Dysphagia Treatment

How do I treat dysphagia?

Muscles of the Swallow

O O

To treat the dysphagia, you must understand how the SYSTEM works. We treat the swallowing system, not the specific signs and symptoms.
O

We treat the muscle dysfunction, not the aspiration or penetration.

Swallowing is a biomechanical process characterized quantitatively by displacement of oropharyngeal structures and associated timing and duration of movement during a swallow. (24) (Biomechanical events include tongue base contact with the posterior pharyngeal wall, hyoid bone movement, and UES opening)

Information for Slides 3-71 taken from DPNS Manual by Karlene Stefanakos and VitalStim manual by Yorick Wijting

Lingual Muscles
O Your tongue is comprised of both intrinsic

and extrinsic muscles.

Intrinsic Muscles
O Shapes the tongue O Reflexes
O Tongue Base Retraction-propels bolus into

pharynx O Reflexive lingual groove-maintains cohesive bolus for pharyngeal transfer.

O Innervated by CN XII
O No sensory pathways, all motor. O Sensory is CN V, VII, IX O XII meets with above nerves at nucleus solitarius

in the brainstem.

Intrinsic Muscles of the Tongue

O Transverse O Vertical O Superior longitudinal O Inferior longitudinal

Transverse
O Origin: tongue septum, median portion O Insertion: mucosa at sides of tongue O Action: elongates, narrows, thickens tongue,

lifts the sides. O Innervation CN XII

Vertical
O Origin: superior surface of tongue near tip

edges. O Insertion: inferior surface of the tongue. O Action: assists in TBR posterior depression (cohesive bolus, propels bolus.) O Innervation CN XII

Superior Longitudinal
O Origin: septum of tongue, submucosoa near

epiglottis. O Insertion: sides of tongue O Action: widens, thickens and shortens tongue, raises tongue tip and edges; forms concave dorsum.
O Establishes lingual-dental connection. O A-P pattern.

O Innervation CN XII

Inferior Longitudinal
O Origin: hyoid bone; inferior surface of base

of tongue. O Insertion: apex of tongue. O Action: wides, shortens tongue; creates convex dorsum, depresses teeth.
O A-P pattern-assists in propulsion of the bolus.

O Innervation CN XII.

Extrinsic Muscles of the Tongue

O Give movement to the tongue. O Tongue retraction-primitive, protective reflex. O Styloglossus with glossopalatine generate posterior lingual elevation. O Reflexes: O Tongue base retraction-propels bolus into pharynx. O Reflexive lingual groove-maintain cohesive bolus for pharyngeal transfer. O Reflexive protective retraction-prevents pharyngeal infiltrate, or premature lingual spillover during mastication. O Innervation: CN XII

Extrinsic Muscles of the Tongue

O Styloglossus O Genioglossus O Hyoglossus

Styloglossus
O Origin: inferior portion of the styloid process

of the temporal bone. O Insertion: lateral border of the tongue. O Action: elevates rear of tongue; retracts protruded tongue during mastication. O Innervation: CN XII.

Genioglossus
O Origin: upper mental spine on lingual

surface of the mandible. O Insertion: Lingual fascia, dorsum of tongue and body of hyoid bone. O Action: alternate fibers work to depress, retract and protrude tongue. O Innervation: CN XII.

Hyoglossus
O Origin: greater cornu of hyoid bone. O Insertion: posterior half of the side of the

tongue. O Action: depress and retracts tongue. O Innervation: CN XII.

Intrinsic Muscles of Mastication

O Reflex: jaw jerk reflex-generates rotary mastication

pattern. (Returns jaw from lateral to midline). O Mastication Patterns:

O Rotary-normal. O Vertical-no lateral jaw movement, jaw jerk reflex absent

(trigeminal affected.) O Suck-swallow-primitive, motoric innervation, oral XII, pharyngeal X

O Absent O-M pattern-bilateral destruction of CN motor lines

V, X, XII.

O Tonic bite: Contraction of temporal, masseter and

internal pterygoid bilateral deficit muscles exterior pterygoid, platysmus, digastric, mylohyoid, geniohyoid.

Intrinsic Muscles of Mastication

O Temporal O Masseter O Internal pterygoid O External pterygoid

Temporal
O Origin: temporal fossa and the whole of the

covering fascia. O Insertion: anterior borders of mandibular ramus and coronoid process. O Action: raises and retracts the mandible. O Innervation CN V (mandibular division).

Masseter
O Origin: lower edge of the zygomatic arch

(superficial) medial edge of the zygomatic arch (deep). O Insertion: lateral surface of the angle of the jaw; lateral surface of the ramus. O Action: raises the mandible against the maxilla. O Innervation: CN V (mandibular division).

Internal Pterygoid
O Origin: lateral pterygoid plate; slips from the

palatine bone; maxillary tuberosity. O Insertion: ramus and able of mandible. O Action: raises the mandible and protrudes the jaw.

External Pterygoid
O Origin: upper head arises from the

infratemporal fossa and greater wing of the sphenoid bone; lower head arises from the lateral aspect of the lateral pterygoid plate of the sphenoid bone. O Insertion: mandibular condyle and the disc of the joint of the jaw. O Action: depresses mandible and draws mandible forward and sideways. (additional mandible depressors: platysma, digastric posterior, mylohyoid, geniohyoid.) O Innervation: CN V (mandibular division)

Muscles of the Soft Palate

O Reflex: Palatal Reflex-generates

velopharyngeal closure. O Functions of velopharyngeal closure:

O Maximize nutritional intake O Provide passage of bolus O Cease nasal inhalation O Triggered by anterior faucial arches

Muscles of the Soft Palate

O Levator veli palatine O Tensor veli palatine O Uvula O Glossopalatine O Pharyngopalatine
O The velum is activated by chewing.

Levator Veli Palatine

O Origin: apex of the petrous portion of the

temporal bone; eustachian tube O Insertion: aponeurosis of soft palate O Action:

O Raises soft palate to meet posterior

pharyngeal wall O Dilates eustachian tube orfice

O Innervation: CN X (Pharyngeal plexus)

Tensor Veli Palatine

O Origin: scaphoid fossa; medial pterygoid plate

spine; posterior border of hard palate. O Insertion: palatine aponeurosis; eustachian tube. O Action:
O Tenses the soft palate O Opens the eustachian tube during swallowing

O Innervation: CN V (mandibular division)

Uvula
O Origin: posterior nasal spine; palatal

aponeurosis (anterior) O Insertion: mucous membrane of uvula O Action: raises and shortens the uvula. O Innervation: CN X (pharyngeal plexus)

Glossopalatine
O Origin: merges with transversus and

superficial mm of side and undersurface of tongue O Insertion: palatin aponeurosis O Action:

O Raises posterior portion of tongue O Constricts isthmus of fauces O Depresses side of palate

O Innervation: CN X (pharyngeal plexus)

Pharyngopalatine
O Origin: posterior thyroid cartilage;

aponeurosis of pharynx O Insertion: aponeurosis of the soft palate O Action:

O Depresses the soft palate O aids in elevating larynx and pharynx O Constricts faucial isthmus

O Innervation: CN X (pharyngeal plexus)

Muscles of the Pharynx

O Reflex:
O Peristalsis reflex: propels the bolus to the

esophagus
O Sensory and motor innervation CN IX, X, XI

SUPERIOR CONSTRICTOR
O Origin: Lower posterior border of medial

pterygoid plate; pterygomandibular ligament and raphe; mylohyoid ridge of the mandible; mucous membrane of oral cavity; sides of tongue. O Insertion: Posterior median raphe of pharynx. O Action: Contracts pharynx; aids movement of food bolus toward the esophagus. O CN X-Pharyngeal Plexus

MIDDLE CONSTRICTOR
O Triggers Peristalsis O Origin: both cornua of hyoid bone; stylohyoid

ligament. O Insertion: posterior median raphe of pharynx. O Action: contracts pharynx; aids movement of food bolus toward esophagus. O CN X (pharyngeal plexus)

INFERIOR CONSTRICTOR
O Triggers peristalsis O Origin: inferior side of cricoid cartilage; obliques O O O O

line of thyroid cartilage. Insertion: posterior median raphe of pharynx. Action: Contracts pharynx; aids movement of food bolus. CN X (pharyngeal plexus) Helps to form the pharyngoesophageal segment (PES).

VELOPHARYNGEAL SPHINCTER
O Origin: midline of soft palate. O Insertion: posterior median raphe of

pharynx. O Action: protrusion and elevation of portion of pharyngeal wall; aids in forcing soft palate posteriorly. O CN X (pharyngeal plexus)

CRICOPHARYNGEAL
O Origin: sides of cricoid cartilage. O Insertion: posterior median raphe of

pharynx. O Actions: contracts pharynx. O CN X (pharyngeal plexus) O PES between vertabrae 5 and 6

PHARYNGEAL LEVATOR MUSCLES

STYLOPHARYNGEAL
O Origin: base of styloid process of temporal

bone. O Insertion: mucous membrane of pharynx and thyroid cartilage. O Action: elevates and widens pharynx. O CN IX (only group of muscles to be innervated by IX)

SALPINGOPHARYNGEAL
O Origin: lower edge of eustachian cartilage. O Insertion: muscous membrane of pharynx. O Action: elevates pharynx. O CN X (pharyngeal plexus)

Intrinsic muscles of the larynx

O Lingual-laryngeal connection=CN XII O Reflexes:
O Glottal Effort Closure Reflex which generates

the airway. O Reflexive throat clearing/cough reflex.

CRICOTHYROID
O Origin: anterior and lateral surfaces of arch

of cricoid cartilage. O Insertion: caudal border of the thyroid cartilage; anterior surface of lower cornu of thyroid cartilage. O Action: draws thyroid down and forward; elevates cricoid arch; lengthens, tenses vocal folds. O CN X (superior laryngeal nerve)

CRICOARYTENOIDS LATERAL
O Origin: superior borders of cricoid cartilage. O Insertion: anterior surface of muscular

process. O Action: draws arytenoids forward; aids in rotating arytenoids; tenses and adducts vocal folds. O CN X (recurrent laryngeal nerve)

POSTERIOR
O Origin: posterior surface of cricoid cartilage. O Insertion: muscular process of arytenoid

cartilage. O Action: rotates arytenoid, abducting vocal processess. O CN X (recurrent laryngeal nerve).

INTERARYTENOIDS TRANSVERSE
O Origin: posterior surface of arytenoid

cartilage. O Insertion: posterior surface of opposite arytenoid. O Action: draws together arytenoid cartilages; adducts vocal folds. O CN X (recurrent laryngeal nerve).

