DYSPHAGIA TREATMENT

How do I treat dysphagia?

 MUSCLES OF THE SWALLOW
 To treat the dysphagia, you must understand how
the SYSTEM works.
 We treat the swallowing system, not the specific
signs and symptoms.
 We treat the muscle dysfunction, not the aspiration or
penetration.

Information for Slides 3-71 taken from DPNS Manual by Karlene Stefanakos and VitalStim manual by Yorick Wijting
 LINGUAL MUSCLES
 Your tongue is comprised of both intrinsic and
extrinsic muscles.
 INTRINSIC MUSCLES
 Shapes the tongue
 Reflexes
 Tongue Base Retraction-propels bolus into pharynx
 Reflexive lingual groove-maintains cohesive bolus for
pharyngeal transfer.
 Innervated by CN XII
 No sensory pathways, all motor.
 Sensory is CN V, VII, IX
 XII meets with above nerves at nucleus solitarius in the
brainstem.
 INTRINSIC MUSCLES OF THE TONGUE
 Transverse
 Vertical

 Superior longitudinal

 Inferior longitudinal
 TRANSVERSE
 Origin: tongue septum, median portion
 Insertion: mucosa at sides of tongue

 Action: elongates, narrows, thickens tongue, lifts

the sides.
 Innervation CN XII
 VERTICAL

 Origin: superior surface of tongue near tip edges.

 Insertion: inferior surface of the tongue.

 Action: assists in TBR posterior depression

(cohesive bolus, propels bolus.)
 Innervation CN XII
 SUPERIOR LONGITUDINAL
 Origin: septum of tongue, submucosoa near
epiglottis.
 Insertion: sides of tongue

 Action: widens, thickens and shortens tongue,

raises tongue tip and edges; forms concave
dorsum.
 Establishes lingual-dental connection.
 A-P pattern.
 Innervation CN XII
 INFERIOR LONGITUDINAL
 Origin: hyoid bone; inferior surface of base of
tongue.
 Insertion: apex of tongue.

 Action: wides, shortens tongue; creates convex

dorsum, depresses teeth.
 A-P pattern-assists in propulsion of the bolus.
 Innervation CN XII.
 EXTRINSIC MUSCLES OF THE TONGUE
 Give movement to the tongue.
 Tongue retraction-primitive, protective reflex.
 Styloglossus with glossopalatine generate posterior
lingual elevation.

 Reflexes:
 Tongue base retraction-propels bolus into pharynx.
 Reflexive lingual groove-maintain cohesive bolus for
pharyngeal transfer.
 Reflexive protective retraction-prevents pharyngeal
infiltrate, or premature lingual spillover during
mastication.
 Innervation: CN XII
 EXTRINSIC MUSCLES OF THE TONGUE
 Styloglossus
 Genioglossus

 Hyoglossus
 STYLOGLOSSUS

 Origin: inferior portion of the styloid process of the

temporal bone.
 Insertion: lateral border of the tongue.

 Action: elevates rear of tongue; retracts protruded

tongue during mastication.
 Innervation: CN XII.
 GENIOGLOSSUS

 Origin: upper mental spine on lingual surface of the

mandible.
 Insertion: Lingual fascia, dorsum of tongue and
body of hyoid bone.
 Action: alternate fibers work to depress, retract and
protrude tongue.
 Innervation: CN XII.
 HYOGLOSSUS

 Origin: greater cornu of hyoid bone.

 Insertion: posterior half of the side of the tongue.

 Action: depress and retracts tongue.

 Innervation: CN XII.
 INTRINSIC MUSCLES OF MASTICATION
 Reflex: jaw jerk reflex-generates rotary mastication
pattern. (Returns jaw from lateral to midline).
 Mastication Patterns:
 Rotary-normal.
 Vertical-no lateral jaw movement, jaw jerk reflex absent
(trigeminal affected.)
 Suck-swallow-primitive, motoric innervation, oral XII,
pharyngeal X
 Absent O-M pattern-bilateral destruction of CN motor lines V,
X, XII.
 Tonic bite: Contraction of temporal, masseter and
internal pterygoid bilateral deficit muscles exterior
pterygoid, platysmus, digastric, mylohyoid,
geniohyoid.
 INTRINSIC MUSCLES OF MASTICATION
 Temporal
 Masseter

 Internal pterygoid

 External pterygoid
 TEMPORAL

 Origin: temporal fossa and the whole of the

covering fascia.
 Insertion: anterior borders of mandibular ramus and
coronoid process.
 Action: raises and retracts the mandible.

 Innervation CN V (mandibular division).

 MASSETER
 Origin: lower edge of the zygomatic arch
(superficial) medial edge of the zygomatic arch
(deep).
 Insertion: lateral surface of the angle of the jaw;
lateral surface of the ramus.
 Action: raises the mandible against the maxilla.

 Innervation: CN V (mandibular division).

 INTERNAL PTERYGOID
 Origin: lateral pterygoid plate; slips from the
palatine bone; maxillary tuberosity.
 Insertion: ramus and able of mandible.

 Action: raises the mandible and protrudes the jaw.

