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Ahsan

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Yasmin Naqvi
Yasmin Naqvi

This document provides information on a child named Ahsan Jamil who is 8 years old and diagnosed with a phonological processing disorder secondary to hearing impairment. He has a cochlear implant and was brought to the hospital one year ago with concerns about his speech clarity and language acquisition. His speech initially had many articulation errors, fast rate, and poor eye contact along with some behavior problems. Currently, he communicates verbally, can speak in 4 word sentences with 90% intelligibility, and his behavior problems are decreasing as his language increases. He is making progress in speech therapy.

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Name: Ahsan Jamil Male Age: 8 years Diagnosis: Phonological Processing disorder Secondary to hearing impairment Date: Child with cochlear implant (unilaterally) Concern of speech clarity and acquirement of Age appropriate language Ahsan was brought to the hospital one year ago. Initially childs speech was presented with lot of articulation errors .high rate of speech and poor eye contact accompanied with behavior problems. Ahsan is cooperative and an active child. Communicates verbally. Can speak 4 words sentences confidently with intelligibility of speech in own language 90% of time. Behavior problems are decreasing as the expressive language increasing. Childs reluctances regarding verbal response decreasing. Child can realize his mistakes and tries to correct them immediately Able to follow two stage directions. Enjoys games, active in socialization. Reciprocity in conversation and games intact. Attention span is good. Auditory understanding intact A: Childs strengths and weakness were assessed according to Blank level of questions. Child performs level 1,2, 3 withoutanydifficultybut level 4 takes much time. Why questions are difficult to answer, however able to repeat and remember the answers with prompting. P: child needs regular speech therapy in order to improve spontaneous speech. Yasmin Naqvi: Speech Pathologist/Psychologist/Educationist Shifa International Hospital Islamabad. Pakistan
Please read the disclaimer before reading any of the exercises below. Please work directly with a licensed medical professional before implementing any of the following therapy exercises. This information is for educational purposes only! A Beginning List of Dysphagia Exercises that Have Evidence Base I collectedandtypedthese exercises up from the handouts that we had at work (thanks to Jamie Pulliza for supplyingthem). Also,much thanks to whomever compiled these with references in the beginning. Imindebtedtoyouroriginal hardwork! I want anyone withexperience with these exercises and others that have evidence base (even referenced directly from seminars would be nice) to help add to this list and refine it if you see errors. Thanks for your help! I will alsobe addinga special sectionforexercisesthatuse some sortof device toassist with the swallow. I will even list Vital Stim, when I have a good reference list available. While this one is a polarizing treatmentmethod,Iwill listitbecause there isevidence forandagainstit. Ill letmy readers judge which evidence is more compelling. An additional reference was pointed out by Michelle Skelley Ashford (a fellow SLP), and its a fantastic systematic overview of many of the exercises found below. Check it out here: http://www.rehab.research.va.gov/jour/09/46/2/index.html SUPRAGLOTTIC SWALLOWING MANEUVER PURPOSE To close the airway at the vocal fold level before and during the swallow and to clear residue after the swallow. APPLICABILITY Patientswhohave delayedairwayclosure,reducedairwayclosure,delayedpharyngealswallow,poororal control of liquids with premature loss into the pharynx. Patients who can follow a series of commands. ___ Only saliva swallow ___ Food/Liquid swallow