OBLIQUE
O Origin: base of one arytenoid cartilage at

muscular juncture. O Insertion: apex of the opposite arytenoid. O Action: draws arytenoid cartilages together. O CN X (recurrent laryngeal nerve).

THYROARYTENOID
O Origin: internal and inferior surface of the

angel of the thyroid cartilage. O Insertion: vocal process and anterior lateral surface of the base of the arytenoid cartilages. O Action: draws arytenoids forward; shortens and relaxes vocal folds. O CN X (recurrent laryngeal nerve).

VOCALIS
O Origin: inferior surface of the angle of the

thyroid cartilage. O Insertion: vocal process of the arytenoid cartilage and vocal ligament. O Action: differentially tenses vocal folds. O CN X (recurrent laryngeal nerve).

EXTRINSIC MUSCLES OF THE LARYNX

O Reflexes:
O Laryngeal elevation reflex: epiglottal ROM O Laryngeal depression reflex: epiglottal recoil

speed.

SUPRAHYOID

STYLOHYOID
O Origin: styloid process of the temporal bone. O Insertion: body of the hyoid bone. O Action: elevates and draws hyoid bone

backward. O CN VII

DIGASTRIC
O Origin: anterior belly arises from internal

aspect of mandible close to midline, posterior belly arises on medial side of mastoid process of temporal bone. O Insertion: intermediate tendon and the hyoid bone. O Action: elevates hyoid; depresses mandible. O CN V (anterior belly) CN VII (posterior belly).

MYLOHYOID
O Origin: mylohyoid ridge of mandible. O Insertion: hyoid bone and median raphe. O Action: raises and projects hyoid bone and

tongue. O CN V.

GENIOHYOID
O Origin: internal surface of the mandible at

the inferior mental spine. O Insertion: anterior surface of the hyoid bone. O Action: draws tongue and hyoid bone forward. O CN XII.

INFRAHYOID
O Unsupervised cup drinking and straw usage. O Goes with larynx muscles.

STERNOHYOID C1-C3
O Origin: medial extremity of clavicle; superior

and posterior portion of the sternum; sternoclavicular ligament. O Insertion: body of the hyoid bone, inferior surface. O Action: depresses hyoid bone. O CN XII.

STERNOTHYROID C1-C3
O Origin: superior and posterior portion of the

sternum and first costal cartilage. O Insertion: oblique line of thyroid cartilage. O Action: depresses the thyroid cartilage. O CN XII

THYROHYOID
O Origin: oblique line of the thyroid cartilage. O Insertion: body and greater cornu of hyoid

bone. O Action: depresses hyoid bone or elevates larynx. O CN XII

OMOHYOID C1
O Origin: superior margin of scapula. O Insertion: inferior border of the body of the

hyoid bone. O Action: depress and retracts the hyoid bone. O CN XII.

MUSCLES OF FACIAL EXPRESSION

O Control levels:
O Cortical (conscious): middle brain O Brainstem (oral stage swallow)

QUADRATUS LABIL SUPERIOR

O Origin: frontal process maxilla; lower margin

of orbit; zygomatic bone. O Insertion: upper lip at midline. O Action: elevates upper lip O CN VII

ZYGOMATIC MINOR
O Origin: canine fossa of the maxilla. O Insertion: angle of mouth, upper lip. O Action: elevates portion of upper lip. O CN VII.

ZYGOMATIC MAJOR
O Origin: zygomatic bone. O Insertion: angle of mouth; upper lip. O Action: draws corner of mouth up and back. O CN VII.

RISORIUS
O Origin: fascia over masseter. O Insertion: skin at angle of mouth. O Action: retracts corner of mouth. O CN VII.

DEPRESSOR ANGULI
O Origin: oblique line of mandible. O Insertion: angle of mouth, lower lip. O Action: depresses angle of mouth. O CN VII.

QUADRATUS LABII INFERIOR

O Origin: oblique line of mandible (anterior). O Insertion: lower lip at angle of mouth. O Action: depresses and retracts lower lip. O CN VII.

MENTAL
O Origin: incisive fossa of mandible. O Insertion: integument of chin. O Action: raises and protrudes lower lip. O CN VII.

ORBICULARIS ORIS
O Origin: a sphincteric muscle, driving from

others of the area, with no definite origins or insertions. O Action: closes mouth and puckers lip. O CN VII.

BUCCINATOR
O Origin: alvoelar ridges of maxilla and

mandible; pterygomandibular raphe. O Insertion: angle of the mouth mingling with fibers of mm forming upper and lower lips. O Actions: flattens cheek. O CN VII.

PLATYSMA
O Origin: thoracic fascia over pectoralis major,

deltoid and trapezious mm. O Insertion: mental protuberance of the mandible, skin of cheek and corner of mouth. O Action: depresses mandible; aids in pouting reaction; depresses corner of mouth, wrinkles skin of neck and chin. O CN VII.

Esophagus
O Swallowing starts primary peristaltic wave. O Something stuck in the esophagus starts a

secondary wave. O Negative pressure O Peristalsis depends on size/temperature of bolus.

hyoid
O Only bone in the swallowing mechanism. O Forms foundation of the tongue-embedded

in the base of the tongue suspended by floor of mouth muscles and posterior belly of the digastric and sylohyoid.

Larynx
O Suspended from hyoid by thyrohyoid

ligament and thyrohyoid muscle. O Movement of hyoid moves larynx unless stabilized by other muscles. O The opening is know as the laryngeal vestibule. O Contains false vocal folds, true vocal folds, ary-epiglottic folds, arytenoid cartilage.

Tongue
O Entirely made of muscle. O Consists of tip, blade, front, center, back O Pharyngeal tongue at circumvallate papillae to

hyoid. O Contains taste buds allowing us to taste foods. O Moves the bolus within the oral cavity for proper mastication of bolus and propels the bolus posteriorly initiating the pharyngeal stage of the swallow.

TEETH
O Dentition is important for swallowing and it

is important to assess dentition for appropriate diet recommendations. O Poor oral hygiene can contribute to aspiration pneumonia in patients with dysphagia.

Cheeks
O Buccal tension
O Assists in creating appropriate pressures for

initiating the pharyngeal swallow. O Assists in maintaining the bolus. O Helps to prevent lateral pocketing of the bolus.

Roof of mouth
O Maxilla (hard palate, velum, soft palate and

uvula. O Soft palate is pulled down by palatoglossus, elevated/retracted by palatopharyngeus, levator palatal and superior pharyngeal constrictor.

Salivary Glands
O Parotid, submandibular, sublingual O Found on sides, tongue, lips, cheeks and

roof of mouth. O 2 types of fluid: viscid (from parotid-thicker, mucous-like fluid) and serous (thinner, watery). O Maintains oral moisture, reduces tooth decay, assists in digestion, natural neutralizer of stomach acid.

CRANIAL NERVE V: TRIGEMINAL

O O O O O O O O O O O O O

Cutaneous pressure sensation to anteror 2/3 of tongue. Thermal sensation hot/cold (safety). Oral pain. Cutaneous pressure sensation to all teeth, lips, chin, tongue, oral gums, hard and soft palate. Salivary flow to major and minor glands. Mouth opening (ext. pterygoids). Mandible movement (temporalis, masseter, lat/med pterygoids)-moves mandible from side to side, elevate and protrude the jaw. Innervates muscles of mastication. Innervates floor muscles with aid in elevation of larynx (mylohyoid, ant. Belly of digastric)-depresses mandible, raises hyoid bone, stabilizes hyoid bone. Aids in velopharyngeal closure (tensor veli palatine)-tenses soft palate prior to elevation. Everything powered to contraction by V is mandibular (mastication). Reflex: jaw jerk reflex. Also innervates tensor tympani.

Cranial nerve v: trigeminal

O Motor
O Mastication O HLE O Tenses velum o Sensory o o

cheek anterior 2/3 tongue (not taste)

**(trouble chewing) Brainstem-chewing, palate, hyoid

CRANIAL NERVE VII: FACIAL

Taste receptors: anterior 2/3 of tongue (sweet, sour, salty). Autonomic salivary glands (submandibulars and sublinguals). Muscles of facial expression. Lip shape and movement (orbicularis oris). Closure of lips, cheeks and tongue (buccinator- aids in mastication by pressing the bolus laterally into the molar teeth, platysma-depresses the mandible, stylohyoid-elevates the hyoid, retracts hyoid distally, stapedius)O Lip closure and prep of bolus for transfer (orbicularis oris). O Assists in hyoid bone elevation by raising and stabilizing the hyoid bone (mylohyoid, post belly of digastric). O Raises larynx for airway protection (epiglottic ROM).
O O O O O

Cranial nerve vii: facial

O Motor
O Lip closure O Buccal tone O HLE

O Sensory
O Taste anterior 2/3 of tongue O Salivation O **dry mouth, decreased lip closure

CRANIAL NERVE IX: GLOSSOPHARYNGEAL

O Taste receptors: posterior 1/3 of tongue (bitter). O Cutaneous pressure receptors, pain, thermal receptors, O

O O

O O

posterior 1/3 of tongue. General cutaneous pressure receptors on palatal arch, soft palate, tonsils, mucous membrane of oropharynx, facial pillars and eustachian tube. Autonomic secretory function of parotid salivary glands. Assists in velopharyngeal closure to prevent reflux to nose at start of pharyngeal and end of oral phase through elevation of larynx and pharynx (stylopharyngeal-only muscle). Upper pharyngeal constrictor fibers. General cutaneous pressure/thermal/pain sensation of upper pharynx.

CRANIAL NERVE IX: GLOSSOPHARYNGEAL

O Motor
O Pharyngeal constriction O Pharyngeal shortening

O Sensory
O Taste/sensation posterior 1/3 of tongue, velum,

faucial arches, superior portion of pharynx

O **no thermal stimulation, pharyngeal phase

dysphagia O **oropharynx O Faucial arches-trigger swallow

CRANIAL NERVE XII: HYPOGLOSSAL

O O O O O O O O O O O O O O O

Only motor/no sensory pathways. Tongue movement to posterior oral cavity (A-P propulsion pattern and lingual-alvoelar seal). Creating bolus of proper size (int/ext muscles). Collection of food partilces from lateral/anterior sulci, palate and molars (int/ext muscles). Mixing bolus with saliva. Alvoelar-palatal contact before swallow (inf./sup. Longitudinals, transverse, vertical). Transporting bolus from mid-palate to posterior 1/3 of tongue (same as above). Bolus transport to pharynx. Raises and lowers the hyoid bone to protect the airway (supra/infra muscles). Tongue base retraction and lingual groove reflex and reflexive protective retraction. **if sensory decreased cannot get movement** Genioglossus-depresses tongue and allows protrusion, hypoglossus-depresses and retracts tongue. styloglossus-retracts tongue and draws up lateral borders to generate a chute Geniohyoid-pulls hyoid anteriorly and superiorly widening the pharynx and pulling the larynx out of the bolus path. Sternohyoid, omohyoid, sternothyroid and thyrohyoid (infrahyoids)-depress the hyoid after swallow or stabilizes the hyoid and elevates the larynx.

