Introduction

Based on results of the swallowing evaluation, the treating clinician should have a firm sense of the patient’s current swallowing ability, associated risks to airway protection, and the best rehabilitative approaches to apply in treatment. Box 1 summarizes the primary factors in treatment planning that the rehabilitation team must be cognizant of for all patients with dysphagia. Additional factors that must be considered in treatment planning are the associated medical diagnoses, general health and nutritional status, cognitive and communication status, and whether the patient has family and/or caregivers support.

Assess Aspiration Risk and Deficit Focus

A wide range of deficits may lead to reduced ability to protect the airway, from profound structural and sensory changes due to treatment of head and neck cancer, to sensorimotor changes associated with stroke, or other neurologic disease. Airway protection should always be a consideration of swallowing treatment; however, whether specific instances of aspiration are noted on instrumental swallowing examination should not be the only factor determining the presence or absence of dysphagia, or whether to implement treatment. Focusing on the physiologic deficits found during evaluation allows the clinician to assess both the real (observed) and the assumed risk of aspiration.

If aspiration of material to the airway has been directly observed, did it occur before, during, or after the pharyngeal phase of swallowing is completed? This observation will yield information as to whether there is a problem initiating the swallow (where penetration/aspiration is noted before the pharyngeal swallow is triggered) with the structural movements during the pharyngeal phase of swallowing (where penetration/aspiration is noted during the swallow), or with residual material within the pharynx that enters the airway (where penetration/aspiration is noted after the swallow). If no direct observation of aspiration occurred during the instrumental testing, does material penetrate the airway (enter the laryngeal vestibule, but remain above the level of the vocal cords)? What physiologic findings (whether aspiration is observed) may put the patient at risk of aspiration during swallowing? These physiologic findings may include premature spilling into the pharynx, reduced hyolaryngeal excursion, incomplete closure of the laryngeal vestibule, reduced extent or duration or upper esophageal sphincter (UES) opening, or postswallow pharyngeal residue.

During the instrumental examination, it is highly desirable to test candidate interventions to determine if there is a positive effect on swallowing function. This testing will allow the clinician to determine the immediate effect, if any, of a particular consistency or postural change, or of a swallow-specific exercise. This piece of information can then be used to prepare the therapy plan better. For example, if instructing the patient to use a chin tuck while swallowing thin liquids ameliorates observed airway compromise, then it should be part of the treatment plan. However, if continued aspiration is noted with the chin tuck, or the patient cannot coordinate the chin tuck with other swallow events, then it may not be a good therapeutic choice.

Establishing a Treatment Schedule

Once the case history and examination have been completed, the clinician must recommend an appropriate treatment protocol and schedule for treatment. How many days per week will the patient attend treatment sessions? How long will each treatment session last? How many weeks (or months) will treatment continue? Will a maintenance program be possible, whereby the patient continues certain aspects of treatment on his/her own after formal treatment sessions end? The answers will vary by patient, with consideration given not only to severity of the deficit but also to the proximity of the patient to a treatment source, insurance coverage, other treatments/therapies in which the patient participates, and caregiver availability and support.

The treatment schedule should be structured to include short-term and long-term goals, and the timeframe in which meeting those goals should be met. It is imperative to document progress clearly, or lack thereof, toward goals. This documentation is a concrete way for clinicians to monitor progress or decline in function, and whether changes to the treatment and/or treatment schedule are warranted.

When to Reassess

Multiple considerations contribute to the question of when to reassess a patient’s swallowing function. Box 2 outlines the major considerations for reassessment of the patient.

The establishment of long-term goals and incremental short-term goals at treatment initiation should give a clear progression with an associated timeline. In the absence of other factors that may warrant reassessment, this timeline should guide the clinician to a point where he/she must reassess to document treatment progress/lack of progress and any further recommendations. Acute changes to function, whether observed during therapy or reported by the patient, may warrant reassessment.

Oral Care

The most common location of bacteria is in the mouth. Therefore, patients with swallowing disorders should brush their teeth, or someone should do it for them, 3 times per day. Mouth rinse is also suggested provided it does not lead to aspiration if swallowed accidently.

Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is a technique that has been used for many years by physical therapists and works by applying electrical stimulation, causing muscle fibers to contract when the correct amount of stimulator intensity is applied. NMES can be either percutaneous (intramuscular) or transcutaneous (surface). Percutaneous NMES delivers stimulation via hook-wire electrodes that are inserted directly into the muscle of interest. Transcutaneous electrical stimulation (TES) is a noninvasive form of NMES that applies stimulation to the skin overlaying the target muscles. Thus, TES activates sensory fibers in the skin as well as underlying muscles, when the right amount of intensity is applied.

The primary hypothesis governing the use of TES for dysphagia is that by stimulating the muscles in the neck via surface stimulation, the swallowing musculature will be strengthened and/or the sensory pathways important for swallowing will have heightened awareness. To date, there is a small body of literature supporting the use of TES as a dysphagia treatment. A 2009 review by Clark and colleagues concluded limited evidence suggests positive treatment effect of NMES for swallowing therapy, and an ongoing need for examination of dosage, timing, and applications to specific populations. Moreover, the level of evidence for NMES was limited due to the lack of controlled studies, control groups, and sufficient outcome measures over a long period of time. A more recent review by Humbert and colleagues concludes similarly and discusses data that suggest certain electrode configurations may negatively impact swallowing. In a 2010 report, Ludlow suggests that electrical stimulation is most effective when the electrical stimulus is applied directly to the muscle via intramuscular electrodes. In contrast to surface stimulation, intramuscular stimulation uses a hooked wire electrode inserted into the muscle of interest to direct the current to a specific muscle. However, because of the invasive nature of intramuscular electrode placement, it is not commonly used by most speech-language clinicians at this time.

Thermal-tactile Stimulation

Thermal tactile oral stimulation (TTOS) is the stroking or rubbing of one or more of the structures (typically the anterior faucial pillars) involved with swallowing with an ice stick or cold probe. As well, it can include presentation of boluses with varying temperature, carbonation, and gustatory properties. These methods are used when dysphagia is caused, at least in part, by sensory deficits. The underlying hypothesis is that manipulation of touch, cold, and taste stimulation provide heightened oral awareness and an alerting stimulus to the brainstem and brain, causing the pharyngeal swallow to trigger faster than it would without the stimulation. Support for this hypothesis is provided by Teismann and colleagues, whose study of cortical activation during TTOS using whole head magnetoencephalography (MEG) showed functional cortical changes the authors suggest reflect short-term cortical plasticity of sensory swallowing areas.

To date, there is little empiric research to support the extensive use of cold stimulation to the oral-pharyngeal mucosa to improve general swallow function, outside of a short-term acute affect. That is, although results of multiple studies have shown various physiologic changes to oral and pharyngeal swallow function following cold stimulation, that effect is generally limited to the first swallow immediately following the stimulation. A few studies have combined cold and gustatory stimulation and shown significant results also in terms of swallowing timing. Bove and colleagues found no significant differences in healthy individuals in swallowing durational measures following stimulation with a cold laryngeal mirror, but they did find that swallow times were shorter when swallowing cold water compared with swallowing water warmed to body temperature. A study of stimulation with a sour bolus by Logemann and colleagues found that there was an earlier onset of lingual activity to propel a bolus into the pharynx, triggering the pharyngeal motor response, and a shorter pharyngeal component of the swallow in patients following stroke or mixed neurologic disorders. Other studies of temperature and/or carbonation have been equivocal in showing acute changes in swallow function. It remains to be studied if these acute changes would induce permanent cortical adaptation and consequently enduring functional improvement over time.