By Maria Quici, MS, CCC-SLP
There are many ways to manage oral-pharyngeal dysphagia, ranging from basic oral-motor exercises to the use of electrical stimulation to diet and liquid modifications to compensatory strategies used while eating. Exercises and strategies facilitate the management of food during the oral phase of the swallow and also aim to decrease the risk of aspiration (food or liquid entering the airway) during the pharyngeal phase.
Basic oral-motor exercises focus on strengthening the muscles used for chewing and swallowing. Exercises to improve the oral control of food include lip, facial and tongue exercises. Improving lip closure and lingual movement can help in reducing food falling from the mouth, drooling and the pocketing of food in the mouth (residual food or liquid left behind after the swallow – usually on the side of the mouth that is weak or has decreased sensation).
Exercises targeting the pharyngeal phase of swallowing are geared toward improving laryngeal elevation, base of tongue and posterior pharyngeal wall movement (Swigert, 2007). These include the Mendelsohn maneuver, the Masako maneuver, Shaker exercises and thermal-tactile stimulation. Specially trained speech-language pathologists (SLPs) can provide NMES (neuromuscular electrical stimulation) which involves the placing of electrodes on the surface of the skin and using an electrical current, which causes contraction of the muscle fibers, to strengthen the muscles used for swallowing. Improving sensory input via thermal-tactile stimulation may help to facilitate the initiation of the swallow reflex (Clark, 2003).
Exercises to improve airway protection include breath hold, supra-glottic swallow and push-pull with voicing. Strengthening the voice is important in reducing the risk of aspiration since the vocal folds sit at the top of the airway and need to close (adduct) during the swallow, thereby protecting the airway from food or liquid “going down the wrong pipe.”
Modifying the texture of foods and the consistency of liquids can facilitate the oral management of a bolus and also reduce the risk of aspiration. Solid foods can be chopped, ground or pureed. Dentition should also be taken into consideration when deciding which texture is appropriate. Avoiding particle foods like rice and seeds may also be necessary as they can be difficult to form into a cohesive bolus (the ball or mass of food formed prior to swallowing). Liquids can be thickened to nectar, honey or pudding consistency (a non-thickened – or regular/thin consistency liquid – is like water). The thicker a liquid is, the slower it moves and may be more easily controlled in the mouth. Commercial thickening agents as well as pre-thickened liquids are available for purchase at most drug stores and also online.
The form in which medications are given should comply with diet and liquids recommendations. For example, a person requiring nectar thick liquids should not take pills with regular water. Pills may need to be crushed and mixed with a carrier like yogurt, applesauce or pudding. For pills that cannot be crushed, other forms of the medication may be available, for example, a trans-dermal patch. Liquid medications can be mixed with thickened liquids. Supplements like protein drinks should be thickened to the prescribed liquid consistency.
Compensatory strategies are techniques that are used during a meal and when taking medications. Sitting as upright as possible is ideal, but not always possible due to pain or recent surgery. Bolus size is also important. The amount of food taken per bite should be large enough to trigger a swallow and be safely managed orally, but not so large as to potentially be aspirated. Liquids may be given via cup, spoon, controlled sip from a straw or even via a syringe if necessary. Eating and drinking slowly rather than quickly is generally safer. Alternating liquids and solids, using a tongue sweep and placing the food on the strong side of the mouth can help reduce pocketing. Other strategies include using a head turn, chin tuck, reducing environmental distractions and ensuring adequate levels of alertness during a meal.
How effective are these treatment options? In 2009, Clark, Lazarus, Arvedson, Schooling and Frymark completed a systematic review of current evidence for NMES. For muscle strengthening for swallowing, 2 studies showed an advantage of NMES compared to traditional treatment, 1 study showed no difference. Still, the results are promising and warrant further research.
In 2011, Lazarus, Clark, Arvedson, Schooling and Frymark published another systematic review of the evidence, this time on the effects of oral-motor exercises. The authors concluded that there is “insufficient evidence” for the use of oral-motor exercises for dysphagia and that “current best practice, client values and clinical expertise should be incorporated into decisions about the use of treatment techniques.”
ASHA’s Treatment Efficacy Summary states that “treatment outcome studies have provided evidence that compensatory strategies designed to have an immediate effect on the swallow (ie postural changes or diet manipulation) can improve swallowing safety and efficiency.”
In managing dysphagia, it’s important to work with a certified and licensed speech-language pathologist who specializes in the assessment and treatment of swallowing disorders. This SLP can design a treatment program, recommend an appropriate diet and/or liquid level and teach compensatory strategies, all designed to ensure the safe intake of food and liquids. To find a certified SLP in your area who specializes in dysphagia, go to: www.asha.org or visit the website of your state’s speech and hearing association.
Ashford, J., Logemann, J. & McCullough, G. Treatment Efficacy Summary: Swallowing Disorders (Dysphagia) in Adults. American Speech and Hearing Association (ASHA). Retrieved December 16, 2013, from http://www.asha.org
Clark, H. (2003). Neuromuscular Treatments for Speech and Swallowing: A Tutorial. AJSLP, 12, 400-415.
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. AJSLP, 18, 361-375.
Lazarus, C., Clark, H., Arvedson, J., Schooling, T. & Frymark, T. (2011). Evidence-Based Systematic Review: Effects of Oral Sensory-Motor Treatment on Swallowing in Adults. ASHA’s National Center for Evidence-Based Practice in Communication Disorders. Retrieved December 16, 2013, from
Swigert, N. (2007). The Source for Dysphagia (3rd ed.). East Moline, IL: LinguiSystems.