Download Understanding the Physiology of Impaired Pharyngeal Swallowing

Understanding the Physiology of
Impaired Pharyngeal Swallowing
Nancy B. Swigert, M.A., CCC-SLP., BCS-S
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Disclosures
FINANCIAL
Nancy B. Swigert received an honorarium for this
presentation
Some of this information is included in The Source
for Dysphagia and Nancy receives royalties on the
book
NON-FINANCIAL
Nothing to disclose
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Goals for the presentation:
Match cranial nerve to specific pharyngeal
movements
Describe relationship between specific muscles and
pharyngeal movements.
Explain specific exercises for improving pharyngeal
movements
Choose appropriate techniques to treat pharyngeal
disorders
Discuss evidence for specific techniques
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Cranial nerves and muscles
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Why is understanding neuro-physiology
important?
You might select the wrong treatment techniques for
the problem
A sign/symptom may have more than one possible
physiologic cause
You might select a treatment technique or method
which doesn’t even make sense for the problem (e.g.
treating a delay when the problem is reduced
laryngeal elevation)
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
One “symptom” can have more than one
cause
Sign/symptom
Different physiologic causes
Functional short term goal
Patient has residue in the
pyriforms after the
swallow
Reduced laryngeal
elevation
Patient will increase
laryngeal elevation to
reduce the amount of food
remaining in the pyriforms
which could fall into the
airway
Reduced anterior
Patient will increase
movement of hyolaryngeal anterior movement of
complex
hyolaryngeal complex to
reduce the amount of food
remaining in the pyriforms
which could fall into the
airway
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Let’s look at muscles and innervations for
motor and sensory for:

