The Pulse

This is the third and final installment of our “Exercise in Swallowing Therapy” series. This article will examine some commonly used interventions in light of exercise principles. But first, a quick review. In order to be considered an exercise the activity must meet certain criteria (for more information refer to the two previous articles).

Patient Information: Male, Age 86

Diagnosis: Stroke / Oropharyngeal Dysphagia / Dysarthria

History: This gentleman was admitted to a skilled nursing facility for rehabilitation services due to oropharyngeal dysphagia (difficulty swallowing) and difficulty managing saliva after hospitalization due to a stroke. He was only consuming 0-25% of his meals. Prior to his stroke, he lived at home with family, worked two days a week, and ate a regular diet.

In the first installment of “Exercise in Swallowing Therapy” the roles of overload and adequate
duration of therapy were discussed. In this second installment, additional exercise principles of intensity progression and repetition are described.

My current role as a Dysphagia Clinical Program Consultant (CPC) for Accelerated Care Plus is one that is energizing, enjoyable, and also challenging at times. It is a role I feel incredibly grateful to have at this point in my career. I often have the opportunity to sit down with Speech Language Pathologists who are the only SLP working in the facility, which can feel like being on an island without a colleague with whom to brainstorm on a case. I can’t claim I have all of the answers to dysphagia questions, but I am happy to combine knowledge from articles I have read, experience I have, and evidenced based assessment and treatment techniques I been trained to utilize to help problem solve with treating clinicians to provide the best clinical care for the patients they serve. I am also fortunate to have a team of SLP CPC colleagues to consult with for perspective and insights on effective dysphagia rehabilitation for tough cases.

Swallow efficacy and safety are influenced by more than oropharyngeal muscle strength and performance. Head and neck positioning and posture can have a significant impact on an individual’s ability to effectively and safely swallow. Poor positioning can develop as a result of advanced age, neurologic impairment, and musculoskeletal involvement. The incidence of postural malalignment of the head, neck, and shoulders is increasing as a result of repetitive poor positioning with the use of computers and hand-held devices.

Patient Information: Female, Age 78

Diagnosis: Stroke / Oropharyngeal Dysphagia

History: This woman with a history of several strokes had a subsequent stroke that resulted in severe oropharyngeal dysphagia (difficulty swallowing). She had weakness in her lips, tongue, and muscles involved in her swallow, and required a feeding tube for all nutrition and hydration. She was admitted to a skilled nursing facility after discharge from the hospital. Prior to her most recent stroke she ate a normal diet with thin liquids.

Recently I was engaged in a conversation related to the ability of a speech pathologist to clinically determine swallowing pathophysiology. A therapist responded she had paid a great deal of money for her degree and if she could not rely on her “clinical judgement” to accurately diagnose patients with dysphagia she had wasted her money.  I was not sure how to respond. However, after some reflection, here is my thoughtful response.

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.

The treatment of any disorder relies on the ability to recognize when an impairment exists. This can be problematic when it comes to swallowing as the understanding of “normal” continues to evolve. This article will discuss some often outdated notions concerning the swallow.