Medical Speech Pathology

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Dysphagia Exercises


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Retrieved from flickr.com by fs999

Please read the disclaimer before reading any of the exercises below.  Please work directly with a licensed medical professional before implementing any of the following therapy exercises.  This information is for educational purposes only!

A Beginning List of Dysphagia Exercises that Have Evidence Base

I collected and typed these exercises up from the handouts that we had at work (thanks to Jamie Pulliza for supplying them).  Also, much thanks to whomever compiled these with references in the beginning.  I’m indebted to your original hard work!  I want anyone with experience with these exercises and others that have evidence base (even referenced directly from seminars would be nice) to help add to this list and refine it if you see errors.  Thanks for your help!

I will also be adding a special section for exercises that use some sort of device to assist with the swallow.  I will even list Vital Stim, when I have a good reference list available.  While this one is a polarizing treatment method, I will list it because there is evidence for and against it.  I’ll let my readers judge which evidence is more compelling.

An additional reference was pointed out by Michelle Skelley Ashford (a fellow SLP), and it’s a fantastic systematic overview of many of the exercises found below.  Check it out here:  http://www.rehab.research.va.gov/jour/09/46/2/index.html

Walt Greenslade, M.S., CCC-SLP

SUPRAGLOTTIC SWALLOWING MANEUVER

PURPOSE

To close the airway at the vocal fold level before and during the swallow and to clear residue after the swallow.

APPLICABILITY

Patients who have delayed airway closure, reduced airway closure, delayed pharyngeal swallow, poor oral control of liquids with premature loss into the pharynx. Patients who can follow a series of commands.

___ Only saliva swallow

___ Food/Liquid swallow

INSTRUCTIONS

1. Take a breath in.

2. Hold your breath after you inhale (lightly cover your tracheostomy tube, if present).

3. Keep holding your breath while you swallow.

4. Clear your throat immediately after swallow before breathing.

5. Swallow again.

Perform with each food/liquid swallow.

Perform ___ times throughout the day.

WARNING

Patients with uncontrolled high blood pressure should not use this maneuver; bearing down may raise blood pressure. Talk with your Doctor before beginning any exercise regimen.

References

Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral

cancer patient. Head and Neck, 15, 419-424.

Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993). Normal laryngeal valving patterns during three 

breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20.

McConnel, F.M., Mendelsohn, M.S., & Logemann, J.A. (1987). Manofluorography of deglutition after supraglottic

laryngectomy. Head and Neck Surgery, 5, 142-150.

SUPER-SUPRAGLOTTIC SWALLOWING MANEUVER

PURPOSE

To close the airway at the vocal fold level before and during swallow, to increase tongue base retraction and pressure generation, and to clear residue after the swallow.

APPLICABILITY

Patients who exhibit penetration into the airway with aspiration after the swallow. Patients who can follow multistep directions.

___ Only saliva swallow

___ Food/Liquid swallow

INSTRUCTIONS

1. Hold your breath very tightly, bearing down (lightly cover your tracheostomy tube, if present).

2. Continue to hold your breath tightly while swallowing. Swallow hard.

3. Clear your throat/cough immediately after swallowing.

4. Swallow again.

___Perform with each food/liquid swallow.

Perform ___ times throughout the day.

WARNING

Patients with uncontrolled high blood pressure should not use this maneuver; bearing down may raise blood pressure. Talk with your Doctor before beginning any exercise regimen.

References

Martin, B.J.W., Logemann, J.A., Shaker, R., & Dodds, W.J. (1993). Normal laryngeal valving patterns during three

breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20.

Ohmae, Y., Logemann, J.A., Kaiser, P., Hanson, D.G., & Kahrillas, P.J. (1996). Effects of two breath-holding maneuvers on 

oropharyngeal swallow. Annals of Otology, Rhinology, and Laryngology, 105, 123-131.

HARD / EFFORTFUL SWALLOW

PURPOSE

To increase tongue base retraction and pressure during the pharyngeal phase of the swallow and reduce the amount of food residue in the valleculae of the throat.

APPLICABILITY

Patients who exhibit residue in the valleculae after the swallow.

SUPPLIES

___ Only saliva swallow

___ Food/Liquid swallow

INSTRUCTIONS

Swallow normally but squeeze very hard with your tongue and throat muscles throughout the swallow. Excess effort should be clearly visible in your neck during the swallow.

Perform with each food/liquid swallow.

Perform ___ times throughout the day.

References

Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral

cancer patient. Head and Neck, 15, 419-424.

