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According to the American Speech-Language-Hearing Association (n.d.), the primary goals of dysphagia intervention are to:
Support adequate nutrition and hydration and return to oral intake.
Determine the optimum supports (e.g., posture, or assistance) to reduce patient and caregiver burden while maximizing the patient’s quality of life.
Develop a treatment plan to improve the safety and efficiency of the swallow.
Prevent pulmonary disease processes (e.g. aspiration pneumonia).
This is not an exhaustive resource. This resource was structured to discuss the importance of biofeedback in treatment, provide information regarding selected therapy activities, and provide methods effective in the prevention of aspiration, as aspiration in persons with dysphagia can lead to additional health issues (e.g. aspiration pneumonia) and longer hospital stays (Reagan et al., 2017). While the following are not discussed on this page, it is important to note there are several steps that need to be done prior to treatment selection, including a careful chart review, obtaining a case history, an evaluation of present levels of cognition, and an evaluation of present swallow function (e.g. clinical observation, bedside swallow evaluation, modified barium swallow studies (MBSS), fiberoptic endoscopic evaluation of swallowing (FEES), etc.) (Crary & Groher, 2010; Gallegos et al., 2017; Metheny, 2008). It is important to note that an individualized treatment plan is crucial for dysphagia patients, considering varying anatomical differences, diagnoses, and levels of functioning. Persons with dysphagia are treated for various medical diagnoses (e.g. head and neck cancer (HNC), stroke (CVA), degenerative disorders, etc.), in a variety of settings (e.g. acute care, outpatient, skilled nursing facility (SNF), etc.), and these are important to consider when creating a treatment plan. Furthermore, the patient's and family's goals and values are also crucial factors (Crary & Groher, 2010; Gallegos et al., 2017; Metheny, 2008).
This resource was intended to be used as a reference. Careful patient consideration and further research are necessary before implementing a treatment plan.
Biofeedback
Biofeedback is a process of using electronic or other instruments (e.g. surface electromyography, ultrasound, flexible endoscopic evaluation of swallowing [FEES], mirror, etc.) to improve awareness of physiological functions.
When to use Biofeedback:
In assessment/evaluation to determine present levels and any anatomical differences.
In therapy in conjunction with compensatory strategies and rehabilitation exercises. Biofeedback can allow the patient to see the anatomic functions of the swallow in real time or receive objective feedback in real time from software as therapy exercises are performed. Without biofeedback, patients can only conceptualize interior anatomic functions or are limited to subjectivity, making it difficult to make requested changes to improve swallow function.
Important considerations: Biofeedback is especially useful for patients with the cognitive skills to be taught to interpret visual information and use it to make physiological changes during the swallowing process. The patient needs to have the ability to follow directions, interpret visual information, and use it to make physiological changes during the swallowing process. Due to the necessity of adequate cognitive abilities, the primary setting to use biofeedback in therapy attempts to improve functional swallow is outpatient.
See the link below for additional information regarding surface electromyographic biofeedback (sEMG).
Compensatory Strategies
There is no rehabilitative impact and no lasting functional effect on swallowing. These strategies are appropriate to use if prognosis is good for the eventual successful swallow in the absence of compensatory strategies. Compensatory strategies allow for a safe swallow until a functional swallow can be restored. Clinicians are not intentionally attempting to improve the swallowing mechanism. Compensatory strategies can be effective for patients with head and neck cancer, Amyotrophic Lateral Sclerosis (ALS), Traumatic Brain Injuries (TBI), and additional neurodegenerative diseases.
Swallowing Exercises
Rehabilitative swallowing exercises aim to restore the swallowing mechanism and function and improve the quality of life of patients experiencing dysphagia. Swallowing exercises intentionally focus on improving specific dysphagia impairments identified during evaluation. Swallowing exercises are intended to have lasting positive effects of the swallowing mechanism. Please note some rehabilitative exercises may sometimes be considered a compensatory strategy as well.
Prevention of Aspiration
Aspiration prevention should be considered in persons with dysphagia. According to Metheny (2008), the risk of pneumonia (PNA) is three times higher in patients with dysphagia.
Clinical symptoms of aspiration (Metheny, 2008):
The sudden appearance of respiratory symptoms (e.g. coughing) during eating and/or drinking.
Vocal change during eating and/or drinking (e.g. wet vocal quality, hoarseness).
Pocketing of food during mealtimes.
It is important to note, small-volume aspirations are often not discovered until the condition progresses to aspiration pneumonia (Crary & Groher, 2010; Metheny, 2008). PNA is under-diagnosed in older persons, as they often complain of fewer symptoms than younger persons (Metheny, 2008).
Clinical symptoms of aspiration pneumonia (Metheny, 2008):
Delirium in elderly persons.
An elevated respiratory rate.
Fever, chills, chest pain.
Patient example:
Stroke: The primary methods used to prevent aspiration during oral intake in dysphasic stroke patients include modified diets and swallowing maneuvers (Smithard, 2016).
Methods to prevent aspiration during hand feeding (Metheny, 2008):
Provide 30-minute rest prior to feeding time.
Sit the person upright, at a 90-degree angle.
Implement postural changes that improve swallowing.
Adjust rate of feeding and size of bites.
Alternate solids and liquids.
Methods to prevent aspiration during NG-tube feeding (Metheny, 2008):
Tube feedings may be appropriate in the early weeks of care for persons with acute stroke resulting in sever dysphagia (Metheny, 2008). While spontaneous and/or treatment induced recovery may occur and the NG-tube removed, the following should be considered during NG-tube feeding to reduce aspiration:
Position the bed's backrest to an elevation at least 30-degrees.
Monitor tube location per institution policy to ensure the tube isn't displaced.
Observes for signs of intolerance (e.g. abdominal distention, large residual volumes).
Depending on ability to respond, ask the patient if the following signs fo gastrointestinal intolerance are present: nausea, feeling of fullness, abdominal pain. These signs can indicate slowed gastric emptying, which increases probablility of regurgitation and aspiration (Metheny, 2008).
Click the links below for more information on how modified diets and oral care can be used to reduce aspiration in persons with dysphagia.
American Speech-Language-Hearing Association (n.d.). Adult dysphagia. American Speech-Language-
Hearing Association. Retrieved November 30, 2022, from https://www.asha.org/practice-
portal/clinical-topics/adult-dysphagia/#collapse_6
Crary, M.A., & Groher, M.E. (2010). Dysphagia: Clinical management in adults and children,
Mosby Elsevier, Maryland Heights, MO.
Metheny, N. A. (2008). Preventing aspiration in older adults with dysphagia. AJN, American
Journal of Nursing, 108(2), 45–46. https://doi.org/10.1097/01.naj.0000310333.78303.62
Regan, J., Lawson, S., & De Aguiar, V. (2017). The eating assessment tool-10 predicts
aspiration in adults with stable chronic obstructive pulmonary disease. Dysphagia,
32(5), 714–720.https://doi.org/10.1007/s00455-017-9822-2.
Smithard, D.G. (2016). Dysphagia management and stroke units. Current Physical Medicine
and Rehabilitation Reports, 4(4), 287-294.
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