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Dysphagia

As an occupational therapist specialized in dysphagia, it is important that you are able to discriminate between the following terminologies:

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  • Feeding: the process of setting up, arranging, and bringing food / fluid from the plate or cup to the mouth. This process can be done either by others or by the individual himself and therefore it can be called self-feeding.

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  • Eating: the ability to keep and manipulate food / fluid in the mouth and swallow it.

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  • Swallowing: food / fluid is moved from the mouth through the pharynx and esophagus into the stomach.

 

Keep in mind that eating and swallowing are often used interchangeably!

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  •   Rotatory chewing starts 

*Suck followed immediately by swallow is called suckle

*Suckle = it is the early pattern for babies. The tongue moves back and forth + weak lip closure

*Munching = it is the early chewing pattern and it involves vertical movement of the jaw; biting in an up and down movement.

*Chewing = rotatory movement

 

 

Further details of the oral motor skills and the skills related to feeding can be found in the links of other websites below

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  • Oral Preparatory (Voluntary)

    1. The food is introduced into the oral cavity and mastication (chewing) occurs

    2. The food is prepared into Bolus

    3. Soft palate is in a lowered position and resting against the tongue to prevent the food/ liquid from entering the pharynx before swallowing is produced

 

  • Oral (Voluntary)

    1. Tongue elevates anteriorly and posteriorly to move the bolus to the pharynx

    2. Voluntary initiation of swallowing

    3. Triggering of the pharyngeal swallow

    4. This stage takes 1 – 1.5 seconds

 

  • Pharyngeal (Involuntary)

    1. This involves the passage of food into the common area of food and air

    2. Elevation and retraction of the soft palate to close off the nasopharynx

    3. Larynx closes to protect the airway

    4. Epiglottis closes

    5. The Upper Esophageal Sphincter relaxes and opens

    6. Aspiration is most likely to occur during this phase (passage of food into the airways)

    7. This stage takes 1 second

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  • Esophageal (Involuntary)

  1. The food moves into the esophagus which is a muscular tube that contracts (peristalsis) to push the bolus into the stomach

  2. Lower Esophageal sphincter relaxes

  3. Food enters the stomach

  4. Risk of GERD (Gastroesophageal Reflex Disease)

 

For further explanation watch these YouTube videos:

  • It is defined as any difficulty that may occur in the oral, pharyngeal or esophageal stage of swallowing.

YouTube Video for further explanation: Dysphagia and Aspirations, what is it? - YouTube

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Diagnosis Related to Oral Issues 

Neurological

Cleft Palate and cleft lip are both birth defects. These occur with the baby’s lip or mouth do not form properly during pregnancy. A cleft means a gap or a split. A child may have one of them or both at the same time.

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Cleft Lip is an opening in the upper lip:

  • It can be a small slit (incomplete) or a large opening that goes into the nose (complete)

  • It can be unilateral or bilateral

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Cleft Palate:

  • It can either be a small opening in the back of the mouth (incomplete) or a split that runs all the way to the front of the mouth (complete)

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Facial / Bell’s Palsy is paralysis or severe weakness of the facial muscles on one side of the face. It occurs when the nerve that controls the facial muscle becomes inflamed, swollen or compressed and therefore results on one side of the face to droop or become stiff. This condition is temporary.

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  • Impaired postural control

  • Persistence of primitive oral reflexes

  • GI issues

  • Gastroesophageal Reflex Disease (GERD):  it is a digestive disorder that occurs when acidic stomach juices, or food and fluids back up from the stomach into the esophagus

*Other website for further info: Gastroesophageal Reflux Disease Symptoms, Diagnosis & Treatment (aaaai.org)

  • Difficulty with suck-swallow-breath coordination (Ex. cardio-respiratory issues)

  • Weak, arrhythmic, or in-coordinating sucking

  • Weak, arrhythmic, or delayed swallowing

  • Poor jaw stability and closure

  • Tonic Bite Reflex: forceful biting on spoon due to hypersensitivity or increased tone in the jaw muscles following stimulation of teeth or gums. It increases if the item is pulled on 