Shanahan, T.K., Logemann, J.A., Rademeker, A.W., Pauloski, B.R., & Kahrillas, P.J. (1993). Chin down posture effects on

aspiration in dysphagic patients. Archives of Physical Medicine and Rehabilitation, 74, 736-739.

TONGUE HOLD EXERCISE

PURPOSE

To increase the tongue base and throat muscles range of motion.

APPLICABILITY

Patients who exhibit reduced tongue base/pharyngeal wall movement.

SUPPLIES

___ Only saliva swallow

___ Liquid swallow between repetitions

INSTRUCTIONS

1. Protrude your tongue slightly from your mouth. Keeping your mouth moist is helpful for this exercise.

2. Hold the tongue gently with your teeth.

3. Swallow while keeping your tongue protruded.

Perform ___ times throughout the day.

References

Fujiu, M., & Logemann, J.A. (1996). Effect of a tongue holding maneuver on posterior pharyngeal wall movement during

deglutition. American Journal of Speech Language Pathology, 5, 23-30.

Fujiu, M., Logemann, J.A., & Pauloski, B.R. (1995). Increase postoperative posterior pharyngeal wall movement in

patients with anterior oral cancer. Prelminary findings and possible implications for treatment. American Journal

of Speech Language Pathology, 4, 24-30.

Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral

cancer patient. Head and Neck, 15, 419-424.

MENDELSOHN MANEUVER

PURPOSE

To accentuate and prolong laryngeal elevation and thereby increase the extent and duration of cricopharyngeal opening.

APPLICABILITY

Patients who exhibit reduced laryngeal movement and consequent reduced cricopharyngeal opening.

SUPPLIES

___ Only saliva swallow

___ Food/Liquid swallow

INSTRUCTIONS

1. Swallow normally. Feel the larynx (voice box) lift during the swallow.

2. On the next swallow, feel your larynx (voice box) elevating and hold it up with your neck muscles. Do not try to lift the larynx early. Let the larynx lift normally and then hold it up so that it does not drop for ___ seconds. Complete the swallow.

Perform with each food/liquid swallow.

Perform ___ times throughout the day.

References

Kahrilas, P.J., Logemann, J.A., Krugler, C., & Flanagan, E. (1991). Volitional augmentation of upper esophageal sphincter 

opening during swallowing. American Journal of Physiology, 260, G450-456.

Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral

cancer patient. Head and Neck, 15, 419-424.

Logemann, J.A., & Kahrilas, P.J. (1990). Relearning to swallow post CVA: Application of maneuvers and indirect

feedback: A case study. Neurology, 40, 1136-1138.

HEAD LIFTING MANEUVER

PURPOSE

To strengthen muscles of the neck in order to facilitate opening of the bottom of the throat (e.g.- upper esophageal sphincter) for food passage.

APPLICABILITY

Patients who exhibit reduced upper esophageal sphincter opening and who demonstrate food residue in the pyriform sinuses.

SUPPLIES

None

INSTRUCTIONS

Part one: Sustained Hold

1. Lie flat on your back with no pillow under your head.

2. Lift your head to look at your toes.

3. Keep your shoulders flat on the floor / bed.

4. Hold this position for ___ seconds.

5. Release. Repeat 3 times and rest 1 minute between repetitions.

Part two: Lift and Lower (same starting position as sustained hold)

1. Lift your head and look at your toes.

2. Let your head go back down with control.

3. Repeat 30 times.

4. Rest in between as needed.

5. Repeat 3 times a day.

WARNING Patients with neck problems (e.g.- arthritis) may not be able to perform this exercise.

References

Easterling, C., Kern, M., Nitschke, T., Grande, B., Kazandjian, M., Dikeman, K., Massey, B.T., & Shaker, R. Restoration of

oral feeding in 17 tube fed patients by the Shaker Exercise. Dysphagia, 15: 105, 2000.

Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E., Hoffmann, R.G., Arndorfer, R.C., Hoffmann, C., & Bonnevier, J.

Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. AJR, 272: G1518-1522,

1997.

JAW-OPENING EXERCISE

PURPOSE

To improve upper esophageal sphincter (UES) opening during the swallow.

APPLICABILITY

Patients that have poor hyoid elevation and/or poor UES opening as a result of the decreased hyoid elevation.

SUPPLIES

Mirror if biofeedback is needed.

