The following is a sponsored post from Dysphagia-Tech, the makers of Phagia Cup!
Dorothy: Now which way do we go?
Scarecrow: Pardon me, this way is a very nice way.
Dorothy: Who said that? [Toto barks at scarecrow]
Dorothy: Don’t be silly, Toto. Scarecrows don’t talk.
Scarecrow: [points other way] It’s pleasant down that way, too.
Dorothy: That’s funny. Wasn’t he pointing the other way?
I present the story of The Wizard of Oz only as a simplified platform for us to understand, or rather question our understanding, of treatment in dysphagia. Do you ever feel like Dorothy? The process in treating patients with dysphagia can be a challenging one.
This post is sponsored by Dysphagia-Tech, makers of Phagia Cup. Find out more here!
Each individual presents something different and there is by no means a “fix-all” in swallow rehabilitation —Some patients require postural changes, diet modifications, or dining tools to aid in their safety of swallowing. How do we know which way to go?
Langmore & Pisegna (2015) bring up a great question, “How does one define a ‘better swallow’?” They go on to state that it depends on what you’re measuring and what the goal is. Are you trying to decrease pre-mature spillage?
I invite you to think of dysphagia rehabilitation as a story with many characters…
Are you trying to strengthen the swallow? Decrease aspiration? Include patient preferences? The list goes on and on.
So, what would the story be without Dorothy or without the Scarecrow? I invite you to think of dysphagia rehabilitation as a story with many characters, namely incorporation of many entities. Thank goodness for a field that allows us to continue to grow in our own clinical knowledge while incorporate amazing evidence! Anyone notice anything missing? Ah, yes. Patient values! Maybe the full story includes incorporating a free water protocol because your patient really wants some clean, thin water. Or maybe you see on your instrumental that they really benefit from a head turn to decrease pharyngeal residue, so you suggest they complete this until you can strengthen their swallow and thus decrease pharyngeal residue all-together.
We must not limit ourselves to just one mode of treatment towards “a better swallow” in our road to dysphagia management. To exhibit this incorporation of multiple treatment techniques, I bring up a recent study completed by Byeon, (2016). This particular study examined postural techniques and expiratory muscle strength training (EMST) on the enhancement of swallow function in individuals with dysphagia caused by Parkinson’s Disease. Byeon found that postural techniques in conjunction with EMST was more effective than EMST alone. Through this example as well as continued research in the field, there appears to be a place for not one, but many treatment techniques, and we can only hope that research conducted on specifics of treatment protocols as well as research completed with dysphagic patients will continue.
As mentioned above, postural techniques can be useful for some patients with dysphagia. Postural techniques redirect the bolus and modify pharyngeal dimensions in a strategic way. Patient preferences can also come into play in using postural changes. Are they comfortable with it? Do they REALLY want to drink thin liquids vs. thickened liquids and a postural change allows them to safely do so? Again, there is no one-size-fits all approach.
Below are some of the compensatory strategies that aim to reduce a deficit in the swallow:
- Chin Tuck- Brings the posterior tongue closer to the pharyngeal wall, widens vallecular space, and narrows the opening to the airway.
- Head Rotation- The head is turned the right or left, generally turned towards the weak side, to direct the bolus down the strong side of the pharynx.
- Controlled Swallow- Decreases pre-mature spillage of the bolus into the pharynx.
- Effortful swallow- Increases base of tongue movement to facilitate bolus clearance.
Now, postural techniques are only one piece of the story, right? Why are they benefiting from a postural adjustment? Because, their swallow is weakened or less adaptive in some way. Below are a few swallowing exercises that aim to change the strength or timing of the swallow. Again, what does this specific patient’s “better swallow” include?
- Masako/Tongue hold- Strengthens the posterior pharyngeal wall. Aids in decreasing pharyngeal residue.
- Shaker- Increases hyoid and laryngeal elevation and excursion resulting in increased opening of the esophageal sphincter
- Laryngeal elevation/Pitch glides- Increases laryngeal elevation for airway closure.
Overall, the story and road to treatment in dysphagia is by no means complete, or a single road for that matter. However, for now we can only aim to include all of the known characters and help move our patients closer to their safe, comfortable “better swallow”—for there’s no place like home.
Links of Interest
Byeon, H. (2016). Effect of simultaneous application of postural techniques and expiratory muscle strength training on the enhancement of the swallow function of patients with dysphagia caused by parkinson’s disease. Journal of Physical Therapy Science, Jun, 28(6), pp.1840-1843. doi: 10.1589/jpts.28.1840
Langmore, S.E., Pisegna, J.M. (2015) Efficacy of exercises to rehabilitate dysphagia: A critique of the literature. International Journal of Speech-Language Pathology, 17(3), pp. 222-229. doi: 10.3109/17549507.2015.1024171