 EXTERNAL PTERYGOID
 Origin: upper head arises from the infratemporal
fossa and greater wing of the sphenoid bone; lower
head arises from the lateral aspect of the lateral
pterygoid plate of the sphenoid bone.
 Insertion: mandibular condyle and the disc of the
joint of the jaw.
 Action: depresses mandible and draws mandible
forward and sideways. (additional mandible
depressors: platysma, digastric posterior,
mylohyoid, geniohyoid.)
 Innervation: CN V (mandibular division)
 MUSCLES OF THE SOFT PALATE
 Reflex: Palatal Reflex-generates velopharyngeal
closure.
 Functions of velopharyngeal closure:
 Maximize nutritional intake
 Provide passage of bolus
 Cease nasal inhalation
 Triggered by anterior faucial arches
 MUSCLES OF THE SOFT PALATE
 Levator veli palatine
 Tensor veli palatine

 Uvula

 Glossopalatine

 Pharyngopalatine
 LEVATOR VELI PALATINE
 Origin: apex of the petrous portion of the temporal
bone; eustachian tube
 Insertion: aponeurosis of soft palate

 Action:
 Raises soft palate to meet posterior pharyngeal wall
 Dilates eustachian tube orfice
 Innervation: CN X (Pharyngeal plexus)
 TENSOR VELI PALATINE
 Origin: scaphoid fossa; medial pterygoid plate
spine; posterior border of hard palate.
 Insertion: palatine aponeurosis; eustachian tube.

 Action:
 Tenses the soft palate
 Opens the eustachian tube during swallowing
 Innervation: CN V (mandibular division)
 UVULA

 Origin: posterior nasal spine; palatal aponeurosis

(anterior)
 Insertion: mucous membrane of uvula

 Action: raises and shortens the uvula.

 Innervation: CN X (pharyngeal plexus)

 GLOSSOPALATINE

 Origin: merges with transversus and superficial mm

of side and undersurface of tongue
 Insertion: palatin aponeurosis

 Action:
 Raises posterior portion of tongue
 Constricts isthmus of fauces
 Depresses side of palate
 Innervation: CN X (pharyngeal plexus)
 PHARYNGOPALATINE

 Origin: posterior thyroid cartilage; aponeurosis of

pharynx
 Insertion: aponeurosis of the soft palate

 Action:
 Depresses the soft palate
 aids in elevating larynx and pharynx
 Constricts faucial isthmus
 Innervation: CN X (pharyngeal plexus)
 MUSCLES OF THE PHARYNX
 Reflex:
 Peristalsis reflex: propels the bolus to the esophagus
 Sensory and motor innervation CN IX, X, XI
 SUPERIOR CONSTRICTOR
 Origin: Lower posterior border of medial pterygoid
plate; pterygomandibular ligament and raphe;
mylohyoid ridge of the mandible; mucous
membrane of oral cavity; sides of tongue.
 Insertion: Posterior median raphe of pharynx.

 Action: Contracts pharynx; aids movement of food

bolus toward the esophagus.
 CN X-Pharyngeal Plexus
 MIDDLE CONSTRICTOR
 Triggers Peristalsis
 Origin: both cornua of hyoid bone; stylohyoid
ligament.
 Insertion: posterior median raphe of pharynx.

 Action: contracts pharynx; aids movement of food

bolus toward esophagus.
 CN X (pharyngeal plexus)
 INFERIOR CONSTRICTOR
 Triggers peristalsis
 Origin: inferior side of cricoid cartilage; obliques
line of thyroid cartilage.
 Insertion: posterior median raphe of pharynx.

 Action: Contracts pharynx; aids movement of food

bolus.
 CN X (pharyngeal plexus)
 VELOPHARYNGEAL SPHINCTER
 Origin: midline of soft palate.
 Insertion: posterior median raphe of pharynx.

 Action: protrusion and elevation of portion of

pharyngeal wall; aids in forcing soft palate
posteriorly.
 CN X (pharyngeal plexus)
 CRICOPHARYNGEAL
 Origin: sides of cricoid cartilage.
 Insertion: posterior median raphe of pharynx.

 Actions: contracts pharynx.

 CN X (pharyngeal plexus)
PHARYNGEAL LEVATOR MUSCLES
 STYLOPHARYNGEAL
 Origin: base of styloid process of temporal bone.
 Insertion: mucous membrane of pharynx and
thyroid cartilage.
 Action: elevates and widens pharynx.

 CN IX (only group of muscles to be innervated by

IX)
 SALPINGOPHARYNGEAL
 Origin: lower edge of eustachian cartilage.
 Insertion: muscous membrane of pharynx.

 Action: elevates pharynx.

 CN X (pharyngeal plexus)
 INTRINSIC MUSCLES OF THE LARYNX
 Lingual-laryngeal connection=CN XII
 Reflexes:
 Glottal Effort Closure Reflex which generates the
airway.
 Reflexive throat clearing/cough reflex.
 CRICOTHYROID
 Origin: anterior and lateral surfaces of arch of
cricoid cartilage.
 Insertion: caudal border of the thyroid cartilage;
anterior surface of lower cornu of thyroid cartilage.
 Action: draws thyroid down and forward; elevates
cricoid arch; lengthens, tenses vocal folds.
 CN X (superior laryngeal nerve)
 CRICOARYTENOIDS LATERAL
 Origin: superior borders of cricoid cartilage.
 Insertion: anterior surface of muscular process.

 Action: draws arytenoids forward; aids in rotating

arytenoids; tenses and adducts vocal folds.
 CN X (recurrent laryngeal nerve)
 POSTERIOR
 Origin: posterior surface of cricoid cartilage.
 Insertion: muscular process of arytenoid cartilage.

 Action: rotates arytenoid, abducting vocal

processess.
 CN X (recurrent laryngeal nerve).
 INTERARYTENOIDS TRANSVERSE
 Origin: posterior surface of arytenoid cartilage.
 Insertion: posterior surface of opposite arytenoid.