CRANIAL NERVE XII: HYPOGLOSSAL

O Motor
O Tongue motility O HLE O **decreased laryngeal elevation O **no sensory component

CRANIAL NERVE X: VAGUS

O O O O O O

O O O O O

Taste receptors in pharynx and epiglottis/mucosa of valleculae. Visceral sensation from pharynx and larynx. Trachea. Pharyngeal reflexes and pharyngeal constrictor muscles except sylopharyngeus. Superior, meidal and inferior constrictors to constrict the walls of the pharynx. Salpinopharyngeus-elevates pharynx and larynx. Laryngeal reflexes-all laryngeal muscles (intrinsic laryngeal muscles-oppose vocal cords to protect the airway during the swallow, cricothyroid tips thyroid cartilage anteriorly to help protect the airway during the swallow). General sensation of abdominal viscera. Upper esophageal sphincter (UES) function-cricopharyngeus inhibits reflux. Peristalsis/motility of esophagus. Velopharyngeal closure-all muscles of soft palate except tensor veli palatine (levator veli palatini elevates the soft palate). Palatoglossus-elevates posterior part of the tongue and draws the soft palate onto the tongue. Palatopharyngeus tenses the soft palate, draws pharynx superiorly, anteriorly and medially. Supraglottis CN X-laryngeal branch.

CRANIAL NERVE X: VAGUS

O Motor O VP closure O TBR O UES closure/opening O Esophageal motility O Sensory O Posterior/inferior portions of pharynx O Larynx O Esophagus

**affects entire swallow **recurrent laryngeal nerve can be affected by lung tumor or sx cervical vertabrae O Gag reflex=relating to dysphagia if bilateral gag is absent.
O O

SWALLOWING FACTS
O Approximately 300,000 to 600,000 people with

neurogenic disorders are diagnosed with dysphagia. O Swallowing involves the use of 6 cranial nerves. O Approximately 40% of patients with dysphagia silently aspirate. O Swallowing is one of the most complex body reflexes, yet in the normal adult, this process is automatic, effortless and efficiently performed an average of 600 times a day.

The swallow
O O O O O O O O

We swallow 1x/minute at rest. We swallow to manage secretions and for hydration/nutrition. Start swallowing at 12 weeks gestation. Swallowing involves the activation of 55 muscles, via innervation of 6 cranial nerves. It is a voluntary system. Muscles work together to create pressure. Without pressure in the oral cavity, tongue and tongue base loses function. The tongue is the major force in the swallow. Pharyngeal constriction-stripping wave (sup/med/inf constrictors). Pharyngeal contraction-narrows and shortens (stylopharyngeus, palatopharyngeus, salpingopharyngeus.)

O We increase timing, coordination and pressure of the

swallow. O Should be fast and explosive.

Dysphagia
O Dysfunction=what is not right. O Impairment-=why the system is not working O O O O

right. Symptoms=clinical indicators MASA is the only standardized bedside swallowing assessment. Complications=pneumonia, malnutrition, dehydration Swallow Apraxia/Tactile Agnosia-not recognizing food or able to orally initiate swallow.

ORAL CARE
O Microorganisms found in the lungs of elderly patients

with pneumonia originate in the mouth and gingival, making a link between poor oral hygiene and aspiration pneumonia.
O Three categories that add to the risk factors that lead to

aspiration pneumonia: any factor that increases the bacterial load or colonization in the oral-pharyngeal cavity (lack of tooth-brushing, xerostomia). O Any factor that decreases the patients resistance to the inoculums (i.e. malnutrition or ventilator dependency.) O Any factor that increases the risk of aspiration (i.e. paralysis from stroke or chronic neurological disease affecting the muscles and nerves involved in swallowing.

PATIENTS AT RISK FOR ASPIRATION PNEUMONIA

O O O O O O O O O O O O O O O O O O O O

Patients who are dependent for oral care Have large numbers of missing teeth Dentures Have limited hand dexterity Decreased mental capacity Multiple medical co-morbidities Immunosuppressed Ventilator dependant Receive non-prandial feedings Have had a stroke Neurologically impaired Xerostomia Known dysphagia Poor access to professional dental care Active smoking Depression Use of sedative medicine Use of gastric acid-reducing medication Use of ACE inhibitor Poor feeding position

Norms for swallowing

O Hyoid increases to 1 cervical vertabrae (hyoid rests at C3O O O O O O O O O

4/thyroid rests at C4-5) Pharyngeal squeeze-airspace is obliterated. Barium passes through the PES in a single column. Lips closed, cheeks tensed. Velum goes up and back to make contact with the superior pharyngeal constrictor. Tongue Base retracts to meet the SPC and velum. Hyoid and thyroid approximate Hyoid forward to about halfway between anterior and posterior mandible (geniohyoid). PES rests at C5-7. Pharyngeal contraction-Pharynx shortens 1.5 cm from tongue base to PES.

Phases of the Swallow

O Oral Prepatory Phase-Sensory recognition of

food approaching the mouth and placed in the mouth. Tongue seals around bolus, oral manipulation, mastication with rotary jaw motion. O tippers-food held between midline of tongue and hard palate with tongue tip elevated. O dippers-approximately 20% of people-held on the floor of the mouth in front of the tongue. O Sensory information processed throughout the tongue and oral cavity

Phases of the Swallow

O Oral Phase-initiated when the tongue begins posterior O O O O O

movement of the bolus. If dipper, tongue tip moves bolus up and collects on tongue. Tongue movement is described as a stripping wave. Increased viscosity=increased tongue-palate pressure. Less than 1-1.5 seconds to complete. Involves-labial seal, lingual movement, buccal tension, palatal muscles, ability to breath through nasal passages.

Phases of the Swallow

O As tongue propels bolus, sensory receptors in

the oropharynx and tongue send info to the brainstem and cortex. O Pharyngeal swallow is triggered when bolus head reaches point where mandible crosses the tongue base. O The following must occur: velopharyngeal closure, elevation/anterior movement of hyoid, closure of larynx, cricopharyngeal opening, tongue base and pharyngeal wall movement.

Phases of the Swallow

O Esophageal phase O From when the bolus passes through the

PES and through the LES.

Swallow in detail
O Hunger O Smell of food, empty stomach or electrolyte imbalance informs hypothalamus of the need to eat. O Brainstem activates nucleii of CN VII and IX to promote secretion of salivary gland juices to prep for bolus.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

Swallow in detail
O

Chewing
O O O O O O O O

Bolus in mouth. CN VII ensures good lip seal (orbicularis oris) while CN V relays sensory info to brainstem to constantly modify the fine motor control of bolus prep. Motor activity to CN V, VII, IX, X, XII to create an enclosed environment within the mouth to prepare the bolus. Cheeks provide tone (buccinator CN VII) Soft palate tense and drawn down towards tongue (tensor veli palatini CN V and palatopharyngeus CN IX) Tongue is drawn up towards the soft palate (palatopharyngeus CN X, styloglossus CN XII) Hyoid bone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow movement of the mandible). Bolus prepared by closing (temporalis, masseter, meial pterygoid, lateral pterygoid, CN V) and opening (mylohyoid and anterior belly of digastric CN V, geniohyoid CN XII &C1-C3.) Bolus pushed around the mouth by actions of the tongue to create a consistent, homogenous texture (hypoglossus, genioglossus, styloglossus and 4 groups of intrinsic muscles of the tongue CN XII). Taste sensations (CN VII and IX) provide info to cortex to stimulate areas of brain required to coordinate the swallow (insula and cingulate cortex).

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

Swallow in detail
O Volutary initiation O Once bolus is adequately prepared. O Soft palate elevates slightly (levator veli palatini and palatopharyngeus CN X). O Slight elevation of hyoid bone (suprahyoid muscles contracting on rigid mandible with slight relaxation of infrahyoid muscles. O Pharyngeal tube is elevated (stylopharyngeus CN IX, palatopharyngeus and salpingopharyngeus CN X). O Tongue delivers bolus to force bolus distally towards posterior wall of the pharynx in a piston-like manner using hard palate for resistance. O Sensation by CN XI and by CN X (pharyngeal plexus).
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

Swallow in detail
O Larngeal elevation O 1st motion for tongue to propel bolus into oropharynx is elevated anterior direction toward roof of mouth (mylohyoid and anterior belly of digastric, CN V; stylohyoid and posterior belly of digastric CN VII; palatoplossus CN X; genioglossus, hyoglossus and styloglossus CN XII; geniohyoid CN XII and C1-C3) affects hyoid elevation in an anterior direction. O Soft palate seals off nasopharynx. O Superior constrictors begin medialization of the lateral walls. O Larynx elevated and moved anteriorly in relation to hyoid bone by thyrohyoid CN X.
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

Swallow in Detail
O

Laryngeal closure
O O O O O O O O

During laryngeal elevation-vestibule closes and rises relative to thyroid cartilage (cricothyroid and intrinsic laryngeal muscles CN X). Opposition and elevation of arytenoid cartilages provide medial curtains of pyriform recesses (aryeppiglottic folds). Pressure exerted on base of epiglottis causing it to tip and cover the laryngeal vestibule. Medial constrictors (CN X) strip the pharynx by medialization following on from superior constrictors. Palate descends (palatopharyngeus CN X), constrictors strip and tongue moves posteriorly (styloglossus CN XII) to close oropharynx. Once the bolus has reached pharyngeal areas innervated by the internal branch of the superior laryngeal nerve swallow reflexive and cannot be stopped. Anterior and elevated movement of larynx allows cricopharyngeus to be stretched (UES) and opened. Inferior constrictor finishes medialization and bolus in esophagus.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

Swallow in detail
O Resting state O CN X O Cricopharyngeus resumes tonic state. O Glottic opens and larynx lowers. O If bolus present should cough. O Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and the pharyngeal phase with all consistencies should take 1 second. **The ability to contain a bolus is prognostic. **The swallow is a positive pressure phenomena where the pressure is always on the tail of the bolus.
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*

Age Differences in Swallowing

O Infants-tongue fills oral cavity, fat pads in cheeks

O O O

narrow oral cavity, hyoid and larynx are higher than in adults (more natural protection for airway), velum hangs lower, uvula rests inside the epiglottis forming a pocket in the valleculae. When the tongue pumps, the bolus is collected at the back of the mouth in front of an anteriorly bulging velum or in vallecular pocket. Swallowing begins with the fetus. 2-7 tongue pumps per swallow. Bite is achieved at 7 months, chewing at 10-12 months, normal adult chewing pattern around 3-4 years.

