Swallowing interventions take several forms. One tool in the Speech Language Pathologist (SLP) toolbox is compensation, postural and behavioral interventions that impact the kinematics of the swallow. The most common compensatory technique is the chin down posture. An example of adaptation would be, the patient consumes a pureed diet due to dysphagia. Instead of fixing the problem, the environment or stimulus remains indefinitely modified. The most valuable tool, and often the most under-utilized item, in the therapist’s toolbox is rehabilitation.
Rehabilitation by definition is “to restore to a good condition or operation.” This requires much more than putting a Band-Aid on the situation. It requires analysis of the underlying issue and consideration of available options for intervention.
Lori Burkhead (2007) published a seminal article, “Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Directions for Future Research.” It is time to review it
and use it to guide our thought processes when treating dysphagia. So, let’s get started:
1. Exercises must challenge the system beyond normal levels of activity.
“ Exercise efforts that do not force the neuromuscular system beyond the level of usual activity will not elicit adaptations. By challenging the system beyond typical use, adaptations occur to accommodate the increased demand. Engaging in exercise that is not intense enough to push the system beyond the level of activity to which it is accustomed will not result in adaptation.”
Selecting underwhelming activities will not result in change. In 1989 Perlman published information concerning the use of velar sounds in dysphagia therapy. What she taught us was, in 1989, that velar sounds produce less muscle activity than an actual swallow. With this in mind, we understand that velar sounds will not produce the required amount of force necessary for base of tongue retraction in swallowing.
2. The activity must be performed with adequate duration for the system to realize there is a need for change.
“ Exercise task must exceed usual levels of activity and be performed for an adequate duration (within a session and over time) to trigger the need for changing the system’s response. With that premise, intensity can be defined on three levels: (1) the mechanical or resistive load placed on the system, (2) amount or repetition of practice during the training regimen, and (3) duration of training over time. Each of these levels of intensity has proven critical in bringing about neuromuscular adaptations.”
The length of therapy sessions and the time focused on actual treatment within each session matters. One take-away here is, for every minute you spend chatting with your patient you are wasting a minute of therapy. Make the most of the time you have.
Stay tuned for the “rest of the story”
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(3), 251-265