 Action: draws together arytenoid cartilages;

adducts vocal folds.
 CN X (recurrent laryngeal nerve).
 OBLIQUE
 Origin: base of one arytenoid cartilage at muscular
juncture.
 Insertion: apex of the opposite arytenoid.

 Action: draws arytenoid cartilages together.

 CN X (recurrent laryngeal nerve).

 THYROARYTENOID
 Origin: internal and inferior surface of the angel of
the thyroid cartilage.
 Insertion: vocal process and anterior lateral surface
of the base of the arytenoid cartilages.
 Action: draws arytenoids forward; shortens and
relaxes vocal folds.
 CN X (recurrent laryngeal nerve).
 VOCALIS
 Origin: inferior surface of the angle of the thyroid
cartilage.
 Insertion: vocal process of the arytenoid cartilage
and vocal ligament.
 Action: differentially tenses vocal folds.

 CN X (recurrent laryngeal nerve).

EXTRINSIC MUSCLES OF THE LARYNX
 Reflexes:
 Laryngeal elevation reflex: epiglottal ROM
 Laryngeal depression reflex: epiglottal recoil speed.
SUPRAHYOID
 STYLOHYOID
 Origin: styloid process of the temporal bone.
 Insertion: body of the hyoid bone.

 Action: elevates and draws hyoid bone backward.

 CN VII
 DIGASTRIC
 Origin: anterior belly arises from internal aspect of
mandible close to midline, posterior belly arises on
medial side of mastoid process of temporal bone.
 Insertion: intermediate tendon and the hyoid bone.

 Action: elevates hyoid; depresses mandible.

 CN V (anterior belly) CN VII (posterior belly).

 MYLOHYOID
 Origin: mylohyoid ridge of mandible.
 Insertion: hyoid bone and median raphe.

 Action: raises and projects hyoid bone and tongue.

 CN V.
 GENIOHYOID
 Origin: internal surface of the mandible at the
inferior mental spine.
 Insertion: anterior surface of the hyoid bone.

 Action: draws tongue and hyoid bone forward.

 CN XII.
 INFRAHYOID
 Unsupervised cup drinking and straw usage.
 Goes with larynx muscles.
 STERNOHYOID C1-C3
 Origin: medial extremity of clavicle; superior and
posterior portion of the sternum; sternoclavicular
ligament.
 Insertion: body of the hyoid bone, inferior surface.

 Action: depresses hyoid bone.

 CN XII.
 STERNOTHYROID C1-C3
 Origin: superior and posterior portion of the
sternum and first costal cartilage.
 Insertion: oblique line of thyroid cartilage.

 Action: depresses the thyroid cartilage.

 CN XII
 THYROHYOID
 Origin: oblique line of the thyroid cartilage.
 Insertion: body and greater cornu of hyoid bone.

 Action: depresses hyoid bone or elevates larynx.

 CN XII
 OMOHYOID C1
 Origin: superior margin of scapula.
 Insertion: inferior border of the body of the hyoid
bone.
 Action: depress and retracts the hyoid bone.

 CN XII.
 MUSCLES OF FACIAL EXPRESSION
 Control levels:
 Cortical (conscious): middle brain
 Brainstem (oral stage swallow)
 QUADRATUS LABIL SUPERIOR
 Origin: frontal process maxilla; lower margin of
orbit; zygomatic bone.
 Insertion: upper lip at midline.

 Action: elevates upper lip

 CN VII
 ZYGOMATIC MINOR
 Origin: canine fossa of the maxilla.
 Insertion: angle of mouth, upper lip.

 Action: elevates portion of upper lip.

 CN VII.
 ZYGOMATIC MAJOR
 Origin: zygomatic bone.
 Insertion: angle of mouth; upper lip.

 Action: draws corner of mouth up and back.

 CN VII.
 RISORIUS
 Origin: fascia over masseter.
 Insertion: skin at angle of mouth.

 Action: retracts corner of mouth.

 CN VII.
 DEPRESSOR ANGULI
 Origin: oblique line of mandible.
 Insertion: angle of mouth, lower lip.

 Action: depresses angle of mouth.

 CN VII.
 QUADRATUS LABII INFERIOR
 Origin: oblique line of mandible (anterior).
 Insertion: lower lip at angle of mouth.

 Action: depresses and retracts lower lip.

 CN VII.
 MENTAL
 Origin: incisive fossa of mandible.
 Insertion: integument of chin.

 Action: raises and protrudes lower lip.

 CN VII.
 ORBICULARIS ORIS
 Origin: a sphincteric muscle, driving from others of
the area, with no definite origins or insertions.
 Action: closes mouth and puckers lip.

 CN VII.
 BUCCINATOR
 Origin: alvoelar ridges of maxilla and mandible;
pterygomandibular raphe.
 Insertion: angle of the mouth mingling with fibers of
mm forming upper and lower lips.
 Actions: flattens cheek.