Aging Changes
O

The 60 80-year-old
O

Timing of the Swallow

O

O O 

Oral transit times slightly but significantly longer in older adults (.5-.6 sec). Tipper (tongue tip against alveolar ridge at initiation of swallow) vs. dipper (tongue tip behind lower teeth at initiation of swallow) swallow types - Elderly more often dippers Pharyngeal delay times slightly but significantly longer in older adults (.5-.6 sec) Pharyngeal wall contraction inconsistently found to be slower Reduced tongue pressure Penetration occurs more frequently Aspiration occurs no more frequently in the elderly Residue is generally only slightly greater (2-3%) in the elderly than in younger adults

Safety and Efficiency of the Swallow

O O O

80+ year-olds - Range and pattern of pharyngeal movements during the swallow in
O

80-year-olds are different from younger adults which increase the older adult's risk of dysphagia as the result of illness and subsequent general weakness.
O O O O

Reduced reserve - especially in men Hyoid & laryngeal maximum vertical movement significantly reduced in the elderly (over age 80) Hyoid and laryngeal movements up to the time of cricopharyngeal opening virtually identical in young adults and elderly patients Reduced flexibility

O O

Cricopharyngeal opening durations across volumes reduced in the elderly Cricopharyngeal opening diameter across volumes reduced in the elderly
O O 

Timing similar to 60-80-year-olds Safety and efficiency of swallow unchanged Range of motion exercises may improve reserve and flexibility in otherwise normal, healthy elderly.

Age Differences in Swallowing

O O O O

O O O O O O

Aged Swallow Masticatory performance is maintained. More chewing strokes needed with poor dentition or dentures. At 70 and older, the larynx may be lower in the neck, around the 7th vertabrae. Arthritic changes in the cervical vertebrae may impinge on the pharyngeal wall, decreasing flexibility. May cause decreased strength of contraction. More older adults use a dipper swallow. Oral stage slightly longer. Slight increase in oral/pharyngeal residue Penetration increases, but not aspiration. Younger men had laryngeal elevation reserve, elderly men did not. Older=decreased flexibility with cricopharyngeal opening.

Movements of the swallow

o o o o o o o o o o o o

Larynx elevates 2 cm. Arytenoids contact base of epiglottis. Movement of tongue base is major pressure generating force of swallow. Posterior movement of tongue base 2/3 of distance to posterior pharyngeal wall, anterior bulging of pharynx covers approximately 1/3. PES opening involves: relaxation of cricopharyngeus, hyolaryngeal excursion (anterior movement of cricoid cartilage, bolus pressure. (only negative prssure generator of the swallow). Typically no bolus hesitation in pyriform sinuses, the bolus head reaches PES as it opens. Saliva swallows usually 1-2 ccs. During swallow-bolus divides fairly evenly between valleculae and pyriform sinuses. When the hyoid and larynx are at their extreme point, should have epiglottic inversion. Generation of pressure by BOT is highest pressure generated during the swallow (bolus propulsion through pharynx). Look at epiglottic inversion and pharyngeal stripping wave for therapy (liquid is the most revealing of the viscosities. **You do NOT have to aspirate to have dysphagia.

(14)

Components of the swallow

O O O O O O O O O O O O O O

Lip closure Hold position/tongue control Bolus preparation/mastication Bolus transport/lingual motion Initiation of the pharyngeal swallow Soft palate elevation and retraction Laryngeal elevation Anterior hyoid excursion Laryngeal closure Pharyngeal stripping wave Pharyngeal contraction Pharyngoesophageal segment opening Tongue base retraction Esophageal clearance

Robbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N., Rosenbek J.C. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. JSLPR; 51: S276S300.

Movements of the swallow

O Laryngeal elevation-participates in early

vestibule closure-facilitated by pharyngeal shortening. **indicator of pharyngeal shortening. O If hyoid movement is not good, laryngeal elevation will collapses too early (geniohyoid, mylohyoid, anterior belly of the digastric).

Oral Swallowing components

O Lips O Teeth O Hard palate O Soft palte O Uvula O Mandible O Floor of mouth (submentals) O Tongue O Faucial arches

Respiration and swallowing

There is a pharyngeal role switch for respiration/swallow-presence of specialized neural networks in the brainstem and cortex to facilitate smooth transition.) O Shared structures for respiratory, vocal tract and aerodigestive system
O
O

Tongue
O O

Respiration: airway patency, EMG respiratory activity Swallow: most mobile element-positive pressure generator-airway protection (BOT helps obliterate airway during TBR)

Pharynx
Respiration: airway patency (pulmonary disorders-pharynx is large=dead space more resistive to airflow, harder to breath.) O Swallow: bolus passageway, contracts
O

Larynx
O O

Respiration: airflow exhalation-V.C. nearly adduct, inhalation V.C. abduct. Swallow: sensation-expectoration, closes, PES opening.

Respiration and swallowing

O Swallowing resets the respiratory pattern. O Most common swallow/breath pattern is

exhale/swallow/exhale/inhale. (exhale after the swallow may be a clearance mechanism). O Important respiratory mechanical advantages to swallow function: 1.) facilitates superior/anterior hyoid and laryngeal movement 2.) facilitates esophageal clearance. O Apnea-deep breath, have pt. say huh to ensure glottic closure O **babies swallow more on inhalation-by 2 the mechanism is more similar to an adult.

Cough
O Coughing is a mechanism of airway

clearance that adds to normal ciliary function comprised of three events, inspiratory effort, followed by rapid vocal fold adduction and contraction of the expiratory muscles. O Expiratory Phase Peak Flow is highly dependent on pulmonary function and not entirely on the participants effort of strength.

Neural plasticity
O The ability of the brain to change. O May result in behavorial change, not necessarily vice

versa. O Increasing evidence that N.P. Plays a substantial role in centrally remodeling human function after cerebral injury. O 10 Principles: Use it or lose it; Use it and improve it; Plasticity is experience specific; Repetition matters; Intensity matters; Time matters; Salience matters; Age matters; Transference; Inference.
Robbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N., Rosenbek J.C. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. JSLPR; 51: S276S300.

Disorders of Swallow
O Decreased Labial Closure-anterior spillage of O O O O

food. Decreased tongue shaping/coordinationdecreased ability to hold bolus. Decreased lingual ROM/coordination-cannot form bolus. Decreased labial tension/tone-material falls into anterior sulcus. Decreased buccal tension/tone-material falls into lateral sulci.

Disorders of Swallow
O Apraxia of swallow-reduced oral sensation-delayed oral O O O O O O O O

onset Apraxia of swallow-searching tongue movement. Tongue thrust-tongue moves forward to start swallow. Decreased labial tension-anterior sulcus residue. Decreased lingual ROM/strength-lingual residue. Lingual discoordination-disturbed lingual contraction. Decreased lingual elevation-incomplete tongue-palate contact. Decreased lingual elevation/strength-hard palate residue. Piecemeal deglutition.

Disorders of Swallow
O Delayed pharyngeal swallow-normal during mastication for O O O O O O O O

bolus to fall to valleculae Nasal penetration during the swallow-decreased VP closure Unilateral pharyngeal wall weakness-residue on one side of pharynx and in P.S. Decreased TBR-valleculae residue Residue at top of airway-decreased L.E. Reduced closure of the airway entrance-laryngeal penetration and aspiration. Reduced laryngeal closure-aspiration. Reduced anterior laryngeal motion, CP dysfunction-P.S. residue Pharyngeal transit time-less that 1 second.

Disorders of Swallow
O Espophageal-Pharyngeal backflow O Tracheoesophageal fistula O Zenkers Diverticulum O GERD

ASSESSMENT OF SWALLOWING
O Bedside assessment
O Cervical auscultation O Laryngeal elevation palpation O Monitor s/s aspiration O Trial consistencies O Pulse oximetry O Heart rate O Blue dye assessment O 3 ounce water test O Bolus manipulation task

Bedside Assessment of Swallowing

O Exam of Oral Anatomy-lip configuration, hard palate

configuration (heigth/width), soft palate and uvular relative to PPW, faucial arches, lingual configuration, adequacy of sulci, scarring, asymmetry, dentition, oral secretions. O Oral-Motor Exam-Eval range, rate and accuracy of lips, tongue, soft palate and pharyngeal walls.
O Open lips, close lips, /i/, /u/, diadochokinetic rate. O Anterior motion of tongue, touch each corner of

mouth, rapidly alternate side, open mouth wide and tongue tip to alveolar ridge then depress tongue tip. Poster tongue-open mouth and lift back of tongue.

Bedside Assessment of Swallowing

O Chewing function-Gauze dipped in liquid. O Soft Palate function-/ah/, gag, palatal reflex. O Laryngeal eval-voice assessment, /ha/-rapid

productions, cough, clear throat, s/z ratio O Cervical auscultation-Listen for sounds of swallowing and respiration sounds. O Palpation of larynx and hyoid. Palpate for laryngeal elevation and hyoid anterior movement. (Pointer finger on mandible, middle on hyoid, ring on thyroid, pinky on cricoid notch.)

Assessment of Swallowing
O O O O O O

Instrumental assessment MBSS-Most frequently used. Used since early 1900s, gives us most info. FEES-Videoendoscopy-examines anatomy of oral and pharyngeal cavities, to the level of soft palate or below, no oral, can maybe see velopharyngeal closure, better for kids older than 8 and adults. Good for anatomy, can provide biofeedback Manometry-nonimaging, provides biofeedback (effortful swallow, Mendelsohn) Ultrasound-observe tongue function, measure oral transit times, motion of hyoid bone. Cannot see pharynx. Scintigraphy-nuclear medicine test, patient swallows measured amounts of a radioactive substance, bolus is imaged and recorded by a gamma camera. Aspiration and residue can be measured in amount. Physiology not visualized. Electroglottogrphy-EGG-designed to track vocal fold movement by recording the impedance changes as the vocal fold move toward and away from each other during phonation.

MBSS
O Two swallows each at 1ml, 3ml, 5ml, 10ml, cup

drink thin, pudding, Lorna Doone cookie. O Should focus on the lips anteriorly, hard palate posterior pharyngeal wall and bifurcation of the airway and esophagus. O Trials: (In this order)
O Postural Techniques O Improve Oral Sensory Awareness O Swallow Maneuvers O Diet Changes

MBSS
O Postural Techniques
O Head back-inefficient oral transit. O Head down-widen valleculae, push tongue base

back, place epiglottis more posterior, narrow airway. O Head rotated to damaged side-increase vocal fold closure, narrows layrngeal entrance, twists pharynx, eliminates affected side from bolus path, pulls cricoid cartilage away from PPW. O Lying down on side-increase vocal fold closure, narrows laryngeal entrance, change gravitational direction of bolus.

