Swallowing Therapies: The Evidence, How To

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Swallowing Therapies The Evidence, How To Why
NotTheme and Variations Clinical Observations

• Adeline R. Schultz, M.Ed, CCC-SLP/L, BRS-S
• Department of Rehabilitation Medicine
• Thomas Jefferson University Hospital
• Philadelphia, Pennsylvania
• ASHA 2006

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Chin Tuck

• What kind of chin tuck do you instruct patients
  to use?
• Total flexion of the cervical spine with chin
  down to chest Look at your belly button.
• Chin pulled back toward spine like a military
  stance cervical spine is straight
• Head flexed but in fairly neutral position
  Look down at you knees.

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Head in Extension

• Patients with spinal cord injury with head
  immobilized in a halo
• Patients post spinal surgery for anterior
  cervical fusion in hard collar
• Patients after head and neck surgery with poor
  oral stage function. Head extended to let
  gravity move bolus back in oral cavity

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Breath Hold Controlled Swallow

• Variation of the Supra-Glottic Swallow
• Combination of the breath hold, preparatory set
  and effortful swallow
• Directions
• Hold liquid or chewed food in mouth, but dont
  swallow.
• Breathe in through nose, hold your breath.
• Swallow one or two times.
• Breathe out.

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• Helps patient to feel as though s/he has some
  control over swallow initiation
• Patient can breathe back out through nose if
  unable to initiate the swallow, and try again,
  while still containing the bolus in the mouth
• Helps with oral retention
• Helps to organize the swallow

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• Provides for a stronger pharyngeal contraction
• Gives patients a sense of control to cough out if
  worried about choking
• Patients must be able to follow 3-4 directions
  in a sequence
• Start with swallow of own saliva, and work up to
  foods that are feared or difficult

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Patients who have a fear of swallowing

• Patients who have previously choked
• Patients who have pain upon swallowing
• Patients who have difficulty initiating and/or
  coordinating the swallow
• Patients who cannot take pills or capsules

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Patients who have pain upon swallowing

• Post or during Radiation Therapy
• Post head and neck surgery
• Post surgery for Anterior Cervical Fusion
• Post extubation

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Other Patient Populations

• Paralysis of one or both vocal folds
• Paradoxical Vocal Fold Dysfunction or Spasms
• Esophageal dysmotility and reflux
• Neurological conditions causing inco-ordination
  of the swallow

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Variation of Masako

• Pharyngeal Wall strengthening
• Without food or liquid
• Stick your tongue out as far as it will go, bite
  on tongue to stabilize, now try to swallow.
• Variation to make it harder Stick your tongue
  out as far as it will go, and swallow with your
  mouth open.

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Lee Silverman Voice Therapy

• Extensively researched for Parkinsons patients
• Current research with other types of dysarthric
  patients for improved volume, improved vocal fold
  function and improved articulation
• Improved strength and coordination of swallowing

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Organic Bases for Functional Swallowing Problems

• Pulmonary
• Reflux and GI related
• Post-Traumatic Event or Surgery
• Post-intubation
• Aneurexia/bulemia
• Irritable Larynx/Neurogenic cough

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Holistic Approach

• Relaxation Techniques, Stress Management and
  Guided Imagery
• Self-Hypnosis with rehearsal for swallowing
  different foods/textures and medications
• Referral for counseling or psychotherapy
• Life style, behavioral and dietary modifications
  for GERD and LPR

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• Physician prescribed medications such as Proton
  Pump Inhibitors (PPIs), anti-spasm medications,
  and BoTox
• Medical Interventions such as Esophageal
  Dilitation
• Hierarchical introduction of foods, from the
  easiest to the most feared
• Feared foods eaten in treatment session

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Food Journals

• What was tried
• Amounts
• Time it took to eat
• Any difficulty with the swallow
• This log can also be shared with the nutritionist
• Helps the patient to see progress

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Bibliography Stress Management, Meditation and
Self-Hypnosis

• Kabat-Zinn, J, (2005 Re-issue), Full Catastrophe
  Living Using the Wisdom of your Body and Mind to
  Face Stress, Pain, and Illness, Bantam Dell, A
  Division of Random House, Inc., New York, New
  York
• Kabat-Zinn, J (2005), Coming to Our Senses
  Healing Ourselves and the World Through
  Mindfulness, Hyperion, New York, New York

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• Alman, BM, (1992), Self-Hypnosis the Complete
  Manual for Health and Self-Change, 2nd Edition,
  Routledge, New York, New York
• Hunter, ME (1994), Creative Scripts for
  Hypnotherapy, Bruner-Mazel, Inc., United Kingdom
• Weil, A, Gurgevich, S, Heal Yourself with Medical
  Hypnosis, (2005), Self-Healing, Mt. Morris,
  Illinois

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Bibliography Nutrition Websites and Texts

• www.dysphagiabooks.com Site for ordering
  dysphagia books for texture modifications
• www.dysphagia-diet.com Site with links to
  companies who carry dysphagia products
• www.eatright.org American Dietetic
  Associations web site. Includes the National
  Dysphagia Diet.
• www.hciglobal.org Healthcare Caterers
  International. Educational resources on
  dysphagia.
• www.novartisnutrition.com Novartis Medical
  Nutrition
• www.oley.org The Oley Foundation. Information
  and support for patients on IV and tube feedings.
• Worthington,P, Practical Aspects of Nutritional
  Support, (2004), Elsevier, Philadelphia.

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Bibliography Dysphagia Treatment

• Huckabee,ML, Pelletier, CA (1999), Management of
  Adult Neurogenic Dysphagia, Singular, San Diego,
  29-50
• Logemann, JA, (1998) Evaluation and Treatment of
  Swallowing Disorders, Pro-Ed, Austin, 205-240
• Murry, T, Carrau, RL, (2006), Clinical Management
  of Swallowing Disorders, Plural Publishing, San
  Diego, 139-167