 CN VII.
 PLATYSMA
 Origin: thoracic fascia over pectoralis major, deltoid
and trapezious mm.
 Insertion: mental protuberance of the mandible,
skin of cheek and corner of mouth.
 Action: depresses mandible; aids in pouting
reaction; depresses corner of mouth, wrinkles skin
of neck and chin.
 CN VII.
 CRANIAL NERVE V: TRIGEMINAL
 Cutaneous pressure sensation to anteror 2/3 of tongue.
 Thermal sensation hot/cold (safety).
 Oral pain.
 Cutaneous pressure sensation to all teeth, lips, chin, tongue, oral gums,
hard and soft palate.
 Salivary flow to major and minor glands.
 Mouth opening (ext. pterygoids).
 Mandible movement (temporalis, masseter, lat/med pterygoids)-moves
mandible from side to side, elevate and protrude the jaw.
 Innervates muscles of mastication.
 Innervates floor muscles with aid in elevation of larynx (mylohyoid, ant.
Belly of digastric)-depresses mandible, raises hyoid bone, stabilizes
hyoid bone.
 Aids in velopharyngeal closure (tensor veli palatine)-tenses soft palate
prior to elevation.
 Everything powered to contraction by V is mandibular (mastication).
 Reflex: jaw jerk reflex.
 Also innervates tensor tympani.
 CRANIAL NERVE V: TRIGEMINAL
 Motor
 Mastication
 HLE
 Tenses velum
o Sensory
o cheek
o anterior 2/3 tongue (not taste)

**(trouble chewing)
 CRANIAL NERVE VII: FACIAL
 Taste receptors: anterior 2/3 of tongue (sweet, sour,
salty).
 Autonomic salivary glands (submandibulars and
sublinguals).
 Muscles of facial expression.
 Lip shape and movement (orbicularis oris).
 Closure of lips, cheeks and tongue (buccinator- aids in
mastication by pressing the bolus laterally into the molar
teeth, platysma-depresses the mandible, stylohyoid-
elevates the hyoid, retracts hyoid distally, stapedius)-
 Lip closure and prep of bolus for transfer (orbicularis
oris).
 Assists in hyoid bone elevation by raising and stabilizing
the hyoid bone (mylohyoid, post belly of digastric).
 Raises larynx for airway protection (epiglottic ROM).
 CRANIAL NERVE VII: FACIAL
 Motor
 Lip closure
 Buccal tone
 HLE
 Sensory
 Taste anterior 2/3 of tongue
 Salivation

 **dry mouth, decreased lip closure

 CRANIAL NERVE IX:
GLOSSOPHARYNGEAL
 Taste receptors: posterior 1/3 of tongue (bitter).
 Cutaneous pressure receptors, pain, thermal receptors,
posterior 1/3 of tongue.
 General cutaneous pressure receptors on palatal arch,
soft palate, tonsils, mucous membrane of oropharynx,
facial pillars and eustachian tube.
 Autonomic secretory function of parotid salivary glands.
 Assists in velopharyngeal closure to prevent reflux to
nose at start of pharyngeal and end of oral phase
through elevation of larynx and pharynx
(stylopharyngeal-only muscle).
 Upper pharyngeal constrictor fibers.
 General cutaneous pressure/thermal/pain sensation of
upper pharynx.
 CRANIAL NERVE IX:
GLOSSOPHARYNGEAL
 Motor
 Pharyngeal constriction
 Pharyngeal shortening
 Sensory
 Taste/sensation posterior 1/3 of tongue, velum, faucial
arches, superior portion of pharynx

 **no thermal stimulation, pharyngeal phase dysphagia

 CRANIAL NERVE XII: HYPOGLOSSAL
 Only motor/no sensory pathways.
 Tongue movement to posterior oral cavity (A-P propulsion pattern and lingual-alvoelar seal).
 Creating bolus of proper size (int/ext muscles).
 Collection of food partilces from lateral/anterior sulci, palate and molars (int/ext muscles).
 Mixing bolus with saliva.
 Alvoelar-palatal contact before swallow (inf./sup. Longitudinals, transverse, vertical).
 Transporting bolus from mid-palate to posterior 1/3 of tongue (same as above).
 Bolus transport to pharynx.
 Raises and lowers the hyoid bone to protect the airway (supra/infra muscles).
 Tongue base retraction and lingual groove reflex and reflexive protective retraction.
 **if sensory decreased cannot get movement**
 Genioglossus-depresses tongue and allows protrusion, hypoglossus-depresses and retracts
tongue.
 styloglossus-retracts tongue and draws up lateral borders to generate a chute
 Geniohyoid-pulls hyoid anteriorly and superiorly widening the pharynx and pulling the larynx out
of the bolus path.
 Sternohyoid, omohyoid, sternothyroid and thyrohyoid (infrahyoids)-depress the hyoid after
swallow or stabilizes the hyoid and elevates the larynx.
 CRANIAL NERVE XII: HYPOGLOSSAL
 Motor
 Tongue motility
 HLE

 **decreased laryngeal elevation

 **no sensory component
 CRANIAL NERVE X: VAGUS
 Taste receptors in pharynx and epiglottis/mucosa of valleculae.
 Visceral sensation from pharynx and larynx.
 Trachea.
 Pharyngeal reflexes and pharyngeal constrictor muscles except sylopharyngeus.
Superior, meidal and inferior constrictors to constrict the walls of the pharynx.
 Salpinopharyngeus-elevates pharynx and larynx.
 Laryngeal reflexes-all laryngeal muscles (intrinsic laryngeal muscles-oppose vocal
cords to protect the airway during the swallow, cricothyroid tips thyroid cartilage
anteriorly to help protect the airway during the swallow).
 General sensation of abdominal viscera.
 Upper esophageal sphincter (UES) function-cricopharyngeus inhibits reflux.
 Peristalsis/motility of esophagus.
 Velopharyngeal closure-all muscles of soft palate except tensor veli palatine
(levator veli palatini elevates the soft palate).
 Palatoglossus-elevates posterior part of the tongue and draws the soft palate onto
the tongue. Palatopharyngeus tenses the soft palate, draws pharynx superiorly,
anteriorly and medially.
 CRANIAL NERVE X: VAGUS
 Motor
 VP closure
 TBR
 UES closure/opening
 Esophageal motility
 Sensory
 Posterior/inferior portions of pharynx
 Larynx
 Esophagus