INSTRUCTIONS

1. Hold the jaw in the maximally opened position for 10 seconds.

2. Rest for 10 seconds.

3. Repeat 5 times.

4. Do two sets a day.

WARNING: “When the jaw is closed, the superior head of the lateral pterygoid muscle maintains contraction in order to properly position the articular disk. When the jaw is fully open, however, the superior head is controlled in a relaxed position. Thus, this exercise is probably safer when patients open their jaw to the fullest extent. However, dislocation of the mandibular joint could occur if aging has caused some wear of the articular fossa or condyle, or degeneration of the articular disk. Accordingly, patients with a history of mandibular joint dislocation should not perform this exercise” (Wada, et al 2012).

References

Satoko Wada, Haruka Tohara, Takatoshi Iida, Motoharu Inoue, Mitsuyasu Sato, Koichiro Ueda, Jaw-Opening Exercise for Insufficient Opening of Upper Esophageal Sphincter, Archives of Physical Medicine and Rehabilitation, Available online 10 May 2012, ISSN 0003-9993, 10.1016/j.apmr.2012.04.025.

 

 

TONGUE MOVEMENT EXERCISES

PURPOSE

To improve tongue control for food and liquid bolus manipulation, mastication, and front to back bolus movement.

APPLICABILITY

Patients who exhibit reduced tongue range of motion.

SUPPLIES

Mirror

INSTRUCTIONS FORWARD / BACKWARD MOVEMENT

Stick your tongue out as far as you can and hold for 5 seconds. Relax. Try to keep your tongue in the middle. Use a mirror for visual feedback.

Pull your tongue back as far as you can. Hold for 5 seconds. Relax.

SIDE-TO-SIDE MOVEMENT

Put the tip of your tongue in your right cheek, as far back as you can, and hold it. Relax. Repeat with the tip of the tongue in the left cheek.

Smile. Put the tip of the tongue in the corner of your lips on the right, then move it to the left.

Perform the exercise(s) ___ times a day, ___ repetitions each time.

References

Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition.

Logemann, J.A., Pauloski, B.R., Rademaker, A.W., & Colangello, L. (1997). Speech and swallowing rehabilitation in head

and neck cancer patients. Oncology, 11(5), 651-656, 659.

TONGUE RESISTANCE EXERCISES

PURPOSE

To improve tongue strength and endurance for food and liquid bolus manipulation, mastication, and front to back bolus movement.

APPLICABILITY

Patients who exhibit reduced tongue strength.

SUPPLIES

Tongue depressor or spoon

INSTRUCTIONS

Stick your tongue out as far as you can and push a tongue depressor / spoon against the tip of your tongue. Hold for 5 seconds. Relax.

Stick your tongue out as far as you can. Place a tongue depressor / spoon along the side of the tongue. Push against it with your tongue. Hold for 5 seconds. Relax.

Perform the exercise(s) ___ times a day, ___ repetitions each time.

References

Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition.

Logemann, J.A., Pauloski, BR, Rademaker, AW, & Colangello, L. (1997). Speech and swallowing rehabilitation in head and

neck cancer patients. Oncology, 11(5), 651-656, 659.

CLOSURE OF THE LARYNX

PURPOSE

To improve airway closure and prevent aspiration.

APPLICABILITY

Patients who exhibit laryngeal aspiration with liquids and foods during the swallow.

INSTRUCTIONS

Breath Hold / Valsalva Maneuver

Take a breath. Bear down and hold your breath. You should not hold your breath with your lips, but in your throat, like you do if you are trying to lift something very heavy. Hold for ___ seconds. Relax. Repeat ___ times, ___ a day.

Push – Pull with Breath Hold

Place one or both hands under your chair and pull as if you are trying to lift your chair up with you in it. (You can also do it by standing up and pushing against the wall). Hold your breath tightly. Relax. Repeat ___ times a day.

Head Rotation with Phonation

Turn your head to the left / right. Hold your breath tightly. Let go of your breath and say “ahh”. Perform this exercise ___ times a day, ___ repetitions each time.

References

Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition.

Logemann, J.A., Pauloski, B.R., Rademaker, A.W., & Colangello, L. (1997). Speech and swallowing rehabilitation in head

and neck cancer patients. Oncology, 11(5), 651-656, 659.

BASE OF TONGUE EXERCISES

PURPOSE

To improve base of the tongue movement and strength in order to better propel the bolus (food / liquid).

APPLICABILITY

Patients who exhibit reduced tongue base / pharyngeal wall movement and vallecular residue.

INSTRUCTIONS

Gargle with Water / Pretend to Gargle

Look up toward the ceiling. Gargle for ___ seconds. Relax. Repeat ___ times. Gradually increase duration of gargling time. Perform the exercise ___ times a day ___ repetitions each time.

