Major focus area

Feeding Therapy -> Swallowing

Short description

Compensatory techniques are used by the SLP during therapeutic feedings to compensate for deficits. The SLP determines the use of these techniques by the swallowing deficits and include; oral sensitivity training, food placement, external pressure to the cheek, labial and chin support, food presentation, multiple swallows, and thermal-tactile application (Swigert, 2007; Logemann 1998; Cherney, 1994).

Long description

Compensatory techniques are used by the SLP during therapeutic feedings to compensate for deficits. The SLP determines the use of these techniques by the swallowing deficits and include; oral sensitivity training, food placement, external pressure to the cheek, labial and chin support, food presentation, multiple swallows, and thermal-tactile application (Swigert, 2007; Logemann 1998; Cherney, 1994).

Oral Sensitivity Training: Patients who aren’t eating by mouth may show educed sensitivity to material in the oral cavity. Position the patient upright and then use a toothette or swab to moisten the oral cavity. Adequate saliva is essential for a patient to be able to form a good bolus. If the patient is able to complete such a maneuver, you may even have him swish and spit some liquid from their mouth. Some patients may benefit from presentation of a sour bolus, like lemon juice. This can significantly improve the onset of the oral and/or pharyngeal phases of the swallow.

Carbonation and other chemesthesis: Studies have found that moderate sucrose, high salt and high citric acid elicited significantly higher lingual swallowing pressures compared to pressures generated with water. High salt and citric acid elicit chemesthesis mediated by the trigeminal nerve therefore chemesthesis may play a crucial role in swallowing physiology. If true, trigeminal irritants like carbonation may be beneficial to individuals with dysphagia.

Food placement: Patients usually do best if food is placed at the midline of the tongue. Some patients do better if placed is placed on the stronger side, especially if it is food that needs to be chewed.

External pressure to the cheek: Placing pressure on the affected cheek may also assist a patient with oral cavity weakness. The benefits for the patient are that pressure decreases the amount of material falling into the weaker lateral sulcus and helps the tongue action in the formation of a cohesive bolus. The tactile cue also reminds the patient to check the buccal pocket for residue. This technique compensates for decreased muscle tone.

Labial and chin support: Place your finger under the chin or lower lip to help maintain closure of the mouth. For a patient with a labial droop, fingertip support may be sufficient to provide lip closure to keep the material in the oral cavity. This technique is helpful for thin liquids maintenance. For more severely involved patients to support both labial and jaw weakness position the thumb along the mandible with your index finger beneath the lower lip and your middle finger beneath the patient’s chin.

Food presentation: This is recommending different ways for food to be presented depending upon the patient’s difficulties. Bolus control deficits can be compensated by all presentations being made from a spoon or only a small amount placed in a cup. Straws help some patients maintain a chin-down position. Alternating solids and liquids is another food presentation compensation method.

Multiple swallow: This is a simple, yet effective compensatory technique that involves directing the patient to swallow two or three times per bolus (e.g., after wet swallows with subsequent dry swallows.) The number of repetitive dry swallow will vary with the size of the bolus, bolus texture, and severity of impairment. This is used with patient who has incomplete pharyngeal clearance during the initial swallow for a variety of reasons that may include decreased tongue base retraction, reduced laryngeal elevation with accompanying reduction in the extent and duration of pharyngo-esophageal segment opening, and weak contraction of the pharyngeal musculature. The second swallow is also beneficial for patient who present with oral residue.

Thermal-Tactile application: This is also called thermal stimulation and is used for patients who show a delay of greater than two seconds in initiating the swallow response or who aspirate during the delay. The stimulation does not cause the response to happen but heightens the awareness of that region in the mouth to increase the likelihood that a swallow will occur. To date there is no evidence that thermal-tactile application effects are long-lasting.

Method: Generally a double 00 laryngeal mirror is used. Hold the mirror like a pencil so you can easily rotate it in your hand. Dip it in ice and rub it up and down five times on one of the patient’s anterior faucial arches. Then dip it back into the ice quickly, rotate it so the flat head of the mirror is facing in the other direction, and rub it on the other faucal arch. Instruct the patient to swallow so that the voluntary component of the swallow is invoked.