 **affects entire swallow

 **recurrent laryngeal nerve can be affected by lung
tumor or sx cervical vertabrae
 SWALLOW IN DETAIL
 Hunger
 Smell of food, empty stomach or electrolyte imbalance
informs hypothalamus of the need to eat.
 Brainstem activates nucleii of CN VII and IX to promote
secretion of salivary gland juices to prep for bolus.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
 SWALLOW IN DETAIL
 Chewing
 Bolus in mouth. CN VII ensures good lip seal (orbicularis oris) while CN
V relays sensory info to brainstem to constantly modify the fine motor
control of bolus prep.
 Motor activity to CN V, VII, IX, X, XII to create an enclosed environment
within the mouth to prepare the bolus.
 Cheeks provide tone (buccinator CN VII)
 Soft palate tense and drawn down towards tongue (tensor veli palatini CN
V and palatopharyngeus CN IX)
 Tongue is drawn up towards the soft palate (palatopharyngeus CN X,
styloglossus CN XII)
 Hyoid bone is stabilized (infrahyoid muscles CN XII and C1-C3) to allow
movement of the mandible).
 Bolus prepared by closing (temporalis, masseter, meial pterygoid, lateral
pterygoid, CN V) and opening (mylohyoid and anterior belly of digastric
CN V, geniohyoid CN XII &C1-C3.)
 Bolus pushed around the mouth by actions of the tongue to create a
consistent, homogenous texture (hypoglossus, genioglossus,
styloglossus and 4 groups of intrinsic muscles of the tongue CN XII).
 Taste sensations (CN VII and IX) provide info to cortex to stimulate areas
of brain required to coordinate the swallow (insula and cingulate cortex).
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
 SWALLOW IN DETAIL
 Volutary initiation
 Once bolus is adequately prepared.
 Soft palate elevates slightly (levator veli palatini and
palatopharyngeus CN X).
 Slight elevation of hyoid bone (suprahyoid muscles
contracting on rigid mandible with slight relaxation of
infrahyoid muscles.
 Pharyngeal tube is elevated (stylopharyngeus CN IX,
palatopharyngeus and salpingopharyngeus CN X).
 Tongue delivers bolus to force bolus distally towards
posterior wall of the pharynx in a “piston-like” manner
using hard palate for resistance.
 Sensation by CN XI and by CN X (pharyngeal plexus).
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
 SWALLOW IN DETAIL
 Larngeal elevation
 1st motion for tongue to propel bolus into oropharynx is
elevated anterior direction toward roof of mouth
(mylohyoid and anterior belly of digastric, CN V;
stylohyoid and posterior belly of digastric CN VII;
palatoplossus CN X; genioglossus, hyoglossus and
styloglossus CN XII; geniohyoid CN XII and C1-C3)
affects hyoid elevation in an anterior direction.
 Soft palate seals off nasopharynx.
 Superior constrictors begin medialization of the lateral
walls.
 Larynx elevated and moved anteriorly in relation to
hyoid bone by thyrohyoid CN X.
*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
 SWALLOW IN DETAIL
 Laryngeal closure
 During laryngeal elevation-vestibule closes and rises relative to thyroid
cartilage (cricothyroid and intrinsic laryngeal muscles CN X).
 Opposition and elevation of arytenoid cartilages provide “medial curtains”
of pyriform recesses (aryeppiglottic folds).
 Pressure exerted on base of epiglottis causing it to tip and cover the
laryngeal vestibule.
 Medial constrictors (CN X) “strip” the pharynx by medialization following
on from superior constrictors.
 Palate descends (palatopharyngeus CN X), constrictors “strip” and
tongue moves posteriorly (styloglossus CN XII) to close oropharynx.
 Once the bolus has reached pharyngeal areas innervated by the internal
branch of the superior laryngeal nerve swallow reflexive and cannot be
stopped.
 Anterior and elevated movement of larynx allows cricopharyngeus to be
stretched (UES) and opened.
 Inferior constrictor finishes medialization and bolus in esophagus.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
 SWALLOW IN DETAIL
 Resting state
 CN X
 Cricopharyngeus resumes tonic state.
 Glottic opens and larynx lowers.
 If bolus present should cough.
 Tongue and hyoid and palate return to resting position.

**Oral phase for liquid boluses should take 1 second and

the pharyngeal phase with all consistencies should take
1 second.