Tongue (we’ll focus on the movements related to
pharyngeal phase)
Pharynx
Hyoid and Larynx
Intrinsic larynx
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We’ll ignore the soft palate due to time constraints
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Tongue
Maintains seal with the soft palate
Squeezes bolus posteriorly
Helps initiate the pharyngeal phase
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Tongue
Muscle
Function
innervations - Motor
Genioglossus
Protrusion; press tongue to
teeth or alveolar ridge
(posterior fibers)
CN XII
Hypoglossal
Retraction (anterior fibers)
Styloglossus
Draw tongue downward (all
fibers)
Pulls tongue up and back
Palatoglossus
Pulls tongue back to make
the groove
Hyoglossus
Retracts or depresses
tongue; elevates hyoid
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innervations –Sensory
CN V Trigeminal–
anterior 2/3
general
VII Facial -anterior
2/3 taste
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CN XII Hypoglossal Glossopharyngeal
posterior 1/3
general and taste
CN X Vagus
(pharyngeal branch) X Vagus posterior
general
CN XII Hypoglossal
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
IMPAIRED PHYSIOLOGY OF TONGUE –
IMPACT ON SWALLOW
What physiologic problem
might you observe if
impairments in tongue
muscles
Back of tongue to soft palate
does not seal to keep bolus in
mouth
What symptoms might it cause What technique might you
try?
Do we have evidence?
Premature loss of bolus over
back of tongue. Can result in
penetration or aspiration
Hard k, g
Base of tongue fails to pull back Residue in valleculae
towards pharyngeal wall
adequately
Tongue retraction
Effort swallow
Pretend to gargle
Pretend to yawn
Increased stage transition
Penetration
duration (is this perhaps a
Aspiration before the swallow
sensory deficit in the back of
the tongue? OR sensory deficit
in the pharynx?)
Sensory stim (cold, sour)
Three second prep
Super-supraglottic
Mendelsohn
We’ll discuss these mostly with
the pharynx though this is a bit
of an artificial separation
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: Three techniques on Maximum
Posterior Movement of Tongue
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Pull-back (tongue retraction): “Pull the back
of your tongue to the back of your mouth
and hold for a second”
Yawn: “Pull your tongue back during a yawn
and hold for a second”
Gargle: “Pull your tongue back during a
gargle and hold for a second”
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(Subjects were consecutively referred patients)
 (Veis, et al 2000)
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: Three techniques on Maximum
Posterior Movement of Tongue Base
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Gargle task most successful in eliciting more
tongue base retraction for the group of subjects
(although not in every subject)
Interesting finding:
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Number of repeat swallows on each bolus
correlated significantly with approximate % of
residue in valleculae
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Should we pay more attention to repeat swallows on
clinical exam?
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful Swallow
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Multiple studies, done mostly with normals
Results in effects in tongue pressures
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Also found changes in pharynx and PES
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Huckabee and Steele (2006, 2007)
And changes in esophageal pressures
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Huckabee and Steele (2006, 2007)
Lever et al 2007
Here are a few examples
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful swallow
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Instructions emphasized increased tongue to palate
pressure
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“push hard with your tongue”
Resulted in increased sEMG amplitudes, tonguepalate pressures and pharyngeal pressures
Effortful swallow may be helpful in clearing the
pharynx in some patients
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Huckabee and Steele (2006, 2007)
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful swallow possible impact on timing
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Compared timing of pharyngeal and PES pressure
onsets across effortful and normal swallows
Delayed onset of effortful swallows (defined by
delayed increase in pharyngeal pressure or
relaxation of PES)
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And overall increased duration of the swallows
So.. Is effortful swallow contraindicated in patients
with increased stage transition duration (i.e. delayed
swallow)?
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Hiss and Huckabee 2005
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful swallow in patients
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One study(6 stroke; 2 H&N) found no impact on:
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Frequency of penetration or aspiration
Amount of pharyngeal residue
Did reduce depth of penetration
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Bulow, Olsson & Ekberg 2001
A different study (3 H&N CA patients)
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Increased swallow pressure (base of tongue to posterior
pharyngeal wall)
Increased length of time base of tongue was in contact
with pharyngeal wall
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Lazarus, Logemann, Song et al 2002
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effects of sour on tongue movements
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16 healthy adults
Tongue movement data for tongue body and dorsum
Water + four tastes used: Water, high intensity sour
(2.7% citric acid), moderate intensity sour, moderate
sweet, sweet-sour
High intensity sour stimulus elicited significantly larger
amplitude and higher peak velocity forward and
backward tongue body movements than other stimuli
Suggests Trigeminal irritation may be required to
influence bolus transmit times during swallowing
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Steele, Pelletier & van Lieshout (2007)
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Pharynx
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Muscles of pharynx surround the:
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Nasopharynx
