Frazier Water Protocol

Type

Protocol

Contraindications

Staff education and aggressive oral care is crucial when implementing the protocol.

Impairments/Observations

Materials

• Water

• Oral Care Supplies

Instructions

Frazier Water Protocol Guidelines:

• Any patient, whether NPO or on a dysphagic diet, is permitted to have free water
between meals.

• Water intake is unrestricted prior to a meal, and allowed 30 minutes after a meal.

• Aggressive oral care is provided to patients following the protocol.

• Must be implemented by training staff, patients and family members to follow

guidelines.

Cranial Nerves

Notes

More information about implementation of the Frazier Water Protocol can be found at:

http://www.kentuckyonehealth.org/frazier-water-protocol

Selected References

Carlaw, C., Finlayson, H., Beggs, K., Visser, T., Marcoux, C., Coney, D., & Steele, C. M.
(2012). Outcomes of a Pilot Water Protocol Project in a Rehabilitation Setting.
Dysphagia, 27(3), 297–306.

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Frey, K. L., & Ramsberger, G. (2011). Comparison of outcomes before and after
implementation of a water protocol for patients with cerebrovascular accident and
dysphagia. Journal of Neuroscience Nursing, 43(3), 165-171.

Garon, B.R., Engle, M., Ormiston, C. (1997). A randomized control study to determine
the effects of unlimited oral intake of water in patients with identified aspiration.
Neurorehabil Neural Repair 11:139-148.

Gillman, A., Winkler, R., & Taylor, N. F. (2017). Implementing the free water protocol
does not result in aspiration pneumonia in carefully selected patients with dysphagia: a
systematic review. Dysphagia, 32(3), 345-361.

Karagiannis, M., & Karagiannis, T. C. (2014). Oropharyngeal dysphagia, free water

protocol and quality of life: an update from a prospective clinical trial. Hell J Nucl Med.
Suppl 1:26-9.

Panther, K. (2005). The Frazier Free Water Protocol. Persp Swall Swall Disord
(Dysphagia) 14:4-9.

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 Myofascial Release

Type

Protocol

Impairments/Observations

Impairments:

• Decreased buccal tension

• Decreased lingual strength

• Impaired hyolaryngeal excursion

• Decreased labial range of motion

• Decreased lingual range of motion

Observations:

• Impaired bolus control

• Impaired oral containment

• Impaired bolus formation

• Impaired bolus propulsion

Materials

None

Instructions

Follow protocol.

Cranial Nerves

CN V, CN VII, CN IX, CN X, CN XII

Notes

Training offered.

https://www.ciaoseminars.com/CB-courseDetail.cfm?oid=320&ctid=2&evd=1

Selected References

Duncan, B., McDonough-Means, S., Worden, K., Schnyer, R., Andrews, J., & Meaney,

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F. J. (2008). Effectiveness of osteopathy in the cranial field and myofascial release
versus acupuncture as complementary treatment for children with spastic cerebral
palsy: a pilot study. The Journal of the American Osteopathic Association, 108(10),
559-570.

Hodgson, L., & Fryer, G. (2006). The effect of manual pressure release on myofascial
trigger points in the upper trapezius muscle. International Journal of Osteopathic
Medicine, 9(1), 33.

Marszałek, S., Żebryk-Stopa, A., Kraśny, J., Obrębowski, A., & Golusiński, W. (2009).
Estimation of influence of myofascial release techniques on esophageal pressure in
patients after total laryngectomy. European Archives of Oto-Rhino-Laryngology, 266(8),
1305-1308.

Shah, S., & Bhalara, A. (2012). Myofascial release. International Journal of Health
Science & Research, 2(2), 69-77.

Vernon, H., & Schneider, M. (2008). Chiropractic management of myofascial trigger

points and myofascial pain syndrome: A systematic review of the literature. Journal of
Manipulative & Physiological Therapeutics, 32(1), 14-24.

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 Neuromuscular Electrical Stimulation

Type

Protocol

Impairments/Observations

Impairments:

• Impaired hyolaryngeal excursion

• Impaired pharyngeal constriction

• Decreased labial strength

• Impaired protection of the airway

• Decreased buccal tension

• Decreased tongue base retraction

Observations:

• Anterior spillage of the bolus

• Impaired oral containment

Materials

• NMES Device (see Notes)

• Electrodes

Instructions

Follow protocol.

Cranial Nerves

CN V, CN X

Notes

Must be paired with traditional swallowing exercises to be effective.