Pretend to yawn

Open your mouth wide. Start to yawn. You will feel all the muscles open wide in your throat. Relax. Repeat ___ times throughout the day.

Tongue Base Retraction

Pull the back of your tongue as far back as you can. Pretend you are trying to scratch the back wall of your throat with the back of your tongue. Hold for ___ seconds. Repeat ___ times, ___ times a day.

References

Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral

cancer patient. Head and Neck, 15, 419-424.

Pouderoux, P., & Kahrilas, P.J. (1995). Deglutitive tongue force modulation by volition, volume, and viscosity in

humans. Gastroenterology, 108, 1418-1426.

 

22 comments on “Dysphagia Exercises

  1. Heather Garrabrant
    June 11, 2012

    Thanks. This is great!

  2. Admin
    July 9, 2012

    Your welcome!

  3. Dr.Manish
    October 7, 2012

    very informative
    manish

  4. atklingensmith
    October 7, 2012

    Thanks so much for putting this together! It’s great to have the exercises compiled all in one place!!!

  5. Venkatesh
    October 7, 2012

    The information provided was really very helpful as the exercises are compiled together thank you and my regards

  6. headneckcancerindia
    October 14, 2012

    Great info. I can direct my patients to your blog. Thanks!

  7. Pingback: Evidence-based Dysphagia Exercises | Disfagia Brasil

  8. Lin
    December 27, 2012

    Great cheat sheet! Thx

  9. A. Moad, MCD, CCC-SLP
    January 17, 2013

    This is great!! Thanks for sharing!!

  10. Pingback: Care after total laryngectomy | delhi head neck surgery

  11. Susan
    January 23, 2013

    I know every patient is different, but I’m wondering how long do you usually encourage these daily exercises before you suspect they will not be effective? Two weeks maybe? When do you generally begin to see improvement? Thx!

    • Admin
      January 23, 2013

      Thanks for the question Susan. Based on my readings regarding exercise physiology and on expert opinion at swallowing conferences, I usually shoot for 3-4 specific exercises 90-120 reps a day for a minimum of 4-6 weeks (5/7 days a week). Following this protocol, I expect better neural recruitment of existing muscles within 1-2 weeks and actual muscle hypertrophy (bigger muscle tissue) within 4-6 weeks. This also seems to hold true in most cases in my own practice, but not all cases are the same and getting feedback from a certified SLP/SLT that knows the specifics of your case is critical. Hope that wasn’t too long winded!

      -Walt G.

  12. wawan
    March 26, 2013

    Wonderful…
    thanks…

  13. drdhirenpatel
    March 31, 2013

    a great compilation of all dysphagia exercises
    dr dhiren patel – cardiologist

  14. Pingback: Dysphagia Resources -- Speechy Musings

  15. Hesham kamel
    July 14, 2013

    Thanks for this highly informative effort, i wonder if there are passive excercices( like tongue holding etc..)for patients who suffer weak tongue and pharyngeal muscles who are not totally cooperative like some patients of dementia , regards, H.Kamel

    • Admin
      August 2, 2013

      Good question Hesham. My experience and research point to the need for muscle hypertrophy or at least some increase in neural recruitment through effort (which occurs before the musculature gets stronger/bigger) to effect real functional change in the swallow system. While I don’t know that there is a lot of clear-cut support for it, e-stim could provide improvement for the types of patients that you are describing. If the dementia is that severe, however, there are some ethical questions to be answered by the provider and the caregivers: 1. Does this improve quality of life for the patient? 2. Is this being done to satisfy the urge to “help” on the part of the caregiver and/or clinician? 3. Does the patient tolerate the necessary frequency and intensity of electric stim? (typically 1 hour a day 5 x a week)

      Just some things to consider.

      Walt

      • Jose Pons
        August 7, 2013

        I’m going to try these exercises….Thank You.

      • Admin
        August 7, 2013

        I’m glad you’ve found these exercises. Please make sure you only use these under the supervision of a licensed healthcare provider (Dr. And SLP). Some of these exercises have risks that should be managed through the MD/SLP team. Thanks for commenting and good luck with your therapy!

  16. kimcookeslp
    November 18, 2013

    This is a wonderful resource and I will be using these with my home health patients! Thank you so much for taking the time to put this together and including references!

    • kimcookeslp
      November 18, 2013

      I should add that I will be using these under the supervision of a doctor =) I recently had a patient whose doctor requested tongue base retraction exercises based on the results of the patients MBSS.

    • Admin
      November 18, 2013

      Thanks for your kind words. I’m glad that these have garnered some real interest, and hope to continue to add more content that helps both patients and clinicians.

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