  • Inability to perceive food on gum due to hyposensitivity

*Other website for further information: Beckman Oral Motor - About Beckman Oral Motor

  • Poor lip closure and movement

  • Poor tongue control

  • Changes in muscle tone  

  • Oral sensory issues

  • Drooling

  • Lack of sensory awareness

  • Mouth opening due to poor muscle control or coordination or low muscle tone  

  • ​Teeth Grinding

  • Poor jaw stability

  • Seeking proprioceptive input

  • Structure Dysfunction

  • ​​Micrognathia: lower jaw is smaller than normal, and this leads to mouth opening and ineffective suck

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  • High palate, cleft palate and cleft lip causes pocketing of food, loss of liquid and the food goes through nose

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High Palate 

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Normal Palate 

  • Review the medical history to know if the client had:

    • Medical procedures

    • Medical conditions and complications

    • Allergies

 

  • Interview the client / caregiver to get information about:

    • Feeding history; methods and strategies used

      • History of non-oral feeding; Gastrostomy tube feeding or Nasogastric tube feeding

    • The client’s preferences and dislikes; specific type of food taste and texture

    • How food is prepared and presented

    • Specialized equipment used

    • The average consumption of food and liquids

    • The length of feeding process (how long does the client take to finish the meal)

 

  • Observation of both the client and the caregiver in a naturalistic setting to know more about:

    • Positioning of both

    • Food textures

    • The behavior and emotion of the caregiver as it has a great impact on the client

    • The degree of communication between both

 

  • Use of formal assessments and the normal developmental milestones to check:

    • Oral motor control

    • Reflex development

    • Sensory motor processing  

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Formal Standardized Assessments

  • Dysphagia Assessment

  • Sensory Profile

 

Investigations / Assessments related to other areas of practice: Clinical Bedside Swallowing Evaluation / Video Fluoroscopy (Barium Swallow) / Video Nasal Endoscopy

  1. Check if the patient has the palatal reflex, elevation of the larynx and productive cough

  2. Place food on the middle of the patient’s tongue

    • It would be better to start with pureed food to ensure the process would proceed safely. Ground food can be used to check the client’s ability to chew and form a bolus

  3. Palpate for swallowing by placing the index finger at the hyoid notch, the middle finger at the top of the larynx, and the third finger at the middle of the larynx

  4. Check for the smoothness of swallowing and note if there is any delay (normally would take 1-1.5 seconds)

  5. Ask the client to open his mouth and look for any residue

  6. Check if there is any change in sound

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Be careful! While carrying out the assessment above pay close attention to the client as aspiration might occur

It means the entry of food or liquid into the airways. In this case, you will notice the individual will change in color, have prolonged cough, gurgling voice or loss of voice, and show the following symptoms: Pneumonia (lung inflammation), malnutrition, and dehydration.

Video link: (17) What happens when you swallow something down the 'wrong pipe' - YouTube

Aspiration can be due to:

  • Reduced tongue control – happens before swallow

  • Absence of swallow response –before swallow

  • Reduced laryngeal closure – During swallow

  • Poor esophageal closure – after swallow

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What to do when an individual is aspirating??  Perform the Heimlich Maneuver

During the Intervention process the goals will be focused upon:

  • Facilitating appropriate positioning during feeding process

  • Improving the motor control by normalizing the muscle tone

  • Maintaining adequate nutritional intake

  • Preventing aspiration

  • Re-establish oral eating to the safest level

Feeding Interventions include:

  • Noise Levels and Visual Distractions:

Provide a quiet and comfortable environment for the individual to enable him/her to concentrate and participate in the feeding process

  • Tools, Supplies and Equipment:

Place all the utensils and food in an appropriate position near the individual so that they are within his/her reach. The equipment used during the mealtime must be appropriate and comfortable (Ex. Chair, table, and the height of both in relation to each other…)

We must take into consideration the position of both the individual and the caregiver as they are equally important. Good positioning is the foundation for improving eating and drinking skills

It is advisable that the individual be in an upright position:

  • In midline (symmetrical alignment) with an elongated back of neck during mealtimes

  • If the client is an infant and carried by the caregiver during mealtime then it is important to maintain the chin in a tuck position

It is important to keep in mind that each individual is different so there is not a specific ideal position that suits everyone

As for the caregivers, it is crucial to ensure that they remain:

  • In the same height of the individual they are trying to feed to enable the face to face contact and good communication between them

What to avoid? an extended head, neck and body position makes eating and drinking difficult and dangerous as it increases the risk for aspiration.