VitalStim certification

https://www.ciaoseminars.com/vitalstim.cfm?&onrequest

Guardian certification

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https://spectramedonline.com/continuing-education-dysphagia-treatment/adult-focused-
course/

AmpCare certification

http://swallowtherapy.com/esp-ce-training/

eSwallow certification

http://www.eswallowusa.com/training.html

Selected References

Burns, M. I., & Miller, R. M. (2011). The effectiveness of neuromuscular electrical

stimulation (NMES) in the treatment of pharyngeal dysphagia: a systematic review.
Journal of Medical Speech-Language Pathology, 19(1), 13-25.

Chen, Y. W., Chang, K. H., Chen, H. C., Liang, W. M., Wang, Y. H., & Lin, Y. N. (2016).
The effects of surface neuromuscular electrical stimulation on post-stroke dysphagia: a
systemic review and meta-analysis. Clinical rehabilitation, 30(1), 24-35.

Clark, H., Lazarus, C., Arvedson, J., Schooling, T., & Frymark, T. (2009). Evidence-
based systematic review: effects of neuromuscular electrical stimulation on swallowing
and neural activation. American Journal of Speech-Language Pathology, 18(4),
361-375.

Huckabee, M. L., & Doeltgen, S. (2007). Emerging modalities in dysphagia

rehabilitation: neuromuscular electrical stimulation. 100 Years Ago in the NZMJ.

Humbert, I. A., Michou, E., MacRae, P. R., & Crujido, L. (2012). Electrical stimulation
and swallowing: How much do we know?. Seminars in Speech and Language. 33(3),
203.

Ludlow, C. L. (2010). Electrical neuromuscular stimulation in dysphagia: current status.

Current opinion in otolaryngology & head and neck surgery, 18(3), 159-164.

Ludlow, C. L., Humbert, I., Saxon, K., Poletto, C., Sonies, B., & Crujido, L. (2007).
Effects of surface electrical stimulation both at rest and during swallowing in chronic
pharyngeal dysphagia. Dysphagia, 22(1), 1-10.

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 McNeill Dysphagia Therapy Program

Type

Protocol

Impairments/Observations

Impairments:

• Impaired hyolaryngeal excursion

• Decreased lingual strength

• Impaired pharyngeal constriction

• Impaired relaxation of the pharyngoesophageal segment

Observations:

• Impaired bolus control

• Impaired oral containment

• Impaired bolus formation

• Impaired bolus propulsion

• Oral residue

• Pyriform sinus residue

Materials

• Bolus

• Food Hierarchy

• Data Sheet

• Written Instructions (optional)

Instructions

Follow protocol.

Cranial Nerves

CN V, CN VII, CN IX, CN X, CN XII

Notes

Requires certification.

https://degluted.fdi2.com/pages/MDTP

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Research suggests that patients must be able to tolerate daily therapy and be
reasonably cognitively intact to benefit.

Selected References

Carnaby-Mann, G. D., & Crary, M. A. (2010). McNeill dysphagia therapy program: A

case-control study. Archives of Physical Medicine and Rehabilitation, 91(5), 743-749.

Crary, M. A., & Carnaby, G. D. (2014). Adoption into clinical practice of two therapies to
manage swallowing disorders: exercise based swallowing rehabilitation and electrical
stimulation. Current opinion in otolaryngology & head and neck surgery, 22(3), 172.

Crary, M. A., Carnaby, G. D., LaGorio, L. A., & Carvajal, P. J. (2012). Functional and
physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation
of the McNeill Dysphagia Therapy Program.Archives of physical medicine and
rehabilitation, 93(7), 1173-1178.

Lan, Y., Ohkubo, M., Berretin-Felix, G., Sia, I., Carnaby-Mann, G. D., & Crary, M. A.
(2012). Normalization of temporal aspects of swallowing physiology after the McNeill
dysphagia therapy program. Annals of Otology Rhinology and Laryngology-Including
Supplements, 121(8), 525.

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 Lee Silverman Voice Treatment

Type

Protocol

Impairments/Observations

Impairments:

• Impaired hyolaryngeal excursion

• Decreased lingual strength

• Impaired velopharyngeal closure

Observations:

• Impaired oral containment

• Impaired bolus propulsion

• Oral residue

Materials

• Materials as per LSVT Protocol

Instructions

Follow protocol.

Cranial Nerves

CN X

Notes

Requires certification.

https://www.lsvtglobal.com/Get_LSVTLoud_Certified

Research suggests that patients must be able to tolerate treatment of at least 4

consecutive days per week to benefit.

