Ch. 6
*What type of nutritional management isnecessary?
*Should therapy be initiated and what type?
*What specific therapy strategies should beutilized?
*The continuous goal of any treatment programis the reestablishment of oral feeding whileconstantly maintaining adequate hydration andnutrition and safe swallowing.
*What is the Diagnosis?
*What is the prognosis?
*What is the patient’s reaction to Compensatorystrategies?
*What is the severity of the patient’s dysphagia?
*Can they follow directions?
*What is their respiratory function?
*Do they have supportive caregivers and family?
*What is the patient’s motivation and interest?
*Factors to consider
*Time taken to swallow a single bolus of aparticular consistency of food
*Aspiration- more than 10% of every bolus,regardless of consistency of food- should not beeating orally
*Control the flow of food
*Eliminate the patient’s symptoms
*Do not necessarily change the physiology of thepatient’s swallow.
*Can be used with patient’s of all ages and cognitivelevels
*Postural changes
*Increasing sensory input
*Modifying volume and speed of food presentation
*Changing food consistency
*Chin-Down
*Pushes anterior wall posteriorly
*Tongue base and epiglottis are pushed closer topharyngeal wall
*Airway entrance is narrowed
*Vallecular space is also widenced
*Helps with delay in triggering the pharyngealswallow
*Helps with reduced tongue base retraction
*Helps with reduced airway closure
*Chin-Up
*Uses gravity to drain food from oral cavity
*Helpful with reduced tongue control
*Head Rotation
*Rotate to damaged side
*Allows food to flow down normal side
*Helpful when there is unilateral pharyngeal wallimpairment
*Helpful with unilateral vocal fold weakness or paralysis
*Chin Down with Head Rotation
*Head Tilt
*Chin Down with Head Rotation
*Helpful for airway protection
*Head Tilt
*Helpful when a patient has both a unilateral oralimpairment and a unilateral pharyngealimpairment on the same side
*Tilt to the better/stronger side
*Utilized for the following
*Swallow apraxia
*Tactile agnosia for food
*Delayed onset of the oral swallow
*Reduced oral sensation
*Delayed triggering of the pharyngeal swallow
*Increase downward pressure of spoon againstthe tongue when presenting the food to thepatient
*Presenting a sour bolus
*Presenting a cold bolus
*Presenting a bolus requiring chewing
*Presenting a larger volume bolus
*Thermal-tactile stimulation
*Help to improve the trigger of the pharyngealswallow
*Rubbing anterior faucial arch firmly
*4-5 times on each side
*Use a laryngeal mirror that has been held incrushed ice for several minutes
*Alerts sensory stimulus to cortex and brainstem
*Determining the volume of food per swallowthat will elicit the fastest pharyngeal swalllow
*A larger bolus may facilitate triggering of theswallow
*Taking too much food too rapidly can result in asevere residue in pharynx and possible aspiration
*Thin liquids
*Oral tongue dysfunction
*Reduced tongue base retraction
*Reduced pharyngeal wall contraction
*Reduced laryngeal elevation
*Reduced Upper Esophageal Sphincter opening
*Thickened liquids
*Oral tongue dysfunction
*Delayed pharyngeal swallow
*Puree and thick foods
*Delayed pharyngeal swallow
*Reduced laryngeal closure
*Direct Therapy- work directly on the swallow-introduce food into the mouth and attempt toreinforce behaviors and motor control duringthe swallow
*Indirect Therapy-exercise programs or swallowsof saliva, but no food or liquid is given
*Supraglottic swallow
*Super-supraglottic swallow
*Effortful swallow
*Mendelsohn Maneuver
*See Handout
*See Handout
*Sustain Phonation
*Cough/Glottal Attack
*Pitch scales
*Push/Pull with voicing
*Inpatienets- Acute Care
*Bedside Swallow Evaluation and/or VideoswallowStudy
*Awake and alert
*Seen daily for therapy
*Outpatients
*Videoswallow study results preferred prior to firstvisit
*Clinical Swallow Evaluation in the office
*Twice weekly