MBSS
O Oral sensory awarenessO Increase downward pressure of spoon O Presentation of sour bolus (50% lemon juice, O O O O

50% barium). Presentation of cold bolus Presentation of a bolus requiring chewing Presentation of a larger volumebolus Thermal-Tactile Stimulation

MBSS
O Swallow Maneuvers
O Supraglottic Swallow O Super-Supraglottic Swallow O Effortful swallow O Mendelsohn Maneuver

MBSS
O Food Consistency (Diet) Changes
O Thickened liquids O Pureed O Mechanical soft

Exercise
O O O O O O O O

Exercising healthy muscles=increased muscle tone. Must overload or tax the muscle beyond the typical use. (Masako, Mendelsohn, effortful swallow, Shaker) Swallowing rehab should imitate swallowing movements. Gains in strength generalize only to movement very similar to the exercise itself. Accurate dosage and frequency unknown at this time for therapeutic levels. Continue therapeutic exercise beyond levels needed for minimal functinoal swallow to maintain adequate functional reserve. Develop strength training programs that meet the unique needs of patients with various diagnoses and/or swallowing impairments. Isometric exercise=sustaining movement in exercise. Isokinetic exercise=repeated movement in exercise.

Clark, H.M. (2005). Therapeutic exercise in dysphagia management: Philosophies, practices and challenges. Swallowing and Swallowing Disorders, 24-27.

exercise
O O

Muscles Sarcopenia-age-related reduction in muscle fibers affecting Type II muscles more frequently.
O O

O O

Sarcomes=smallest functional unit in muscle contraction. Contraction achieved when successful binding of proteins (actin and myosin) along the sarcomere causing the filaments to slide toward each other, creating shortening action of contraction. Bundles of sarcomeres form muscle fibers. Type I muscles: slow twitch, slow-oxidative fibers, fatigue-resistant, increased endurance (lingual lateralizers, jaw closers and in anterior tongue along with Type IIa). Type II muscles: to propel and move bolus, fast twitch, larger, generate more force, easily fatigued. (tongue base, pharyngeal constrictors). No resistance=no need for type II muscles.
O O

Type IIa-fast oxidative/glycolytic. Type IIb-greatest capacity for force, easily fatigued, uses glycogen.

Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and directions for future research. Dysphagia; 22: 251-265.

exercise
O Exercise efforts that do not force the neuromuscular system O O O O

beond the level of usual activity will not elicit adaptations. Swallowing is submaximal, meaning it does not generate maximal force of muscles involved. Reps: 8-12 most effective, 6-8=greater outcomes for generating strength. If improved swallowing is the goal, then swallowing would be the optimal training task. Transference might explain swallow imprvement with nonswallow exercise programs (EMST, lingual strengthening, LSVT, Shaker). Combine strength and swallow treatments.

Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and directions for future research. Dysphagia; 22: 251-265.

Treatment outcomes: from Giselle Mann-2005 Florida dysphagia institute

O Lip Pucker-Endurance-Maintenance (I) O Tongue Protrusion and Retraction-EnduranceO O O O O O O O

Maintenance (I) Suck/Blow-Endurance-Maintenance (I) Tongue Bulb-Strengthening (II) Hard Swallow-Endurance (I) Mendelsohn-Strength-(II) Falsetto-Endurance-Maintenance (I) Pushing-Strength (II) Supraglottic-Strength (II) Shaker-Strength (II)

Dysphagia therapy
O O O O

Therapy helps return swallow function. High intensity, aggressive therapy, not diet monitoring helps patients regain swallow function. Fewer complications arise when the swallowing system is rehabilitated. (7). Volitional swallowing involves bilateral neural involvement, however some areas are hemisphere-specific, 63% showing left dominance. (12) **Swallowing is not a true reflex. Stroke patients pharyngeal representation in undamaged hemispere increased significantly with recovered swallow function. No changes were seen in the damaged hemisphere. Recovery of swallowing depends on compensatory reorganization. (13) Cortical input involves actions such as holding a bolus in the mouth and then swallowing on command.

Dysphagia therapy
O Weakness=decreased ability to use force. O Fatigue=weakness that becomes evident during

O O O O

sustained force productions and over repeated trials. Tone=tendency of muscle tissue to resist passive stretch. Oral/tactile agnosia-does not realize food is in the mouth. Watch for right lower lobe pneumonias. Drop of 4 on pulse ox can indicate dysphagia/aspiration.

IntraOral Prosthetics
O Palatal Lift Prosthesis O Palatal Obturator O Palatal Augmentation-Reshaping Prosthesis

Treatment
O Indirect-without use of food or liquids O Direct-utilizing foods/liquids O Therapy should be separate from meals. O Patients who receive therapy months or

years after onset of their problem are still capable of achieving oral intake. Logemann book

treatment
O DPNS (Deep Pharyngeal Neuromuscular O O O O O O O O

Stimulation) Thermal Tactile Stimulation EMST (Expiratory Muscle Strength Training) LSVT (Lee Silverman Voice Treatment) MDTP (McNeill Dysphagia Therapy Program) sEMG (Surface Electromyography) Isometric Lingual Exerises Effortful Swallow Viscous bolus

Interventions
O Exercises O Mendelsohn Manuever O Masako O Shaker O Oral manipulation exercises O Effortful swallow O Cheek/lingual with resistance O Chewing O Weighted bolus O Swallow trials O Suck-swallow O IOPI O MOST (Madison Oral Strength Trainer)

Mendelsohn manuever
O O O O

O O

Endurance/resistance. Can use a bolus. Increases extent and duration of PES opening. (2) Increases tongue-base/pharyngeal wall pressure and contact duration. (2) Found to: increase peak pharyngeal pressure, PES contraction pressure, PES opening duration, duration of hyoid-PES separation, duration of laryngeal elevation, bolus transit time, hyoid excursion, distance from the hyoid bone and the thyroid cartilage, duration of contraction for various muscles. (4) May facilitate clearance of residue. Research: 20 normal subjects, 1 group given 5ml water swallows compared to 5 ml swallows with Mendelsohn manuever. Able to sustain laryngeal elevation for 1.5 seconds or greater with increase in submental muscle group (anterior belly of the digastric, mylohyoid and geniohyoid.) (23) Put your hand on your throat and feel when you swallow. You can feel your Adams apple move up. Now, when you swalow I want you to hold your Adams Apple up for a few seconds, squeezing your throat and neck muscles and not letting go. (25)

Masako
O Resistance. Boluses not recommended. O Increases anterior motion of the posterior

pharyngeal wall at the level of the tongue base. (2) O Increases strength of tongue base and pharygeal constriction, increases efferent drive of tongue base. O Increased pharyngeal clearance. O Logemann recommends resistance exercises to target weak structures, 10 reps, 10x/day.

Shaker
O Resistance/Endurance. O Increased laryngeal anterior excursion and

cross-sectional opening of PES, improved swallow function, decreased post swallow aspiration and ability to return to various levels of oral intake. (2) O Increased strength through HLE and PES opening, increased efferent drive of HLE and PES opening. O Targets anterior belly of the digastric, mylohyoid, geniohyoid (hyoid elevation muscles).

Oral manipulation exercises

O Resistance/Coordination. O Cheese cloth O Toothette O Gauze

Effortful swallow
O O

O O O

O O

Resistance/Endurance. Increased: base of tongue retraction, tongue propulsive force, oral pressure, duration and extent of hyoid movement and laryngeal vestibule closure, longer duration of pharyngeal pressure and PES relaxation. (2) Original goal to maximize posterior BOT motion resulting in improved bolus clearance from valleculae. Increased force-generating ability of swallowing muscles. (4) Increased strength for TB, HLE, PC and PES opening, increased coordination for HLE, PC, PES opening, Increased afferent (sensory) drive for TB, HLE, PC, PES opening, increased efferent (motor) drive for TB, HLE, PC, PES. Evidence of early elevation of the hyoid at initiation of effortful swallow. (20) As you swallow, squeeze hard with all of your throat and neck muscles. (25)

Lingual exercises with resistance

O Research: Progressive resistance training-8 week training, 3

sets, 10 reps 3x/day using IOPI, pressing bulb against palate using tip, blade and dorsum. Lingual strength increased as a result of non-swallowing strengthening exercises. Non-swallow strengthening exercises improved swallow with liquid bolus. Penetration/Aspiration Scores were reduced. (2, 10) O Research: tested strength and endurance-3 groups, 1 with no exercise, 1 with tongue depressors and 1 with IOPI. Exercises completed 5 days/week for 1 month, 10 reps 5x/day. Movement 4 directions (with T.D. and IOPI), left, right, protrusion and elevation. Greater change in both exercise groups. IOPI did not differ therapy. No change in endurance. Increased change in those with initial lower baselines. (9)

Lingual exercises with resistance

O BOT=base, between tip of uvula and valleculae. O Pull tongue straight back. O Yawn and hold most retracted. O Gargle and hold at most retracted (most BOT movement). O Increased strength with resistance, IOPI, oral manipulation,

swallow trials. Increased ROM with MFR, stretch (Beckman), oral manipulation, swallow trials. Increased coordination with oral manipulation, sensory stim (Beckman, DPNS), suckswallow, resistance, swallow trials. Increased afferent drive with chewing (cold/sour bolus), swallow trials, CN V, VII, XII. Increased efferent drive with resistance, textured/chewy bolus, weighted bolus with straw, swallow trials.

Chewing
O Texture O Viscosity O Cold-**For pulmonary patients, cold may

not stimulate as well as warm. O Sour

Weighted bolus
O Add viscosity O Thickened liquids/pudding through straw

Swallow trials
O Challenging boluses-find a safe, challenging

consistency to increase strength.

Iowa oral performance instrument

O IOPI uses a bulb and a hand-held device to

measure tongue strength. O Can be used as a therapeutic tool for visual feedback. O Available at www.iopi.info

Stretches
O Myofascial release O Beckman program

Modalities
O Biofeedback (sEMG) O NMES (VitalStim, Eswallow) O Thermal Tactile Stimulation (TTS) O Pressure Biofeedback (IOPI)

Neuromuscular electrical stimulation

O NMES-training and equipment through

VitalStim (FDA approved) or Eswallow. O Research: significant descent of the hyoid and larynx at rest during maximal electrical stimulation. Aspiration and pooling during swallowing were only reduced during low sensory thresholds of stimulation. Also greater hyoid depression during stimulation at rest. (23).