Oropharynx
Laryngopharynx
They squeeze the bolus into the esophagus
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Pharynx
Muscle
innervations- Motor
innervations – Sensory
Superior and middle Contract on bolus to squeeze
constrictors
it down
Lowest portion
superior constrictor
= glossopharyngeus
Inferior constrictor Includes thryopharyngeus
(superior) and
cricopharyngeus(CP)
(Inferior).
CP is tonic until it relaxes
during swallowing to open so
bolus can pass
Palatopharyngeus
Elevates; contracts on bolus;
some laryngeal elevation
CN X Vagus
(pharyngeal branch)
CN IX and CN X (pharyngeal
plexus) – general sensory
CN X (pharyngeal
branch)
CN IX and CN X (pharyngeal
plexus) – general sensory
CN X (pharyngeal
branch)
CN IX and CN X (pharyngeal
plexus) – general sensory
Salpingopharyngeus Elevates and laterally draws
walls up
CN X (pharyngeal
branch)
CN IX and CN X (pharyngeal
plexus) – general sensory
Stylopharyngeus
CN IX
(Glossopharyngeal)
CN IX and CN X (pharyngeal
plexus) – general sensory
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Function
Elevates pharynx; some
laryngeal elevation
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Impaired physiology of pharynx – Impact on
Swallow
What physiologic problem
might you observe if
impairments in tongue muscles
What symptoms might it
cause
Increased stage transition
Penetration
duration (is this perhaps a
Aspiration before the
sensory deficit in the back of the swallow
tongue? OR sensory deficit in
the pharynx?)
Reduced laryngeal
Can contribute to
elevation/pharyngeal shortening penetration during swallow
Can result in residue in
pyriforms
Reduced constriction of
Residue in pharynx,
pharyngeal walls
pyriforms
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What technique might you try?
Do we have evidence?
Sensory stim (cold, sour)
Three second prep
Super-supraglottic *
*For timing – we’ll discuss with larynx
Mendelsohn *
** For timing – we’ll discuss with
hyolaryngeal elevation
Pitch glide (falsetto)
Mendelsohn* We’ll discuss with
hyolaryngeal elevation
Tongue hold
Effortful swallow We talked about this
with the tongue. More evidence that
tongue/pharynx is artificial
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
separation
Efficacy of Mechanical, Cold, Gustatory and
Combined Stimulation
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Study broke the components down
Normal healthy adults
Only when all three components were presented was there
statistically quicker average activity compared to no stimulation
Used a different methodology: slowly introduced liquid bolus until
patient felt capable of swallowing
Supports explanation of temporary facilitative effect of this stimulus
combination on swallow-specific activity
Raised more questions than it answered
 Sciortino, et al 2003
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: Gustatory (Sour)
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11 SNF residents
10 aspirated water (1 penetrator)
Citric acid (2.7%) improved swallowing safety
compared to water
Eliminated aspiration in 8/10
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Pelletier 2002
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: Gustatory (Sour)
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Taste stimuli increased the # of spontaneous
swallows observed within 1 minute after initial
swallow compared to water
Gustatory stimuli might facilitate swallowing in
some patients with neurogenic dysphagia
Best response in patients without dementia
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Sour bolus
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6 healthy participants
High Resolution Manometry, intramuscular EMG and
surface EMG
Magnitude and duration of swallow-related intrapharyngeal pressure and muscle activity increased
with the lemon bolus
Frequency of spontaneous swallows increased
following ingestion of sour bolus
Also had greater difficulty suppressing the swallow
compared to water swallow
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Hammer et al 2012
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Lemon glycerin swabs
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When used for oral hygiene, considered ineffective
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Lemon reduces oral pH to 2-4 (below the normal 6-7)
Acid conditions can irritate the mouth, cause pain and
decalcify teeth and increase risk of dental caries
Glycerin dehydrates the oral tissues
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Trenter-Roth 1986
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful Pitch Glide (EPG) aka Falsetto
+ Pharyngeal Squeeze
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11 healthy young taught the maneuver
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No statistical difference b/t EPG and swallowing for
these kinematic measures:
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Performed it and repeated swallows during dynamic MRI
Anterior hyoid, laryngeal elevation, pharyngeal
shortening, lateral pharyngeal wall approximation
Hyolaryngeal approximation is greater in EPG than
swallowing
Superior hyoid movement greater in swallowing than
EPG….
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Miloro et al 2012
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful Pitch Glide (EPG) aka Falsetto +
Pharyngeal Squeeze
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The EPF recruits several muscle groups also used in
swallowing
May be beneficial exercise to strengthen
hyolaryngeal approximation, anterior hyoid
movement, laryngeal elevation, pharyngeal
shortening and lateral pharyngeal wall approximation
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Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: tongue hold maneuver effect on
pharyngeal wall (Masako)
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CA patients with tongue resection
Noted increased anterior bulging of PPW 3 months
after surgery
More bulging with greater tongue resection
Suggested PPW could compensate for tongue base
not retracting
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Fujiu, Logemann & Pauloski 1995
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: Tongue hold (Masako)
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10 normal adults
Swallows of 3 ml barium without and with
tongue hold
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“Protrude tongue maximally but comfortably”