*Dysphagia Foundation, Theory and Practice by Julie Cichero and Bruce Murdoch*
 MOVEMENTS OF THE SWALLOW
o Larynx elevates 2 cm.
o Arytenoids contact base of epiglottis.
o Movement of tongue base is major pressure generating force
of swallow.
o Posterior movement of tongue base 2/3 of distance to
posterior pharyngeal wall, anterior bulging of pharynx covers
approximately 1/3.
o UES opening involves: relaxation of cricopharyngeus,
hyolaryngeal excursion (anterior movement of cricoid
cartilage, bolus pressure.
o Typically no bolus hesitation in pyriform sinuses, the bolus
head reaches UES as it opens.
o Saliva swallows usually 1-2 cc’s.
o During swallow-bolus divides fairly evenly between valleculae
and pyriform sinuses.
(14)
 COMPONENTS OF THE SWALLOW
 Lip closure
 Hold position/tongue control
 Bolus preparation/mastication
 Bolus transport/lingual motion
 Initiation of the pharyngeal swallow
 Soft palate elevation and retraction
 Laryngeal elevation
 Anterior hyoid excursion
 Laryngeal closure
 Pharyngeal stripping wave
 Pharyngeal contraction
 Pharyngoesophageal segment opening
 Tongue base retraction
 Esophageal clearance
Robbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N.,
Rosenbek J.C. (2008). Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically
oriented evidence. JSLPR; 51: S276-S300.
 NEURAL PLASTICITY
 The ability of the brain to change.
 May result in behavorial change, not necessarily
vice versa.
 Increasing evidence that N.P. Plays a substantial
role in centrally remodeling human function after
cerebral injury.
 10 Principles: Use it or lose it; Use it and improve it;
Plasticity is experience specific; Repetition matters;
Intensity matters; Time matters; Salience matters;
Age matters; Transference; Inference.
Robbins J., Butler S.G., Daniels S.K., Gross R.D., Langmore S., Lazarus C.J., Martin-Harris B., McCabe D., Musson N., Rosenbek J.C. (2008).
Swallowing and dysphagia rehabilitation: Translating principles of neural plasticity into clinically oriented evidence. JSLPR; 51: S276-
S300.
 EXERCISE
 Exercising healthy muscles=increased muscle tone.
 Must overload or tax the muscle beyond the typical use.
(Masako, Mendelsohn, effortful swallow, Shaker)
 Swallowing rehab should imitate swallowing
movements. Gains in strength generalize only to
movement very similar to the exercise itself.
 Accurate dosage and frequency unknown at this time for
therapeutic levels.
 Continue therapeutic exercise beyond levels needed for
minimal functinoal swallow to maintain adequate
functional reserve.
 Develop strength training programs that meet the unique
needs of patients with various diagnoses and/or
swallowing impairments.

Clark, H.M. (2005). Therapeutic exercise in dysphagia management: Philosophies, practices and challenges. Swallowing and Swallowing Disorders, 24-27.
 EXERCISE
 Muscles
 Sarcopenia-age-related reduction in muscle fibers affecting
Type II muscles more frequently.
 Sarcomes=smallest functional unit in muscle contraction.
 Contraction achieved when successful binding of proteins (actin
and myosin) along the sarcomere causing the filaments to slide
toward each other, creating shortening action of contraction.
 Bundles of sarcomeres form muscle fibers.
 Type I muscles: slow twitch, slow-oxidative fibers, fatigue-
resistant, increased endurance (lingual lateralizers, jaw closers
and in anterior tongue along with Type IIa).
 Type II muscles: to propel and move bolus, fast twitch, larger,
generate more force, easily fatigued. (tongue base, pharyngeal
constrictors). No resistance=no need for type II muscles.
 Type IIa-fast oxidative/glycolytic.
 Type IIb-greatest capacity for force, easily fatigued, uses glycogen.
Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and
directions for future research. Dysphagia; 22: 251-265.
 EXERCISE
 Exercise efforts that do not force the neuromuscular
system beond the level of usual activity will not elicit
adaptations.
 Swallowing is submaximal, meaning it does not
generate maximal force of muscles involved.
 Reps: 8-12 most effective, 6-8=greater outcomes for
generating strength.
 “If improved swallowing is the goal, then swallowing
would be the optimal training task.”
 Transference might explain swallow imprvement with
non-swallow exercise programs (EMST, lingual
strengthening, LSVT, Shaker).
 Combine strength and swallow treatments.
Burkhead, L.M., Sapienza C.M., Rosenbek J.C. (2007). Strength-training exercise in dysphagia rehabilitation: principles, procedures and directions for future
research. Dysphagia; 22: 251-265.
 DYSPHAGIA THERAPY
 Therapy helps return swallow function.
 High intensity, aggressive therapy, not diet monitoring
helps patients regain swallow function.
 Fewer complications arise when the swallowing system
is rehabilitated. (7).
 Volitional swallowing involves bilateral neural
involvement, however some areas are hemisphere-
specific, 63% showing left dominance. (12)
 Stroke patients pharyngeal representation in
undamaged hemispere increased significantly with
recovered swallow function. No changes were seen in
the damaged hemisphere. Recovery of swallowing
depends on compensatory reorganization. (13)
 DYSPHAGIA THERAPY
 Weakness=decreased ability to use force.
 Fatigue=weakness that becomes evident during
sustained force productions and over repeated
trials.
 Tone=tendency of muscle tissue to resist passive
stretch.
 INTERVENTIONS
 Exercises
 Mendelsohn Manuever
 Masako
 Shaker
 Oral manipulation exercises
 Effortful swallow
 Cheek/lingual with resistance
 Chewing
 Weighted bolus
 Swallow trials
 Suck-swallow
 IOPI
 MENDELSOHN MANUEVER
 Endurance/resistance. Can use a bolus.
 Increases extent and duration of UES opening. (2)
 Increases tongue-base/pharyngeal wall pressure and contact
duration. (2)
 Found to: increase peak pharyngeal pressure, UES
contraction pressure, UES opening duration, duration of
hyoid-UES separation, duration of laryngeal elevation, bolus
transit time, hyoid excursion, distance from the hyoid bone
and the thyroid cartilage, duration of contraction for various
muscles. (4)
 May facilitate clearance of residue.
 Research: 20 normal subjects, 1 group given 5ml water
swallows compared to 5 ml swallows with Mendelsohn
manuever. Able to sustain laryngeal elevation for 1.5 seconds
or greater with increase in submental muscle group (anterior
belly of the digastric, mylohyoid and geniohyoid.) (23)
 MASAKO
 Resistance. Boluses not recommended.
 Increases anterior motion of the posterior
pharyngeal wall at the level of the tongue base. (2)
 Increases strength of tongue base and pharygeal
constriction, increases efferent drive of tongue
base.
 Increased pharyngeal clearance.

