55.Swallowing Maneuvers for Direct Training

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Explanation

Direct training uses appropriate maneuvers to make swallowing stronger and safer. Patients eat real food in these exercises, so all necessary structures are used in an integrated manner to achieve functional improvement. Key to having good outcomes from direct training is choosing an appropriate maneuver based on a good understanding of the purpose of, and procedure for, each maneuver.

In this module, we cover the indications, procedure, contraindications, and precautions of each swallowing maneuver.

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Explanation

Here, we look at precautions common to all swallowing maneuvers. We look at precautions specific to each maneuver later in the module.

Because we give verbal instructions to patients during direct training, their ability to understand these spoken instructions and to execute them is a precondition. So, patients should not have severe aphasia or hearing impairment. Nevertheless, we can help patients to master a maneuver by actually demonstrating it to them. Observe their performance closely to assess their comprehension level and learning pace and give them instructions accordingly.

It's not possible to routinely perform videofluorography, endoscopy, or electromyography to confirm the effect of direct training. So, to evaluate the effectiveness and applicability of the maneuver used, we need to note changes such as improvement in voluntary throat clearing, choking, and expectoration. We can then decide how to proceed with the direct training.

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Explanation

The purpose of the "think swallow technique" is to make patients think about the process from oral transit to swallowing, to help with swallowing and prevent aspiration and pharyngeal retention (pooling).

Indications: Patients who choke after casually swallowing liquids even though they don't have severe functional oral or pharyngeal impairment. Patients who tend to swallow food without sufficient mastication. Patients who have timing issues that cause choking and other swallowing problems.

Procedure: Encourage patients to think about the location and status of food and liquids in the mouth, the rhythm of chewing, and formation of the bolus before initiating a swallow. Explain to them how each piece of food is chewed and how liquid is transported in the mouth during actual swallowing, and encourage them to swallow strongly in one swallow.

Precautions: Patients need the ability to give feedback of their oral status and movement (what happens and changes in the oral cavity) by themselves.

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Explanation

Purpose: In this method, patients intentionally hold their breath to close the glottis before initiating a swallow. Aspiration will be prevented because the airway is closed, and supraglottic retention, if any, will be expectorated. Also, this is good for learning about coordination of breathing and swallowing.

Applicability: Patients who tend to choke or aspirate immediately before or during swallowing.

Procedure: 1) Inhale lightly, or deeply if possible, through the nose, and hold the breath. Nose breathing will reduce the risk of aspiration upon inhalation if food and drink are used in the training. 2) Swallow while holding the breath. 3) Breathe out strongly through the mouth (say "haa" when breathing out), or cough immediately after swallowing. Patients need to practice this maneuver without food. After acquiring the skill, patient can use this maneuver at actual mealtimes.

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Explanation

Cautions and modifications: 1) Food and liquids can be taken after breathing in, depending on the patient's preference. 2) In direct training, practicing the supraglottic swallow in the beginning is beneficial. When practicing it during the meal, it can be performed with each swallow, or with every few swallows, depending on the patient's condition.

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Explanation

Purpose: This method is designed to ensure closure of the entrance to the airway voluntarily before and during swallowing.

Indications: Patients with difficulty closing the laryngeal vestibule. Particularly effective for patients who have undergone partial supraglottic laryngectomy.

Procedure: Instruct patients to keep holding their breath and squeezing the laryngeal area more tightly and then to swallow strongly. This should ensure complete laryngeal closure during swallowing.

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Explanation

Purpose: This maneuver helps patients squeeze the muscles of the structures involved in swallowing so that the bolus can be transported forcefully and effortfully. Effort increases posterior tongue base movement and improves the bolus clearance from valleculae.

Indications: Patients who show the pharyngeal residue especially in valleculae and show penetration by the residue, due to the difficulty in transporting the bolus to the pharynx, impaired tongue base muscle strength, or impaired pharyngeal function.