Thermal tactile stimulation

O 00 laryngeal mirror. O Stimulate faucial arches 4-5x then assess

speed of swallow. O Repeat when swallow slows. O Best dosage is 5x/day. O Pipe 1cc into floor of mouth for swallow following stim

Sensory stimulation
O Sour bolus lemon juice, barium or water.

Helps to decrease time to initiate oral onset of the swallow and reduce oral transit time. Quicker swallow onset, more synchronous activation of submental muscles, making the muscle contraction stronger. (17/18) O Carbonated bolus. O Massage-improves circulation of blood and lymph system, increases oxygenation of tissues, facilitates waste removal, relieves pain (does not increase strength or prevent atrophy or hypotonia.) (8)

EMST
O Exhale into a device with 1-way, spring-loaded pressure valve, O

O O O

with valve at 60-80% of max expiratory pressure. Afferent stimulation to brain stem swallow centers through peripheral sensory receptors in tongue and oropharynx and strengthening oropharyngeal, laryngeal and supralaryngeal muscles. Improves ability to cough. (6) Hyoid vertical elevation and velopharyngeal closure during active blowing into the device. (24) Increased activation of the submental muscles (anterior belly of the digastric, mylohyoid and geniohyoid-responsible for hyoid movement), similar to swallowing counterparts. (24) Expiratory Pressure Threshold Trainer (24)

Maneuvers/postures
O Mendelsohn O Chin Tuck O Head Turn O Supraglottic O Super Supraglottic O Head back O Side lying
O

Postures effective 75-80% of the time.

Chin tuck
Research comparing chin tuck with thin liquids to NTL and HTL. Estimated $200/month for people on thickened liquids. More aspiration with chin tuck than with NTL or HTL. More adverse affects with thickened liquids (dehydration, UTI, fever). (3) O Narrows the airway, varies pressures in pharynx and UES during swallow, duration of timing of swallowing events and displacement of anatomical structures during the swallow. O Significant change in pharyngeal contraction pressure, duration of pharyngeal contraction pressure, larynx to hyoid bone distance, hyoid to mandible distance before the swallow, *angle between mandible to posterior pharyngeal wall, *angle between epiglottis to PPW of trachea, *width of airway entrance, *distance from epiglottis to PPW. (*all decreased). (4) O Chin tuck effective in 72% of patients studied. May be contraindicated in those with weak pharyngeal contraction pressure as it decreased pharyngeal contraction pressure and duration. (10/11)
O

Head turn
Head rotated to weaker side-Increased pharyngeal contraction pressure at the level of the valleculae and pyriform sinus on side of rotation, decreased UES resting pressure on side opposite rotation, increased duration from peak pharyngeal pressure in the pyriform sinus to the end of UES relaxation and increased UES anterior/posterior opening diameter. O Redirected bolus flow through the pyriform sinus on the strong side. O Concurrent decrease in UES resistance to bolus flow and prolongation of UES opening allowing bolus material to flow in a less obstructed manner through the UES and providing more time to clear all bolus material from the pharynx. (4)
O
o

Closes weaker side, applies pressure to larynx with closer approximation of vocal chords to weak side, gravity holds food longer to stronger side for unilateral oral and/or pharyngeal dysphagia. If only pharyngeal dysphagia use head turn to weak side.

Super supraglottic swallow

O Facilitates timing and extent of laryngeal closure at

specific levels of the larynx. (2) O For dysphagia secondary to reduced closure of the airway entrance. Increased UES relaxation prssure and duration of hyoid excursion and laryngeal movement, decreased time between UES opening and onset of hyoid movement and BOT movement time between UES opening and the onset of vocal fold adduction and laryngeal closure. (4) O It is indicated that the airway protective sequence happens early in the swallow. O 13/15 subjects with CVA showed abnormal cardiac findings. (21)

Supraglottic Swallow
O For dysphagia accompanied by reduced or late vocal O

O O

cord closure or delayed pharyngeal swallow. Changes timing of UES opening, duration and timing of hyoid excursion and laryngeal closure, timing of BOT movement. Close vocal cords earlier in swallow, prolongs hyolaryngeal excursion-before and during swallow vocal fold closure. Logemann recommends 10x/day x5 min with 5-6 swallows each time. (4) 13/15 subjects with CVA showed abnormal cardiac findings. (21)

Head back (chin up)

O Gravity assistance. O Helps lingual deficits. O Not for use with delayed pharyngeal swallow

or poor airway closure.

Side lying
O Alters gravity for residue. O May help clear residue after the swallow

(pharyngeal). O Before sit upright-cough to clear final residue. O Will hold residual bolus material to the pharyngeal wall instead of allowing it to drop into the airway. When pharyngeal contraction is reduced such that residue is observed throughout the pharynx. (4) O When bilateral reduction in pharyngeal wall contraction reduced laryngeal elevation with pharyngeal residue aspirated after the swallow.

FRAZIER WATER PROTOCOL

O Patients who are on thickened liquids are

often placed on a Frazier Water Protocol to increase hydration.

O Thickened liquids are given with meals and

medications. O Wait for 30 minutes after meal, complete thorough oral care, then patient can have all the sterile water they want until the next meal.

PEG tube and functional dysphagia therapy (FDT)

O Looked at 2 groups, 1 with PEG and 1 without. O Non-PEG group had significant post tx improvement

in functional oral intake. O Severe dysphagia with PEG showed significant improvement, still required some PEG feedings. O More complications and increased mortality in PEG group. O All patients benefited from FDT.

Becker R., Neiczaj R., Egge K., Moll A., Meinhardt M., Schulz RJ. (2010). Functional dysphagia therapy and PEG treatment in A clinical geriatric setting. Dysphagia, Jan 26.

Predictors of aspiration: langmore, et al study (1998)

O Aspiration pneumonia is a 3 phase process: O Colonizes pathogenic bacteria in the oropharynx O Aspirates the bacteria into the airway O Unable to clear the material and then develops a bacterial infection in the respiratory system O Risk factor for aspiration include: O Dependence on others for feeding O Multiple medical conditions O Smoking O Tube feeding O Dependence for oral care O Number of decayed teeth O Number of medications
Langmore S, Terpenning M., Schork A., Chen Y., Murray J., Lopatin D., Loesche W. Predictors of aspiration pneumonia: How important is dysphagia? Dysphagia 1998; 13: 69-81

Symptoms/indications from swallow assessment

O Pharyngeal residue is an indication of decreased O O O O O O

TBR. Residue=decreased muscle function/decreased pressure. Premature spillage indicates decreased force and pressure. Epiglottic movement is an indicator for HLE. Pocketing=decreased buccal/lingual muscles. Decreased pressure=decreased muscle function. No laryngeal movement can indicate decreased pharyngeal contraction.

Outcome Measures for Dysphagia

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Duke University Rating of Radiologic Swallowing Abnormalities - This is a great rating scale during the MBSS. DOSS-Dysphagia Outcome Severity Scale (Dysphagia 14:139-145 1999) EAT-10- http://www.ncbi.nlm.nih.gov/pubmed/19140539 Functional Independence Measure/Functinoal Assessment Measure- (www.udsmr.com) (http://tbims.org/combi/FAM/ FOIS-Functional Oral Intake Scale - (http://srl.phhp.ufl.edu/publications/FOIS.pdf Mann Assessment of Swallowing Ability-MASA M.D. Anderson Dysphagia Inventory-MDADI0 (http://archotol.amaassn.org/cgi/content/abstract/127/7/870) NOMS - http://www.asha.org/members/research/NOMS/health.htm Penetration/Aspiration Scale - (http://www.springerlink.com/content/k166H1653481Ou6) SWAL-QOL and SWAL-CARE (colleen_mchorney@merck.com)

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References
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Postural Changes Rasley, A., Logemann, J.A., Kahrilas, P.J., Rademaker, A.W., Pauloski, B.R. & Dodd s, W.J. (1993). Prevention of barium aspiration during videofluoroscopic swallowing studies: value of change in posture. American Journal of Roentgenology, 160, 1005-1009. Logemann, J.A., Rademaker, A.W., Pauloski, B.R., Kahrilas, P.J. (1994). Effects of postural change on aspiration in head and neck surgical patients. Otolaryngology Head and Neck Surgery, 4, 222-227 Lewin JS, Herbert TM, Putnam JB, DuBrow RA. (2001) Experience with the chin tuck maneuver in postesophagectomy aspirators. Dysphagia 16:216-219 Campion MB, Jones B, Gayler BW, Yang SC. (2006) The esophagectomy patient: Early intervention by speech pathology improves outcome. presented at the Annual DRS Meeting, Scottsdale, AZ Blow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia. 1999;14(2):6772. [PMID: 10028035] DOI:10.1007/PL00009589 Castell JA, Castell DP, Schultz AR, Georgeson S. Effect of head position on the dynamics of the upper esophageal sphincter and pharynx. Dysphagia. 1993;8(1):16. [PMID: 8436016] DOI:10.1007/BF01351470 Welch MV, Logemann JA, Rademaker AW, Kahrilas PJ. Changes in pharyngeal dimensions affected by chin tuck. Arch Phys Med Rehabil. 1993;74(2):17881. [PMID: 8431103] Logemann JA. The role of the speech language pathologist in the management of dysphagia. Otolaryngol Clin North Am. 1988;21(4):78388. [PMID: 3054726] Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale (NJ): Erlbaum; 1998. p. 594. Logemann JA, Kahrilas PJ, Kobara M, Vakil NB. The benefit of head rotation on pharyngoesophageal dysphagia. Arch Phys Med Rehabil. 1989;70(10):76771. [PMID: 2802957] Ohmae Y, Ogura M, Kitahara S, Karaho T, Inouye T. Effects of head rotation on pharyngeal function during normal swallow. Ann Otol Rhinol Laryngol. 1998;107(4):34448. [PMID: 9557771]

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O Range of Motion O Logemann, J.A., Pauloski, B.R., Rademaker,

A.W., Colangelo, L.A. (1997). Speech and swallowing rehabilitation for head and neck cancer patients. Oncology, 5, 651-659