 Logemann recommends resistance exercises to

target weak structures, 10 reps, 10x/day.
 SHAKER
 Resistance/Endurance.
 Increased laryngeal anterior excursion and cross-
sectional opening of UES, improved swallow
function, decreased post swallow aspiration and
ability to return to various levels of oral intake. (2)
 Increased strength through HLE and UES opening,
increased efferent drive of HLE and UES opening.
 Targets anterior belly of the digastric, mylohyoid,
geniohyoid (hyoid elevation muscles).
 ORAL MANIPULATION EXERCISES
 Resistance/Coordination.
 Cheese cloth

 Toothette

 Gauze
 EFFORTFUL SWALLOW
 Resistance/Endurance.
 Increased: base of tongue retraction, tongue propulsive force,
oral pressure, duration and extent of hyoid movement and
laryngeal vestibule closure, longer duration of pharyngeal
pressure and UES relaxation. (2)
 Original goal to maximize posterior BOT motion resulting in
improved bolus clearance from valleculae.
 Increased force-generating ability of swallowing muscles. (4)
 Increased strength for TB, HLE, PC and UES opening,
increased coordination for HLE, PC, UES opening, Increased
afferent (sensory) drive for TB, HLE, PC, UES opening,
increased efferent (motor) drive for TB, HLE, PC, UES.
 Evidence of early elevation of the hyoid at initiation of effortful
swallow. (20)
 LINGUAL EXERCISES WITH RESISTANCE
 Research: Progressive resistance training-8 week
training, 3 sets, 10 reps 3x/day using IOPI, pressing
bulb against palate using tip, blade and dorsum. Lingual
strength increased as a result of non-swallowing
strengthening exercises. Non-swallow strengthening
exercises improved swallow with liquid bolus.
Penetration/Aspiration Scores were reduced. (2, 10)
 Research: tested strength and endurance-3 groups, 1
with no exercise, 1 with tongue depressors and 1 with
IOPI. Exercises completed 5 days/week for 1 month, 10
reps 5x/day. Movement 4 directions (with T.D. and
IOPI), left, right, protrusion and elevation. Greater
change in both exercise groups. IOPI did not differ
therapy. No change in endurance. Increased change in
those with initial lower baselines. (9)
 LINGUAL EXERCISES WITH RESISTANCE
 BOT=base, between tip of uvula and valleculae.
 Pull tongue straight back.
 Yawn and hold most retracted.
 Gargle and hold at most retracted (most BOT movement).
 Increased strength with resistance, IOPI, oral
manipulation, swallow trials. Increased ROM with MFR,
stretch (Beckman), oral manipulation, swallow trials.
Increased coordination with oral manipulation, sensory
stim (Beckman, DPNS), suck-swallow, resistance,
swallow trials. Increased afferent drive with chewing
(cold/sour bolus), swallow trials, CN V, VII, XII.
Increased efferent drive with resistance, textured/chewy
bolus, weighted bolus with straw, swallow trials.
 CHEWING
 Texture
 Viscosity

 Cold

 Sour
 WEIGHTED BOLUS
 Add viscosity
 Thickened liquids/pudding through straw
 SWALLOW TRIALS
 Challenging boluses-find a safe, challenging
consistency to increase strength.
 IOWA ORAL PERFORMANCE INSTRUMENT
 IOPI uses a bulb and a hand-held device to
measure tongue strength.
 Can be used as a therapeutic tool for visual
feedback.
 Available at www.iopi.info
 STRETCHES
 Myofascial release
 Beckman program
 MODALITIES
 Biofeedback (sEMG)
 NMES (VitalStim, Eswallow)

 Thermal-Tactile Stimulation

 Pressure Biofeedback (IOPI)

NEUROMUSCULAR ELECTRICAL STIMULATION
 NMES-training and equipment through VitalStim
(FDA approved) or Eswallow.
 Research: significant descent of the hyoid and
larynx at rest during maximal electrical stimulation.
Aspiration and pooling during swallowing were only
reduced during low sensory thresholds of
stimulation. Also greater hyoid depression during
stimulation at rest. (23).
 THERMAL TACTILE STIMULATION
 “00” laryngeal mirror.
 Stimulate faucial arches 4-5x then assess speed of
swallow.
 Repeat when swallow slows.

 Best dosage is 5x/day.