Selected References

El Sharkawi, A., Ramig, L., Logemann, J. A., Pauloski, B. R., Rademaker, A. W., Smith,

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C. H., & Werner, C. (2002). Swallowing and voice effects of Lee Silverman Voice
Treatment (LSVT®): a pilot study. Journal of Neurology, Neurosurgery & Psychiatry,
72(1), 31-36.

Miles, A., Jardine, M., Johnston, F., de Lisle, M., Friary, P., & Allen, J. (2017). Effect of
Lee Silverman Voice Treatment (LSVT LOUD®) on swallowing and cough in
Parkinson's disease: A pilot study. Journal of the Neurological Sciences, 383, 180-187.

Ramig, L. O., Fox, C., & Sapir, S. (2004, May). Parkinson's disease: speech and voice
disorders and their treatment with the Lee Silverman Voice Treatment. Seminars in
Speech and Language. 25(2), 169-180.

Russell, J. A., Ciucci, M. R., Connor, N. P., & Schallert, T. (2010). Targeted exercise
therapy for voice and swallow in persons with Parkinson's disease.Brain research,
1341, 3-11.

Sapir, S., Ramig, L., & Fox, C. (2008). Speech and swallowing disorders in Parkinson
disease. Current opinion in otolaryngology & head and neck surgery,16(3), 205-210.

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 Effective Swallowing Protocol (with Ampcare NMES)

Type

Protocol

Impairments/Observations

Impairments:

• Impaired hyolaryngeal excursion

• Decreased tongue base retraction

• Decreased intraoral pressure

• Impaired protection of the airway

• Impaired pharyngeal constriction

• Impaired relaxation of the pharyngoesophageal segment

Observations:

• Aspiration after the swallow

• Vallecular residue

• Pyriform sinus residue

• Penetration after the swallow

• Impaired bolus propulsion

• Pyriform sinus residue

Materials

• Restorative Posture Device (https://swallowtherapy.com/product/rpd/)

• Ampcare NMES Device

• Electrodes

Instructions

Follow protocol.

Cranial Nerves

CN V, CN VII, CN IX, CN X, CN XII

Notes

Requires certification.

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http://swallowtherapy.com/esp-ce-training/

Protocol makes use of:

• Mendelsohn Maneuver

• Effortful Swallow

• Chin Down (using device)

Selected References

See Ampcare website for list of references:

http://www.swallowtherapy.com/research/

Watts, C. R. (2013). Measurement of hyolaryngeal muscle activation using surface

electromyography for comparison of two rehabilitative dysphagia exercises. Archives of
Physical Medicine and Rehabilitation, 94(12), 2542-2548.

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 Pharyngocise (Head and Neck Cancer Program)

Type

Protocol

Impairments/Observations

Impairments:

• Decreased labial strength

• Decreased lingual strength

• Impaired hyolaryngeal excursion

• Decreased labial range of motion

• Decreased lingual range of motion

Observations:

• Anterior spillage of the bolus

• Impaired bolus control

• Impaired oral containment

• Impaired bolus formation

• Impaired bolus propulsion

• Oral residue

Materials

• Therabite (http://www.craniorehab.com/therabite)

• Bolus

• Tongue Depressor

Instructions

Complete 4 sets of 10 repetitions, 2 times a day, for 6 weeks:

• Falsetto

• Tongue press

• Hard Swallow (effortful swallow)

• Jaw resistance (using Therabite)

• Dietary Modification

Cranial Nerves

CN V, CN VII, CN IX, CN X, CN XII

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Selected References

Carnaby, G. D., Lagorio, L., Crary, M. A., Amdur, R., & Schmalfuss, I. (2012, March).
Dysphagia prevention exercises in head and neck cancer: pharyngocise dose response
study. In 20th Annual Dysphagia Research Society Meeting.

Carnaby-Mann, G., Crary, M. A., Schmalfuss, I., & Amdur, R. (2012). "Pharyngocise":
randomized controlled trial of preventative exercises to maintain muscle structure and
swallowing function during head-and-neck chemoradiotherapy. International Journal of
Radiation Oncology, Biology, Physics, 83(1), 210-219.

Crary, M. A., & Carnaby, G. D. (2014). Adoption into clinical practice of two therapies to
manage swallowing disorders: exercise based swallowing rehabilitation and electrical
stimulation. Current opinion in otolaryngology & head and neck surgery, 22(3), 172.

Drulia, T. C., & Ludlow, C. L. (2013). Relative Efficacy of Swallowing Versus Non-
swallowing Tasks in Dysphagia Rehabilitation: Current Evidence and Future Directions.
Current physical medicine and rehabilitation reports, 1(4), 242-256.

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