  • Provide adequate sensory stimuli in a relaxed and comfortable environment

  • Oral Desensitization  

  • Deep pressure with constant rhythm

  • Encourage caregiver to touch the individual’s body parts before face

    • Sing head shoulders knees and toes

  • Play around the individual’s mouth and face with safe & differently textured toys

  • Provide sensory stimuli as much as possible

  • Use light touch and irregular intermittent patterns

  • Provide Food with strong & contrasting flavors

  • Introduce toys or food of varying temperatures

  • Use vibration

  • Massaging cheeks in and out in a circular motion (Oral stimulation)

  • Brush teeth before a meal without a toothpaste

  • Avoid introducing increased food texture consistency

    • To prevent choking

  • Use verbal cues

  • Graded approach to tactile input

    • Whole body approach to sensory input

  • Oral Desensitization

  • Firm pressure tactile input for oral area

  • Modify taste, texture, or temperature of food

  • Reduce environmental sensory input

  • Use movement to calm the individual

    •  Allow the individual to use the Swing first then introduce sensation of touch & taste

  • Make sure that the place is quiet

It is the process in which an individual is helped to accept and tolerate stimuli that were previously rejected. Therefore, the individual becomes able to modulate his/her response appropriately. It can be used for both hypersensitive and hyposensitive individuals but the aim for the latter will be to increase sensory awareness. For that reason, the term desensitization will be inappropriate. 

 

  • The individual should be well positioned with the head upright and in midline (symmetrical alignment) with an elongated back of neck. The mouth should be closed if possible

 

  • Start by touching the individual in a part of the body that is tolerated and accepted such as the arms or legs. Use firm, slow, rhythmical, stroking movements with heavy pressure but without causing pain. The hands must be warm  

    • If touching the limbs first go towards the body

    • If touching the body first go toward the face

 

  • Keep movements symmetrical. Do it on both sides simultaneously 

 

  • Stop if any signs of distress are shown

    • Ex. Pushing back, blinking, or retracting the upper lip

How to perform it?

1. Face Massage:

  • When touching the face, aim to move symmetrically towards the mouth to encourage lip closure as shown by the arrows

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  • You can use two fingers (index and middle finger) or one finger (index) when applying the message. Make sure that you do both sides at the same time using both of your hands simultaneously

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  • Keep in mind that some people may have nasal blockage and may be unable to breathe. Be alert and look for signs of distress

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A link for a YouTube Video 6 Oral Motor Exercises for Babies - Oral Stimulation- Speech Development- Feeding Development - YouTube

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2. Gum Massage:  

  • Introduce your finger to the individual’s mouth with the pad of the finger touching the gum and the fingernail touching the inside of the lips

  • Start massaging the gum in the same direction shown by the arrows

  • Start with/in position #1 and move your finger at a speed the individual tolerates

  • Firmly massage it to the side and then go back to the starting point

  • Do not go too far back at first or the individual may gag

  • Do it 3 – 4 times at this side and then move to position #2

  • Repeat until you finish all positions

A link to other website with a video Gum Massage for Oral Stimulation - ARK Therapeutic

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3. Cheeks Massage:

  • Place the pad of your finger on the insides of the individual’s cheek

  • Pull the cheek out gently

  • Start moving your finger in a circular motion

A link for a YouTube Video Oral Stimulation with ARK's proPreefer - YouTube

For gum and cheeks massage:

 

 

 

 

 

 

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Important Instructions:

  • Treat it as a relaxed / playing time for fun not an exercise

  • Do it in short periods of time up to several times a day

  • Playing soothing music during the process may help

  • You can have the individual use his/her own finger as it is easier to tolerate but be careful to prevent him/her from biting it

  • Wash your hands and your nails must be cut and short

   

The massaging techniques mentioned above can be done in different ways:

  • Fingers or objects of various textures and temperatures can be used

  • You can apply different levels of pressure (light or heavy) using finger or objects

  • You can use vibrational objects with different textures (Ex. Brushes)

 

Links for YouTube Videos:

  • For individuals under 5 use the little finger

  • For older ones use the index finger

  • When massaging the gum, try keeping the mouth closed

  • The messaging activities for the gum and cheeks will increase the saliva production so give the individual an opportunity to swallow

  • Once the individual tolerates the finger touch, you can produce more stimuli by wetting the finger with juice or milk  

Jaw Stability and Head Control:

Having a good head control and a stable jaw are required for a safe feeding process. When the individual lacks one of these, it is important that the caregiver is able to provide the stability using his/her arm and hand. The caregiver has to make sure that the individual’s position is appropriate with the head and trunk being aligned in order to provide the support needed. Once this is achieved the support can be provided in any position as long as the individual is comfortable. A firm control must be provided while also avoiding over stimulation.

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A link to another  website  Stubborn TMJ Pain? Try Trigger Point Massage and Jaw Exercises – Health Essentials from Cleveland Clinic

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Bite Reflex

  • Proper Positioning

  • Oral desensitization

  • Apply pressure on temporomandibular joint

  • Help the individual become calm and relaxed

  • Use the 1st stage trainee toothbrush or a tongue depressor to apply pressure in the tongue and hard palate

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GERD

  • Sit in an upright position

  • Avoid using semi reclined position as this will create a bend at the level of LES

  • When bottle feeding use a towel roll or a pillow to straighten the back of the individual

  • Avoid pressure on the stomach and tight clothes

  • Provide small amount of food with more frequent time

  • Modify the diet

  • Improve and facilitate chewing

  • Sleep on the left side

    • Stomach will be below esophagus

    • Maximum help from gravity

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Structural Dysfunction

  • High palate

    • Brush the high palate using the 1st stage trainee toothbrush or a tongue depressor

 

  • Cleft palate

    • Positioning

      • Upright or semi sitting

    • Provide support or facilitate closure using the fingers or mother’s breast

 

YouTube Videos links:

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In this type of intervention, we apply modifications to the food and liquid consistency. The food chosen for dysphagia diets must:

  • Be uniform in consistency and texture 

  • Remain cohesive

  • Have pleasant taste and be in an appropriate temperature

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Thickening agents can either be:

  • Commercial: can be bought

  • Non-Commercial: food items such as potatoes, baby fruits, baby cereals

 Helpful PDF: qrm-standard guidance for food.pdf (virginia.gov)

The progression is as follows:

Level 1 Dysphagia = Pureed food/ thick liquid à Requires very little chewing

  • Moderate to severe Dysphagia

  • The person has:

    •  Little or no jaw control

    • Delayed swallow

    • Slow pharyngeal transit

    • Poor endurance

      • Difficulty in attending to the process

Level 2 Dysphagia = Mashed-soft food / Nectar-like liquids à Requires some chewing

  • The person has:

    • Impaired oral motor control with rotatory chew and tongue control

    • Minimally delayed swallow

Level 3 Dysphagia (Advanced) = Chopped food / Thin liquids à Requires more chewing and bolus formation

  • The person has:

    • Good tongue control

    • Strong swallow

    • Fair delay in swallow

  • Use positive reinforcement in order to increase appropriate behavior

    • Providing a food reward (praise, toys, screen time, a favorite activity, give a hug or a kiss, a sticker to track progress on a chart, blow bubbles, going to the park together) when the desired behavior is completed

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Declaimer:

  • The reinforcement ,whether it is positive or negative, will depend sometimes on an individual's cognitive level.

  • Sometimes the reinforcement should be minimized with time. 

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