Increased PPW bulging at mid and inferior
levels of second cervical vertebra on the
swallows with tongue hold See next slide for example
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Fujiu & Logemann, 1996
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Tongue hold (Masako)
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Do NOT use with food
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The move impairs
some of the natural
movements of
swallowing (inhibits
tongue base retraction)
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Three negative findings:
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Increased pharyngeal residue,
particularly in valleculae
Shortened duration of airway
closure
Increased pharyngeal delay
time in triggering the
pharyngeal swallow
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
More evidence that tongue hold is
rehabilitative only
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20 healthy participants
Tongue hold swallows created significantly
lower pressures in upper pharynx than noneffortful saliva swallows
The increased anterior bulge cannot
compensate for decreased pressure
generation at level of upper pharynx
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This might impede bolus flow through the pharynx
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Doeltgen et al 2007
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Hyolaryngeal complex
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Hyoid bone is attached to thyroid cartilage below and
tongue above
Can be pulled in many different directions
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Supra-hyoid muscles
Infra-hyoid muscles
Moves up and forward as larynx elevates
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Protects the airway
Pulls open the PES
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Hyolaryngeal complex (Hyoid and Larynx)
Muscle
Mylohyoid
Function
CN innervations-motor
Upward movement of
hyoid
Upward and forward of
hyoid
Jaw opener
Moves hyoid upward
Posterior, upward
movement hyoid
Posterior, upward
movement hyoid
Upward hyoid
CN V Trigeminal
(mylohyoid branch)
Cervical plexus C1
Cervical plexus C1
Sternothyroid
Moves hyoid and larynx
together
Pulls larynx down
Sternohyoid
Pulls hyoid down
Ansa cervicalis
Omohyoid
Pulls hyoid down
Ansa cervicalis
Geniohyoid
Anterior belly digastrics
Posterior belly digastrics
Stylohyoid
Hyoglossus
Thyrohyoid
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CN V
CN VII (Facial)
CN VII
CN XII Hypoglossal
Ansa cervicalis
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Sensory
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Cervical spinal, cervical
plexus
Impaired physiology of hyolaryngeal
complex – Impact on Swallow
What physiologic problem
might you observe if
impairments in tongue
muscles
What symptoms might it cause What technique might you
try?
Do we have evidence?
Reduced anterior and
superior movement of
hyolaryngeal complex
Decreased PES opening
Residue in pyriforms
Epiglottis does not fully
invert, allowing
penetration
Reduced closure at
entrance to airway
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Head Lift
EMST
Jaw Opening
Mendelsohn
Effortful *Discussed with
tongue- specifics here on
effects of hyoid m’ment
Super-supraglottic
swallow *Will discuss
with larynx
Allows penetration into
vestibule
May allow aspiration
during the swallow
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy of specific treatment technique
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14 healthy elderly and 14 healthy young
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Head Lift in healthy elderly
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Increase in:
magnitude of anterior excursion of the larynx
maximum A-P diameter
cross-sectional area of UES
decrease in hypopharyngeal intrabolus pressure
(decrease in pharyngeal outflow resistance)
Strengthens suprahyoid muscles
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Shaker et al 1997
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Studies with head lift – interesting finding
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AP deglutitive UES opening and hyoid bone and
thyroid cartilage anterior excursion were noted to be
reduced in the elderly
Reduced excursion is associated with higher intrabolus pressure
Suggests higher pharyngeal resistance
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Kern et al 1999
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: Head lift
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27 patients (hemispheric CVA, brainstem CVA,
pharyngeal radiation)
Six weeks of exercise vs. sham
Improvement in:
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UES opening
Anterior laryngeal excursion
Post-deglutitive aspiration resolved
Returned to PO
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Shaker et al 2002
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy: Head lift (patients)
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11 patients with UES dysfunction
Compared traditional therapy to head lift
In addition to strengthening suprahyoid muscles…
Augments thyrohyoid muscle shortening
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Mepani et al 2009
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Shaker compared to traditional
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Pre and post MBS
Traditional: Super-supraglottic; Mendelsohn; Tongue
base; yawning; gargle; tongue pull back
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Logemann et al 1999
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Shaker vs. traditional
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Shaker: reduced post swallow aspiration to
greater degree than traditional
Traditional: superior hyoid and laryngeal better
(uses greater muscle effort than Shaker)
Both: significant increase in width of UES
opening on paste
Aspiration after: Shaker
Reduced range of movement in structures of
pharynx: traditional therapy
40
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
EMST
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
The EMST device is a calibrated instrument
consisting of a mouthpiece with a one-way springloaded valve and it is referred to as an expiratory
pressure threshold trainer.
The valve blocks airflow produced by the user until a
sufficient “threshold” pressure is produced to
overcome the force.