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Explanation

Procedure: Encourage patients to squeeze the oropharyngeal muscles throughout the swallow. Give them instructions such as "Swallow while you squeeze and lift up the tongue and pharyngeal muscles, especially the muscle at the tongue base" or "Swallow very hard".

Contraindications and precautions: The effortful swallow can't be used in patients with a problem in the pharyngoesophageal junction, for example, those who underwent pharyngoesophageal surgery. Monitor for hypertension following this maneuver. There are very few reliable methods for verifying whether patients actually squeeze the throat or the appropriate muscle groups. The effectiveness of the Effortful Swallow can be confirmed by comparing retention with and without using this maneuver.

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Explanation

Purpose: Mendelsohn maneuver is designed to hold the hyolaryngeal elevation at the most superior and anterior position, and thereby increase the relaxation of the upper esophageal sphincter. It increases the range of extent and duration of elevation of the hyoid bone and larynx, and it can used as a compensatory technique for impaired swallowing to prevent pharyngeal residue and aspiration.

Indications: Patients with pharyngeal retention and aspiration because the hyoid bone and larynx aren't elevated sufficiently in terms of distance and duration due to weakness of the muscles involved.

Procedure: Instruct patients to pause swallowing at the peak of laryngeal elevation and pharyngeal contraction (just before swallowing down), remain in that position for 2-3 s or 5-6 s, and then relax to revert to the pre-swallowing condition with a long exhalation.

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Explanation

Contraindications and precautions: Patients must be able to elevate the larynx and give feedback if it's successful or not by themselves. Changes in vital signs and the presence of unpleasant sensations need to be monitored during exercise. Patients need to hold their breath, so the Mendelsohn maneuver is contraindicated for patients with a respiratory disorder or with difficulty coordinating swallowing and breathing. Applicability of this maneuver must be judged carefully in patients who tend to have imbalanced muscle tone or hypertonicity from the shoulder to the upper chest. Hypertonicity must be avoided by adequate relaxation.

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References

  1. Larsen GL:Conservative management for incomplete paralytica,Arch Phys Med Rehabil,54: 180-185, 1973.
  2. Ichiro Fujishima:Rehabilitation for swallowing disorders associated with stroke. Second edtion, p116, Ishiyaku publishers, 1998
  3. J.A.Logemann(1998):Evaluation and treatment of swallowing disorders 2nd ed.pp214-217、1998
  4. Kenichi Michi, Yukihiro Michiwaki translated & supervised: 2nd Logemann, Evaluation and treatment of swallowing disorders, pp170-173, Ishiyaku publishers, 2000
  5. Ichiro Fujishima:Rehabilitation for swallowing disorders associated with stroke. Second edtion, p119-120, Ishiyaku publishers, 1998
  6. Ichiro Fujishima tranlated: Adult swallowing disorders, pp218-221, Ishiyaku publishers, 2007
  7. J.A.Logemann(1998):Evaluation and treatment of swallowing disorders 2nd ed.pp217-221、1998
  8. Kenichi Michi, Yukihiro Michiwaki translated & supervised: 2nd Logemann, Evaluation and treatment of swallowing disorders, pp170-173, Ishiyaku publishers, 2000
  9. J.A.Logemann(1998):Evaluation and treatment of swallowing disorders 2nd ed.p221、1998
  10. Kenichi Michi, Yukihiro Michiwaki translated & supervised: 2nd Logemann, Evaluation and treatment of swallowing disorders, pp175, Ishiyaku publishers, 2000
  11. Ichiro Fujishima tranlated: Adult swallowing disorders, pp222-224, Ishiyaku publishers, 2007
  12. J.A.Logemann(1998):Evaluation and treatment of swallowing disorders 2nd ed.pp221-222、1998
  13. Kenichi Michi, Yukihiro Michiwaki translated & supervised: 2nd Logemann, Evaluation and treatment of swallowing disorders, pp175-176, Ishiyaku publishers, 2000
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