 59-60.
• Clarren, S. K., Anderson, B., Wolf, L. S. (1987).
  Feeding infants with cleft lip, cleft palate, or
  cleft lip and palate. Cleft Palate Journal, 24
  (3), 244-249.
• Cleary, S. (2007). Current approaches to managing
  feeding and swallowing disorders for residents
  with dementia. Canadian Nursing Home.18. 11-16.
• Crary, M.A. Groher, M.E. (2003). Introduction
  to adult swallowing disorders. Philadelphia, PA
  Elsevier Science.
• DiBartolo, M., C. (2006). Careful hand feeding A
  reasonable alternative to PEG tube placement in
  individuals with dementia. Journal of
  Gerontological Nursing. 25-35.
• Humbert, I. Ludlow, C. (2004, March 16).
  Electrical Stimulation Aids Dysphagia. The ASHA
  Leader, pp. 1, 23.
• Kummer, A. (2008). Cleft Palate and Craniofacial
  Anomalies Effects on Speech and Resonance.
  Clifton Park, NY Thomson Delmar Learning.
• Lees et al. (2006). Nurse-Led Dysphagia Screening
  in Acute Stroke Patients. Nursing Standard, 21
  (6), 35-42.
• Masiero, S., Briani, C., Marchese-Ragona, R.,
  Giacometti, P., Costantini, M., Zaninotto, G.
  (2006). Successful Treatment of Long-Standing
  Post-Stroke Dysphagia With Botulinum Toxin and
  Rehabilitation. Journal of Rehabilitation
  Medicine, 38, 201-203.
• National Institute of Neurological Disorders and
  Stroke Amyotrophic Lateral Sclerosis Fact Sheet
  http//www.ninds.nih.gov/disorders/amyotrophiclate
  ralsclerosis/detail_amyotrophiclateralsclerosis.ht
  m
• Prosser-Loose, E. Patterson, P. (2006). The
  FOOD Trial Collaboration Nutritional
  Supplementation Strategies and Acute Stroke
  Outcome. Nutrition Reviews, 64 (6), 289-294.
• Restivo, D.A., Marchese-Ragona,R., Patti, F.,
  (2006). Management of swallowing disorders in
  multiple sclerosis. Neurol Sci, 27, S338-S340.
• Steele, C. (2004). Treating Dysphagia with sEMG
  Biofeedback. The ASHA Leader, pp. 2, 23.