41
(Baker et al., 2005),
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
SEMG of submental muscles with EMST

Patterns of activation in the submental muscles while
training on EMST had longer duration of activation
with higher amplitude compared to swallowing

Increases motor unit recruitment
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42
Wheeler, Chiara & Sapienza 2007
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
EMST compared to other techniques
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25 healthy male subjects
Compared normal swallow, effortful swallow,
Mendelsohn and EMST
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Videofluorographic measurements and SEMG
The target threshold was defined as 75% of each
participant’s MEP.
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Wheeler-Hegland, et al 2008
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
EMST
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Compared to normal swallow, Mendelsohn and
Effortful swallow, there was less hyoid displacement
with EMST
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Speaks to specificity of the task
EMST achieved higher maximum and average
submental sEMG activity versus normal swallowing.
44
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
EMST
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With the Mendelsohn maneuver and effortful
swallow, the load imposed was volitional.
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
That is, the submental muscle activity found to increase
on sEMG resulted from the intention of the participant
to “squeeze” those muscles, or to “swallow hard.”
Conversely, the load imposed by EMST results
from an externally imposed threshold that must
be overcome in order to break the spring-loaded
valve and allow air to flow through the device.
45
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
EMST
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
EMST has potential to induce strength gains in the
submental muscles secondary to the externally
imposed load.
Expiratory muscle strength training (EMST)
increases motor unit recruitment of the
submental muscle complex.
46
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Jaw Opening
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Premise: Suprahyoid muscles used not only for
elevating larynx, but for opening jaw
11 Healthy elderly
Open jaw to maximum and hold for 10 s.

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2x day for 4 weeks
Concluded that jaw opening exercise significantly
increased suprahyoid muscle strength

47
Wada et al 2012
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy- particular treatment method
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Mendelsohn maneuver
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48
Use of maneuver increased the duration of the anteriorsuperior excursion of the larynx and hyoid and delayed
sphincter closure by maintaining traction on anterior
sphincter wall (Kahrilas, et al 1991)
Improved extent of UES opening and bolus head velocity
(Logemann & Kahrilas, 1990)
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy of specific method
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Mendelsohn with SEMG
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Changes in swallow physiology
Improved coordination, longer duration, and increased
effort
The sustained oral and pharyngeal postures inhibited
some of the transient movements noted as part of
incomplete swallow (e.g. lingual pumping, repetitive
pharyngeal contraction)

49
(Crary, 1995)
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Mendelsohn with sEMG
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SEMG biofeedback
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50
Chronic dysphagia secondary to brainstem stroke
Physiologic change in swallowing as measured by
severity ratings on VFSS
8 of 10 able to return to full oral intake with elimination
of G-tube
Average of 5.3 months
Huckabee & Cannito, 1999
Bryant & Bryant, 1991
Crary, 1995
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy of specific treatment techniques

SEMG biofeedback
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Patients after stroke and head/neck cancer
Patients had reduced hyolaryngeal elevation, reduced
pharyngoesophageal segment opening & residue
Daily 50 minute sessions and portable biofeedback to
practice at home


Average # sessions 12/stroke and 9/head & neck
87% of patients increased functional oral intake by at
least one scale score on FOIS

Stroke had more functional gains
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51
Crary, et al 2004
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Mendelsohn and Swallowing Duration
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Pilot study: Does intensive intervention using
Mendelsohn maneuver result in lasting changes in
swallowing physiology
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

Hyoid bone excursion, UES opening, bolus flow
characteristics (i.e. pharyngeal residue, laryngeal
penetration, aspiration)
18 patients post stroke
Prospective crossover design

2 weeks treatment; 2 weeks no treatment….

52
McCullough et al 2012
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Mendesohn
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
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Treatment: two sessions per day of Mendelsohn with
sEMG biofeedback
Changes measured on VFSS
Significant changes in:
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

Duration of superior and anterior hyoid movement after
two weeks of treatment
UES opening increased (but not significantly)
No significant differences in penetration, aspiration,
residue, dysphagia severity ratings
53
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful and hyoid movement

Effortful swallow increased hyoid elevation before
swallowing, but decreased overall movement during
swallowing in healthy (Bulow et al 1999)

Huckabee and Winkleman wondered if it would also
result in decreased anterior movement of the
hyoid…..

54
Huckabee & Winkelman 2012
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Effortful and hyoid movement

24 healthy adults



Non-effortful swallow
Effortful swallow
Tongue hold

Measured with ultrasound….

