One of the most difficult parts of the job for a medical speech-language pathologist can be efficiently choosing the most effective dysphagia treatment plan. As healthcare reimbursements get tighter, the days of trialing techniques for weeks, changing techniques, and trialing again are over – we need to choose the best options for our patients right from the start.
As it turns out, there is no “usual care” in dysphagia therapy. 1 There are many different dysphagia treatments being used, often several in a single session. When we look to the scientific literature, there’s no clear evidence pointing us to one technique over another, and often the findings are conflicting.
So how can we develop an appropriate treatment plan for each patient?
1) Know Your Anatomy
The first step is to know and understand the anatomy and physiology of the normal swallow. How can we know what is abnormal if we don’t know what is normal? Take the time to educate yourself on what a healthy swallow of a young person looks like and how it changes as people age normally. Then you can start to understand how neurological damage can impact what you’d expect to see.
Dysphagia Therapy gives you an overview of the anatomy and physiology involved in each component of the swallow, along with assessment techniques.
Did you know that “piecemeal deglutition,” or using multiple swallows to clear one mouthful of food, is perfectly normal? It’s not normal when the bolus is very small, or when it’s caused by fear or anxiety, and it happens more frequently with certain disorders to compensate for structural or physiological abnormalities. But the simple presence of piecemeal deglutition is not abnormal. If you observe it in your patients, you need to know if it’s a normal occurrence or a sign of a problem.
2) Understand the Treatment
We also need to know the anatomy and physiology so that we can understand how changing it, whether through exercises or strategies, can impede or remediate the swallow. To do this, we also need to understand what our dysphagia treatments are actually doing.
Clinicians used to believe the Masako maneuver increased movement of the tongue base back toward the posterior pharyngeal wall. It was later determined that this exercise of swallowing with the tongue between the teeth actually increases the movement of the posterior pharyngeal wall forward, at the level of the tongue base.2
Dysphagia Therapy gives you the details on each swallowing treatment so you’ll know what it’s treating, how to do it, and references to explore the evidence.
There is emerging evidence to support the use of strategies to actually rehabilitate the swallow rather than just compensate for impairments. In much the same manner that occupational therapists will place cups and plates on the affected side of stroke patients to encourage use of that arm, dysphagia clinicians may be able to use strategies such as a head turn to the good side of the pharynx to encourage the patient to recruit the muscles of the impaired side of the pharynx in the swallow.3
3) Keep Up with the Research
We must remain current in research findings if we want to provide our patients with the best treatments based on scientific evidence. Journal articles are widely available online, and key findings are often shared on social media and in blog posts. Your local university or hospital library may be able to give you access to online catalogs.
Every treatment in the Dysphagia Therapy app includes references to published articles or lets you know if there is no evidence.
It’s no easy task to keep up, as new research is published all the time with evidence to support or contradict evidence already available. Studies vary in quality with many variables, so we must look at them closely. For example, the initial study on Chin Tuck Against Resistance (CTAR) looked only at healthy subjects. While the results are promising, it’s important to know the effects were not measured on subjects with impaired swallowing function.
4) Check if Treatment Options are Valid
If you’re doing an instrumental assessment to better understand the problem, it’s also a great time to try to figure out the solution. Take the opportunity to view possible dysphagia treatments, selected on the basis of your findings, during a video fluoroscopic (VFSS) or fiberoptic endoscopic (FEES) study. Does turning or tilting the head to the strong or weak side help? Does a chin tuck prevent or increase aspiration? It is only when we can see the compensation or the treatment strategy in effect that we know it’s working, and that the patient is accurately executing the procedure.
The Mendelsohn maneuver, an exercise to squeeze the muscles of the throat to keep the larynx elevated longer, is a difficult maneuver to execute and to teach. Many patients, and even dysphagia clinicians, may appear to be accurately producing the technique using sEMG biofeedback, but under fluoroscopy, it’s been revealed that they’re actually not doing it correctly.4
During the MBSImP™ training, Dr. Bonnie Martin Harris noted that using nectar thick liquids during a modified barium swallow study could be beneficial to increase movement of the pharyngeal structures. If we watch the effect of thickened substances during fluoroscopy, we may understand that using a thicker bolus in therapy will increase recruitment of the pharyngeal muscles.
Dr. Jeri Logemann stated decades ago that “objective studies need to quantify effects of treatment on particular types of patients and that anatomy and physiology of each patient should be documented when determining an appropriate treatment plan.”5 It’s well past time for us to think of instrumental assessments as only a nice “option” for the identification of dysphagia. They are critical for treatment selection and validation in addition to being critical for accurate diagnosis.
Using the findings of your assessment, you can input your observations and noted impairments in the Therapy Finder of Dysphagia Therapy to find options for treatment in seconds. Try them right away before the assessment is finished.
Dysphagia Treatment Made Easier
By combining our knowledge of the anatomy and physiology of the normal and disordered swallow with our understanding of the treatment options supported by research, we can select the best treatments to try with our patients. We can view these options during our assessments to know immediately if they are being done correctly and are likely to work.
It’s still not easy, but following these steps can increase your efficiency in selecting the right treatments, as well as improve the effectiveness of the intervention plan.
To make life a little easier, you can now reference critical information about swallowing anatomy and treatments in the palm of your hand with the Dysphagia Therapy app for clinicians, with the popular Therapy Finder. Now available for iOS and Android devices on the App Store and Google Play.
- 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.
- Fujiu, M., & Logemann, J. A. (1996). Effect of a tongue-holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech-Language Pathology, 5(1), 23-30.
- Humbert/Plowman Critical Thinking in Dysphagia Management course
- Azola, A. M., Greene, L. R., Taylor-Kamara, I., Macrae, P., Anderson, C., & Humbert, I. A. (2015). The Relationship Between Submental Surface Electromyography and Hyo-Laryngeal Kinematic Measures of Mendelsohn Maneuver Duration. Journal of Speech, Language, and Hearing Research, 58(6), 1627-1636.
- Logemann, J. A. (1987). Criteria for studies of treatment for oral-pharyngeal dysphagia. Dysphagia, 1(4), 193-199.
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