 TREATMENT

 DPNS (Deep Pharyngeal Neuromuscular

Stimulation)
 Thermal Tactile Stimulation

 EMST (Expiratory Muscle Strength Training)

 LSVT (Lee Silverman Voice Treatment)

 EMST
 Exhale into a device with 1-way, spring-loaded
pressure valve, with valve at 60-80% of max
expiratory pressure.
 Afferent stimulation to brain stem swallow centers
through peripheral sensory receptors in tongue and
oropharynx and strengthening oropharyngeal,
laryngeal and supralaryngeal muscles.
 Improves ability to cough. (6)
 MANEUVERS/POSTURES
 Mendelsohn
 Chin Tuck

 Head Turn

 Supraglottic

 Super Supraglottic

 Head back

 Side lying
 CHIN TUCK
 Research comparing chin tuck with thin liquids to NTL and HTL.
Estimated $200/month for people on thickened liquids. More
aspiration with chin tuck than with NTL or HTL. More adverse
affects with thickened liquids (dehydration, UTI, fever). (3)
 Narrows the airway, varies pressures in pharynx and UES during
swallow, duration of timing of swallowing events and
displacement of anatomical structures during the swallow.
 Significant change in pharyngeal contraction pressure, duration
of pharyngeal contraction pressure, larynx to hyoid bone
distance, hyoid to mandible distance before the swallow, *angle
between mandible to posterior pharyngeal wall, *angle between
epiglottis to PPW of trachea, *width of airway entrance, *distance
from epiglottis to PPW. (*all decreased). (4)
 Chin tuck effective in 72% of patients studied. May be
contraindicated in those with weak pharyngeal contraction
pressure as it decreased pharyngeal contraction pressure and
duration. (10/11)
 HEAD TURN
 Head rotated to weaker side-Increased pharyngeal
contraction pressure at the level of the valleculae and pyriform
sinus on side of rotation, decreased UES resting pressure on
side opposite rotation, increased duration from peak
pharyngeal pressure in the pyriform sinus to the end of UES
relaxation and increased UES anterior/posterior opening
diameter.
 Redirected bolus flow through the pyriform sinus on the strong
side.
 Concurrent decrease in UES resistance to bolus flow and
prolongation of UES opening allowing bolus material to flow in
a less obstructed manner through the UES and providing
more time to clear all bolus material from the pharynx. (4)
o Closes weaker side, applies pressure to larynx with closer
approximation of vocal chords to weak side, gravity holds food
longer to stronger side for unilateral oral and/or pharyngeal
dysphagia. If only pharyngeal dysphagia use head turn to weak
side.
 SUPER SUPRAGLOTTIC SWALLOW
 Facilitates timing and extent of laryngeal closure at
specific levels of the larynx. (2)
 For dysphagia secondary to reduced closure of the
airway entrance. Increased UES relaxation prssure
and duration of hyoid excursion and laryngeal
movement, decreased time between UES opening
and onset of hyoid movement and BOT movement
time between UES opening and the onset of vocal
fold adduction and laryngeal closure. (4)
 It is indicated that the airway protective sequence
happens early in the swallow.
 13/15 subjects with CVA showed abnormal cardiac
findings. (21)
 SUPRAGLOTTIC SWALLOW
 For dysphagia accompanied by reduced or late
vocal cord closure or delayed pharyngeal swallow.
 Changes timing of UES opening, duration and
timing of hyoid excursion and laryngeal closure,
timing of BOT movement.
 Close vocal cords earlier in swallow, prolongs
hyolaryngeal excursion-before and during swallow
vocal fold closure.
 Logemann recommends 10x/day x5 min with 5-6
swallows each time. (4)
 13/15 subjects with CVA showed abnormal cardiac
findings. (21)
 HEAD BACK (CHIN UP)
 Gravity assistance.
 Helps lingual deficits.

 Not for use with delayed pharyngeal swallow or

poor airway closure.
 SIDE LYING
 Alters gravity for residue.
 May help clear residue after the swallow
(pharyngeal).
 Before sit upright-cough to clear final residue.

 Will hold residual bolus material to the pharyngeal

wall instead of allowing it to drop into the airway.
When pharyngeal contraction is reduced such that
residue is observed throughout the pharynx. (4)
 SENSORY STIMULATION
 Sour bolus ½ lemon juice, ½ barium or water.
Helps to decrease time to initiate oral onset of the
swallow and reduce oral transit time. “Quicker”
swallow onset, more synchronous activation of
submental muscles, making the muscle contraction
stronger. (17/18)
 Carbonated bolus.

 Massage-improves circulation of blood and lymph

system, increases oxygenation of tissues, facilitates
waste removal, relieves pain (does not increase
strength or prevent atrophy or hypotonia.) (8)
 PEG TUBE AND FUNCTIONAL DYSPHAGIA
THERAPY (FDT)

 Looked at 2 groups, 1 with PEG and 1 without.

 Non-PEG group had significant post tx
improvement in functional oral intake.
 Severe dysphagia with PEG showed significant
improvement, still required some PEG feedings.
 More complications and increased mortality in PEG
group.
 All patients benefited from FDT.

Becker R., Neiczaj R., Egge K., Moll A., Meinhardt M., Schulz RJ. (2010). Functional dysphagia therapy and PEG treatment in A clinical geriatric setting.
Dysphagia, Jan 26.
PREDICTORS OF ASPIRATION: LANGMORE, ET
AL STUDY (1998)

 Aspiration pneumonia is a 3 phase process:

 Colonizes pathogenic bacteria in the oropharynx
 Aspirates the bacteria into the airway
 Unable to clear the material and then develops a bacterial
infection in the respiratory system
 Risk factor for aspiration include:
 Dependence on others for feeding
 Multiple medical conditions
 Smoking
 Tube feeding
 Dependence for oral care
 Number of decayed teeth
 Number of medications
Langmore S, Terpenning M., Schork A., Chen Y., Murray J., Lopatin D., Loesche W. Predictors of aspiration pneumonia: How important is dysphagia?
Dysphagia 1998; 13: 69-81
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