Anterior hyoid movement relatively stable across
swallowing conditions
55
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Larynx

Protects airway by closing and moving up and
forward



See previous slides on hyolaryngeal complex
As larynx lifts, epiglottis flips down to send bolus on
either side of larynx
True and false folds adduct to close the glottis
56
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Larynx
Muscle
Function
CN innervationsmotor
Thyroarytenoid
Includes vocalis
Adductor, tensor or
relaxer
Cricothyroid (pars
oblique and recta)
Lengthen and tense vf, C N X(external
alters distance b/t
laryngeal)
thyroid and arytenoids
Posterior
cricoarytenoids
Abduct and internally
rotate arytenoids
CN X (left recurrent
laryngeal)
Lateral cricoarytenoids Adduct and internally
rotate arytenoids
CN X (left recurrent
laryngeal)
Transverse arytenoids
Adduct arytenoids
CN X (left recurrent
laryngeal)
Oblique arytenoids
Adducts arytenoids
CN X (left recurrent
laryngeal)
57
CN X (left recurrent
laryngeal)
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Sensory
CN X(internal
laryngeal) mucous
membrane at
valleculae, epiglottis,
aryepiglottic folds and
most of larynx
CN X (recurrent
laryngeal) – mucous
membrance below VF
CN X special sensory to
epiglottis
Impaired physiology of larynx – Impact on
Swallow
What physiologic problem
might you observe if
impairments in tongue
muscles
What symptoms might it cause What technique might you
try?
Do we have evidence?
Reduced closure at
entrance to airway
Allows penetration into
vestibule
May allow aspiration
during the swallow
Allows aspiration of
material
Reduced closure of
airway at glottis
58
Super-supraglottic
swallow
Supra-glottic
Valsalva
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy studies - particular approach

Laryngeal closure: Valsalva, Supraglottic and
Supersupraglottic


59
Some subjects close glottis during breath hold, and
others did not (Mendelsohn & Martin, 1993)
Arytenoid approximation and true vocal fold closure
were produced consistently by the majority of
subjects on all breath hold maneuvers, but false vocal
fold approximation and anterior arytenoid tilting
accomplished by majority of subjects only during
effortful breath-hold conditions (Martin, et al 1993)
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy studies - particular approach

Laryngeal closure: Valsalva, Supraglottic and
Supersupraglottic



Normal subjects produced earlier cricopharyngeal
opening, prolonged pharyngeal swallow, some degree of
laryngeal valving before swallow, and change in extent of
vertical laryngeal position before the swallow
Changes more successful and maintained longer with
SSG than SG
Breath-holding maneuvers alter not only airway conditions
before swallow but also temporal relationships and
biomechanical events during (Ohmae, et al 1996)
60
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
How you give Breath Hold instructions
matters Brady 2004

Easy Breath Hold (supra-glottic)
“Hold your breath while I count out loud to 5"
Inhale/Easy Breath Hold
“Take a deep breath, then hold your breath while I
count out loud to 5"
Hard Breath Hold (super-supraglottic)
“Hold your breath very tightly, bearing down, while I
count out loud to 5"
61
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Efficacy studies: Breath-hold




Effortful breath hold instruction most effective
method to obtain TVC closure
Inhale/easy breath hold least effective
Easy breath hold better than inhale/easy
Instructions for supraglottic to take a deep
breath and then hold may be counterproductive

62
(Brady, 2004)
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Caution: Supraglottic and supersupraglottic




Prolonged voluntary closure of glottis may create
Valsalva maneuver, which has been associated
with sudden cardiac death and cardiac
arrhythmias
Subjects: recent stroke, dysphagia and/or CAD
86% demonstrated abnormal cardiac
findings(supraventricular tachycardia, premature
atrial and ventricular contractions)
SG and SSG contraindicated for patients with
history of stroke or CAD (Chaudhuri et al 2002)
63
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Closure at level of larynx



Rarely is it just failure of true and/or false vocal folds
to close
The coordinated movements of closure of the larynx
are intricately related to the elevation and forward
movement of the larynx
Some of the techniques for closure also address
timing (e.g. supraglottic) and elevation (Mendelsohn)
64
Nancy B. Swigert, M.A.,CCC-SLP BCS-S
Information on specific exercises


National Foundation on Swallowing Disorders
www.swallowingdisorderfoundation.com has patient
handout and videos of some exercises
65
Nancy B. Swigert, M.A.,CCC-SLP BCS-S