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Strengthening Sullivan P, Hind JA, Roecker EB, Carnes M, Doyle J, Dengel GA, Robbins J. (2001). Lingual exercise protocol for head and neck cancer: A case study. Dysphagia,16, 154 Lazarus, C.L., Logemann, J.A., Huang, C.H., Rademaker, A.W.(2003) Effects of two types of tongue strengthening exercises in young normals. Folio Phoniatrica, 55:199-205 Robbins J, Gangnon R, Theis S, Kays SA, & Hind J (2005). The effects of lingual exercise on swallowing in older adults. Journal of the American Geriatrics Society, 53, 1483-1489 Kays S, Hind J, Hewitt A, Gangon R, Robbins J (2004). Effects of lingual exercise on swallowing-related outcomes after stroke. Poster presented at the American-Speech-Language-Hearing Association annual meeting, Philadelphia, PA Shaker R, Kern M, Bardan E, Taylor A, Stewart ET, Hoffmann RG, Arndorfer RC, Hofmann C, Bonevier J. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. Am J Physiol 1997;272(Gastrointest Liver Physiol 35):G1518-G1522 Shaker R, Easterling C, Kern M, Nitschke T, Massey B, Daniels S, Grande B, Kazandjian M, Dikeman K. (2002). Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology 122:1314-1321 Palmer PM, Wohlert AB, Easley E. (2004). Oral function and quality of life after LSVT. Poster presented at the American Speech-Language-Hearing Association Annual meeting, Philadelphia, PA. Sharkawi AE, Ramig L, Logemann JA, Pauloski BR, Rademaker AW, Smith CH, Pawlas A, Baum S, and Werner C. (2002). Swallowing and voice effects of Lee Silverman Voice Treatment (LSVT): A pilot study. Journal of Neurology, Neurosurgery and Psychiatry, 72(1):31-36

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O EMST O Sapienza C (2005) Effects of respiratory

strength training on swallowing in Parkinsons patients.Presented at the Charleston Swallowing Conference, Charleston SC

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Maneuvers Martin BJW, Schleicher MA, OConnor A. (1993). Management of dysphagia following supraglottic laryngectomy. Clin Comm Disord 3:2736 Prosiegel M, Heintze M, Sonntag EW, Schenk T, Yassouridis A. Kinematic analysis of laryngeal movements in patients with neurogenic dysphagia before and after swallowing rehabilitation. Dysphagia 2000;15:173-179 Logemann, Pauloskie, Rademaker, Colangelo (1997). Super-supraglottic swallow in irradiated head and neck cancer patients,. Head & Neck, 19:535-540 Lazarus (1993). Effects of radiation therapy and voluntary maneuvers on swallow functioning in head and neck cancer patients. Clin Comm Dis, 3:11-20. Lazarus, Logemann, Song, Rademaker, Kahrilas. (2002). Effects of voluntary maneuvers on tongue base function for swallowing. Folia Phoniatr Logop, 54:171-176 Hind JA, Nicosia MA, Roecker EB, Carnes ML, Robbins J. (2001). Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Archives of Physical Medicine and Rehabilitation 82:1661-1665. Pouderoux P & Kahrilas PJ. (1995). Deglutitive tongue force modulation by volition, volume and viscosity in humans. Gastroenterology, 108, 1418-1426.

Bodn K, Hallgren A, Witt Hedstrm H. Effects of three different swallow maneuvers analyzed by videomanometry. Acta Radiol. 2006;47(7):62833. [PMID: 16950694] DOI:10.1080/02841850600774043
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Ding R, Larson CR, Logemann JA, Rademaker AW. Surface electromyographic and electroglottographic studies in normal subjects under two swallow conditions: Normal and during the Mendelsohn maneuver. Dysphagia. 2002;17(1):112. [PMID: 11820381] Kahrilas PJ, Logemann JA, Krugler C, Flanagan E. Volitional augmentation of upper esophageal sphincter opening during swallowing. Am J Physiol. 1991;260(3 Pt 1):G45056. [PMID: 2003609] Logemann JA. The role of the speech language pathologist in the management of dysphagia. Otolaryngol Clin North Am. 1988;21(4):783 88. [PMID: 3054726]

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Cohen J. Statistical power analysis for the behavioral sciences. 2nd ed. Hillsdale (NJ): Erlbaum; 998. p. 594. Blow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia. 1999;14(2):6772. [PMID: 10028035] DOI:10.1007/PL00009589 Hind JA, Nicosia MA, Roecker EB, Carnes ML, Robbins J. Comparison of effortful and noneffortful swallows in healthy middle-aged and older adults. Arch Phys Med Rehabil. 2001;82(12):166165. [PMID: 11733879] DOI:10.1053/apmr.2001.28006

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Hiss SG, Huckabee ML. Timing of pharyngeal and upper esophageal sphincter pressures as a function of normal and effortful swallowing in young healthy adults. Dysphagia. 2005;20(2):14956. [PMID: 16172825] DOI:10.1007/s00455-005-0008-y Huckabee ML, Butler SG, Barclay M, Jit S. Submental surface electromyographic measurement and pharyngeal pressures during normal and effortful swallowing. Arch Phys Med Rehabil. 2005;86(11):214449. [PMID: 16271562] DOI:10.1016/j.apmr.2005.05.005 Huckabee ML, Steele CM. An analysis of lingual contribution to submental surface electromyographic measures and pharyngeal pressure during effortful swallow. Arch Phys Med Rehabil. 2006;87(8):106772. [PMID: 16876551] DOI:10.1016/j.apmr.2006.04.019 Lever TE, Cox KT, Holbert D, Shahrier M, Hough M, Kelley-Salamon K. The effect of an effortful swallow on the normal esophagus. Dysphagia. 2007;22(4):31225. [PMID: 17694407] DOI:10.1007/s00455-007-9107-2 Pouderoux P, Kahrilas PJ. Deglutitive tongue force modulation by volition, volume, and viscosity in humans. Gastroenterology. 1995;108(5):141826. [PMID: 7729634] DOI:10.1016/0016-5085(95)90690-8 Steele CM. Huckabee ML.The influence of orolingual pressure on the timing of pharyngeal pressure events. Dysphagia. 2007;22(1):3036. [PMID: 17024546] DOI:10.1007/s00455-006-9037-4 Ohmae Y, Logemann JA, Kaiser P, Hanson DG, Kahrilas PJ. Effects of two breath-holding maneuvers on Oropharyngeal swallow. Ann Otol Rhinol Laryngol. 1996;105(2):12331. [PMID: 8659933] Van Daele DJ, McCulloch TM, Palmer PM, Langmore SE. Timing of glottic closure during swallowing: A combined electromyographic and endoscopic analysis. Ann Otol Rhinol Laryngol. 2005;114(6):47887. [PMID: 16042106]

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O Thermal Tactile Stimulation O Rosenbek J, Roecker E, Wood J, & Robbins J

(1996). Thermal application reduces the duration of stage transition in dysphagia after stroke. Dysphagia, 11, 225-233
O Rosenbek J, Williford W, Schiltz A, Robbins J,

Sowell T, Deutsch S et al. (1998). Comparing treatment intensities of tactile thermal application. Dysphagia, 13, 1-9

Evidence based dysphagia

O O O O O O O O O

NMES Ludlow C (2006). Effects of electrical stimulation on swallowing. Presented at the Annual Dysphagia Research Society meeting, Scottsdale, AZ. Power M, Fraser C, Hobson A, Rothwell JC, Mistry S, Nicholson DA et al. (2004). Changes in pharyngeal corticobulbar excitability and swallowing behavior after oral stimulation. American Journal of Physiology-Gastrointestinal and Liver Physiology, 286, G45-G50. FDA. VitalStim 510(k) clearance document K023347; 2002. Freed ML. Clinical trial data in support of VitalStim 510(k) clearance application with FDA; 2001. Christiaanse M, Glynn J, Bradshaw J. Experience with transcutaneous electrical stimulation: A new treatment option for the management of pediatric dysphagia. NCSHA. Charleston; 2003. Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Arch Otolaryngol Head Neck Surg. Jun 2007;133(6):564-571. Bulow M, Speyer R, Baijens L, Woisard V, Ekberg O. Neuromuscular Electrical Stimulation (NMES) in Stroke Patients with Oral and Pharyngeal Dysfunction. Dysphagia. Sep 2008;23(3):302-309. Permsirivanich W, Tipchatyotin S, Wongchai M, et al. Comparing the effects of rehabilitation swallowing therapy vs. neuromuscular electrical stimulation therapy among stroke patients with persistent pharyngeal dysphagia: a randomized controlled study. J Med Assoc Thai. Feb 2009;92(2):259-265. Crary MA, Carnaby-Mann GD, Faunce A. Electrical stimulation therapy for dysphagia: descriptive results of two surveys. Dysphagia. Jul 2007;22(3):165-173. 8. Bauer W. Electrical treatment of severe head and neck cancer pain. Arch Otolaryngol. Jun 1983;109(6):382383. Boswell N. Neuroelectric therapy eliminates xerostomia during radiotherapy-a case history. Med Electron. 1989(115):105-107.

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Boswell N, Bauer W. Noninvasive electrical stimulation for the treatment of radiotherapy side effects. American Journal of Electromedicine. 1985;2(3). 11. McDuffie C, Morgan M, Armstrong C, Nathan C. Electrical stimulation of post irradiated head and neck SCCA. AAO-HNS. Los Angeles; 2005. Langmore S, VanDaele D, Logemann J, et al. Electrical stimulation for dysphagia in head and neck cancer patients. A case series. DRS; 2006. 13. Pattani KM, McDuffie CM, Morgan M, Armstrong C, Nathan CA. Electrical stimulation of post-irradiated head and neck squamous cell carcinoma to improve xerostomia. J La State Med Soc. Jan-Feb;162(1):21-25. Peng G, Masood R, Sinha U. Radiation induces TGF- and blocks MyoD causing fibrosis. Paper presented at: Otolaryngology-Head and Neck Surgery; August, 2008; Chicago, IL. Lin P-H, Hsiao T-Y, Chang Y-C, et al. Effects of functional electrical stimulation on dysphagia caused by radiation therapy in patients with nasopharyngeal carcinoma. Support Care Cancer. Published online 29 November 2009. Freed ML, Freed L, Chatburn RL, Christian M. Electrical stimulation for swallowing disorders caused by stroke. Respir Care. May 2001;46(5):466-474. 17. Leelamanit V, Limsakul C, Geater A. Synchronized electrical stimulation in treating pharyngeal dysphagia. Laryngoscope. Dec 2002;112(12):2204-2210. Chaudhuri G, Brady S, Caldwell R. Electric Stimulation for Dysphagia Following Stroke: Pilot Data. Paper presented at: AAPM&R, 2006; Los Angeles. NMES in the treatment of dysphagia. Review of the evidence. Page 25 of 26 Last updated: 9/28/2010

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Carnaby-Mann GD, Crary MA. Adjunctive neuromuscular electrical stimulation for treatment-refractory dysphagia. Ann Otol Rhinol Laryngol. Apr 2008;117(4):279-287. Ludlow CL, Humbert I, Saxon K, Poletto C, Sonies B, Crujido L. Effects of surface electrical stimulation both at rest and during swallowing in chronic pharyngeal Dysphagia. Dysphagia. Jan 2007;22(1):1-10. Shaw GY, Sechtem PR, Searl J, Keller K, Rawi TA, Dowdy E. Transcutaneous neuromuscular electrical stimulation (VitalStim) curative therapy for severe dysphagia: myth or reality? Ann Otol Rhinol Laryngol. Jan 2007;116(1):36-44. Oh BM, Kim DY, Paik NJ. Recovery of swallowing function is accompanied by the expansion of the cortical map. Int J Neurosci. Sep 2007;117(9):1215-1227. Baijens LW, Speyer R, Roodenburg N, Manni JJ. The effects of neuromuscular electrical stimulation for dysphagia in opercular syndrome: a case study. Eur Arch Otorhinolaryngol. Jan 8 2008. Lagorio LA, Carnaby-Mann GD, Crary MA. Cross-system effects of dysphagia treatment on dysphonia: a case report. Cases J. Jul 30 2008;1(1):67. Bogaardt H, van Dam D, Wever NM, Bruggeman CE, Koops J, Fokkens WJ. Use of neuromuscular electrostimulation in the treatment of dysphagia in patients with multiple sclerosis. Ann Otol Rhinol Laryngol. Apr 2009;118(4):241-246. Ptok M, Strack D. Electrical stimulation-supported voice exercises are superior to voice exercise therapy alone in patients with unilateral recurrent laryngeal nerve paresis: results from a prospective, randomized clinical trial. Muscle Nerve. Aug 2008;38(2):1005-1011. CMS. Medicare program; Revised process for making medicare national coverage determinations. Vol 68: Federal Register; 2003:55634-55641. Doeltgen S, Huckabee M, Dalrymple-Alford J, Ridding M, O'Beirne G. Effect of event-related electrical stimulation on motor evoked potentials at the submental muscle group. DRS. Charleston, SC; 2008.

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Belafsky P, Speirs J, Hiss S, Postma G. The safety and efficacy of transcutaneous electrical stimulation in treating dysphagia: Preliminary experience. NCSHA. Charleston; 2004. Blumenfeld L, Hahn Y, Lepage A, Leonard R, Belafsky PC. Transcutaneous electrical stimulation versus traditional dysphagia therapy: a nonconcurrent cohort study. Otolaryngol Head Neck Surg. Nov 2006;135(5):754-757. Cheung SM, Chen CJ, Hsin YJ, Tsai YT, Leong CP. Effect of neuromuscular electrical stimulation in a patient with Sjogren's syndrome with dysphagia: a real time videofluoroscopic swallowing study. Chang Gung Med J. May-Jun;33(3):338-345. Clark H, Lazarus C, Arvedson J, Schooling T, Frymark T. Evidence-Based Systematic Review: Effects of Neuromuscular Electrical Stimulation on Swallowing and Neural Activation. Am J Speech-Language Pathology. 2009;18(November):361-375. Fowler LP, Gorham-Rowan M, Hapner ER. An Exploratory Study of Voice Change Associated With Healthy Speakers After Transcutaneous Electrical Stimulation to Laryngeal Muscles. J Voice. Jan 14 2009. Gallas S, Marie JP, Leroi AM, Verin E. Sensory Transcutaneous Electrical Stimulation Improves Post-Stroke Dysphagic Patients. Dysphagia. Oct 24 2009. NMES in the treatment of dysphagia. Review of the evidence. Page 26 of 26 Last updated: 9/28/2010 Humbert IA, Poletto CJ, Saxon KG, et al. The effect of surface electrical stimulation on hyolaryngeal movement in normal individuals at rest and during swallowing. J Appl Physiol. Dec 2006;101(6):1657-1663. Kiger M, Brown CS, Watkins L. Dysphagia management: An analysis of patient outcome using VitalStim Therapy compared to traditional swallow therapy. Dysphagia. 2006(DOI: 10.1007/s00455-006-9056-1). Lim KB, Lee HJ, Lim SS, Choi YI. Neuromuscular electrical and thermal-tactile stimulation for dysphagia caused by stroke: a randomized controlled trial. J Rehabil Med. Feb 2009;41(3):174-178.

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Mitchell K, Ramirez K, Robles M, et al. The Effectiveness of NMES (VitalStim) Therapy in the Neonatal Population: Children's Hospital of Orange County; 2010. Park J-W, Youngsun K, Jong-Chi O, Sung-Joon P. Effortful swallow combined with electrical stimulation in post-stroke dysphagic patients. DRS. New Orleans, LA; 2009. Park JW, Oh JC, Lee HJ, Park SJ, Yoon TS, Kwon BS. Effortful swallowing training coupled with electrical stimulation leads to an increase in hyoid elevation during swallowing. Dysphagia. Sep 2009;24(3):296-301. Ryu JS, Kang JY, Park JY, et al. The effect of electrical stimulation therapy on dysphagia following treatment for head and neck cancer. Oral Oncol. Dec 16 2008. Suiter DM, Leder SB, Ruark JL. Effects of neuromuscular electrical stimulation on submental muscle activity. Dysphagia. Jan 2006;21(1):56-60.

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O FEES O Langmore, Susan E. Evaluation of oropharyngeal

dysphagia: which diagnostic tool is superior? Opinion in Otolaryngology & Head & Neck Surgery: December 2003 - Volume 11 - Issue 6 - pp 485-489
O Kidder, T.M, Langmore, S.E. and Martin,

BJ. Indications and techniques of endoscopy in evaluation of cervical dysphagia: Comparison with radiographic techniques. DYSPHAGIA. Volume 9, Number 4, 256-261, DOI: 10.1007/BF00301919

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O MBSS O Susan E. Langmore, and Jeri A. Logemann

After the Clinical Bedside Swallowing Examination: What Next? Am J Speech Lang Pathol 1991;1;13-20

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ORAL CHEMESTHETIC PROPERTIES AND TASTE PROPERTIES Logemann, J.A., Preswallow sensory input: its potential importance to dysphagic patients and normal individuals. Dysphagia, 1996. 11(1): p. 9-10. Kagel, M., C and N.A. Leopold, Dysphagia in Huntington's disease: a 16-year retrospective.Dysphagia, 1992. 7(2): p. 106-114. Ding, R., et al., The effects of taste and consistency on swallow physiology in younger and older healthy individuals: a surface electromyographic study. Journal of Speech, Language and Hearing Research, 2003. 46: p. 977-989. Leow, L.P., et al., The influence of taste on swallowing apnea, oral preparation time, and duration and amplitude of submental muscle contraction. Chem Senses, 2007. 32(2): p. 119-28. Blow, M., R. Olsson, and O. Ekberg, Videoradiographic analysis of how carbonated thin liquids and thickened liquids affect the physiology of swallowing in subjects with aspiration on thin liquids. Acta Radiologica, 2003. 44(4): p. 366-372. Logemann, J.A., et al., Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. Journal of Speech and Hearing Research, 1995. 38(3): p. 556-63. Pelletier, C.A. and H.T. Lawless, Effect of citric acid and citric acid-sucrose mixtures on swallowing in neurogenic oropharyngeal dysphagia. Dysphagia, 2003. 18(4): p. 231-41. Chee, C., et al., The influence of chemical gustatory stimuli and oral anaesthesia on healthy human pharyngeal swallowing. Chemical Senses, 2005. 30: p. 393-400. Pelletier, C.A. and G.E. Dhanaraj, The effect of taste and palatability on lingual swallowing pressure.Dysphagia, 2006. 21(2): p. 121-8. Nixon, T.S., Use of carbonated liquids in the treatment of dysphagia., in Network: A Newsletter of Dietetics in Physical Medicine and Rehabilitation. 1997.

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O Palmer, P.M., et al., Effects of a sour bolus on the

intramuscular electromyographic (EMG) activity of muscles in the submental region. Dysphagia, 2005. 20(3): p. 210-7.

O Miura, Y., et al., Effects of taste solutions, carbonation, and

cold stimulus on the power frequency content of swallowing submental surface electromyography. Chem Senses, 2009. 34(4): p. 325-31. Club Soda and Reeds Extra Ginger Brew on Lingual-Palatal Pressure During Swallowing in Healthy Women. Oral Presentation. Eighteenth Annual Dysphagia Research Society Meeting in San Diego, CA, USA. March, 2010

O Krival, K. & Talbert, C. Effects of Distilled Water, Schweppes

Evidence based dysphagia

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Viscosity, texture, size, and other bolus characteristics Steele, C.M. and P.H. van Lieshout, Influence of bolus consistency on lingual behaviors in sequential swallowing. Dysphagia, 2004. 19(3): p. 192-206. Chi-Fishman, G. and B.C. Sonies, Effects of systematic bolus viscosity and volume changes on hyoid movement kinematics. Dysphagia, 2002. 17(4): p. 278-287. Kuhlemeier, K.V., J.B. Palmer, and D. Rosenberg, Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients. Dysphagia, 2001. 16(2): p. 119-122. Castellanos, V.H., et al., Use of thickened liquids in skilled nursing facilities. Journal of the American Dietetic Association, 2004. 104(8): p. 1222-1226. Garcia, J.M. and E. Chambers, Insights into practice patterns for thickened liquids. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 2006. 15(1): p. 14-18. Steele, C.M. and P.H. Van Lieshout, Does barium influence tongue behaviors during swallowing?American Journal of Speech Language Pathology, 2005. 14(1): p. 27-39. Hiiemae, K.M. and J.B. Palmer, Food transport and bolus formation during complete feeding sequences on foods of different initial consistency. Dysphagia, 1999. 14(1): p. 31-42. Garcia, J.M., E.t. Chambers, and M. Molander, Thickened liquids: practice patterns of speech-language pathologists. American Journal of Speech-language Pathology / American Speech-Language-Hearing Association, 2005. 14(1): p. 4-13.

Online dysphagia resources

O Dysphagia Mail list- http://www.dysphagia.com/ O Dysphagia Research SocietyO

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http://www.dysphagiaresearch.org/ Dysphagia Therapy Group on Facebookhttp://www.facebook.com/home.php?sk=group_1024537365 03465&ap=1 Dysphagia Ramblings-Blog apujo5.blogspot.com Special Interest Group 13-Swallowing and Swallowing Disorders (ASHA)- http://www.asha.org/SIG/13/ ASHA Graduate Curriculum Guidehttp://www.asha.org/docs/html/TR2007-00280.html Board Recognized Specialty in Swallowing (BRS-S)http://www.swallowingdisorders.org/ www.dysphagiaramblings.com