INSTRUCTIONS 1. Take a breath in. 2. Hold your breath after you inhale (lightly cover your tracheostomy tube, if present). 3. Keep holding your breath while you swallow. 4. Clear your throat immediately after swallow before breathing. 5. Swallow again. Perform with each food/liquid swallow. Perform ___ times throughout the day. WARNING Patients with uncontrolled high blood pressure should not use this maneuver; bearing down may raise blood pressure. Talk with your Doctor before beginning any exercise regimen. SUPER-SUPRAGLOTTIC SWALLOWING MANEUVER PURPOSE To close the airwayat the vocal foldlevel before and during swallow, to increase tongue base retraction and pressure generation, and to clear residue after the swallow. APPLICABILITY Patients who exhibit penetration into the airway with aspiration after the swallow. Patients who can follow multistep directions. ___ Only saliva swallow ___ Food/Liquid swallow INSTRUCTIONS 1. Hold your breath very tightly, bearing down (lightly cover your tracheostomy tube, if present).
2. Continue to hold your breath tightly while swallowing. Swallow hard. 3. Clear your throat/cough immediately after swallowing. 4. Swallow again. ___Perform with each food/liquid swallow. Perform ___ times throughout the day. WARNING Patients with uncontrolled high blood pressure should not use this maneuver; bearing down may raise blood pressure. Talk with your Doctor before beginning any exercise regimen. References Martin, B.J.W.,Logemann,J.A.,Shaker,R.,&Dodds,W.J.(1993). Normal laryngeal valvingpatterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20. Ohmae,Y.,Logemann,J.A.,Kaiser,P.,Hanson,D.G.,& Kahrillas,P.J. (1996). Effects of two breath-holding maneuvers on
oropharyngeal swallow. Annals of Otology, Rhinology, and Laryngology, 105, 123-131. HARD / EFFORTFUL SWALLOW PURPOSE To increase tongue base retractionandpressure duringthe pharyngeal phase of the swallow and reduce the amount of food residue in the valleculae of the throat. APPLICABILITY Patients who exhibit residue in the valleculae after the swallow. SUPPLIES ___ Only saliva swallow ___ Food/Liquid swallow INSTRUCTIONS Swallow normally but squeeze very hard with your tongue and throat muscles throughout the swallow. Excess effort should be clearly visible in your neck during the swallow.
Perform with each food/liquid swallow. Perform ___ times throughout the day. References Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. Shanahan, T.K., Logemann, J.A., Rademeker, A.W., Pauloski, B.R., & Kahrillas, P.J. (1993). Chin down posture effects on aspiration in dysphagic patients. Archives of Physical Medicine and Rehabilitation, 74, 736-739. TONGUE HOLD EXERCISE PURPOSE To increase the tongue base and throat muscles range of motion. APPLICABILITY Patients who exhibit reduced tongue base/pharyngeal wall movement.
SUPPLIES ___ Only saliva swallow ___ Liquid swallow between repetitions INSTRUCTIONS 1. Protrude yourtongue slightlyfromyourmouth. Keeping your mouth moist is helpful for this exercise. 2. Hold the tongue gently with your teeth. 3. Swallow while keeping your tongue protruded. Perform ___ times throughout the day. References Fujiu, M., & Logemann, J.A. (1996). Effect of a tongue holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech Language Pathology, 5, 23-30.
Fujiu, M., Logemann, J.A., & Pauloski, B.R. (1995). Increase postoperative posterior pharyngeal wall movement in patientswithanteriororal cancer.Prelminaryfindingsandpossible implications for treatment. American Journal of Speech Language Pathology, 4, 24-30. Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. MENDELSOHN MANEUVER PURPOSE To accentuate and prolong laryngeal elevation and thereby increase the extent and duration of cricopharyngeal opening. APPLICABILITY Patients who exhibit reduced laryngeal movement and consequent reduced cricopharyngeal opening.
SUPPLIES ___ Only saliva swallow ___ Food/Liquid swallow INSTRUCTIONS 1. Swallow normally. Feel the larynx (voice box) lift during the swallow. 2. On the nextswallow,feel your larynx (voice box) elevating and hold it up with your neck muscles. Do not try to lift the larynx early. Let the larynx lift normally and then hold it up so that it does not drop for ___ seconds. Complete the swallow. Perform with each food/liquid swallow. Perform ___ times throughout the day. References Kahrilas, P.J., Logemann, J.A., Krugler, C., & Flanagan, E. (1991). Volitional augmentation of upper esophageal sphincter opening during swallowing. American Journal of Physiology, 260, G450-456.
Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. Logemann, J.A., & Kahrilas, P.J. (1990). Relearning to swallow post CVA: Application of maneuvers and indirect feedback: A case study. Neurology, 40, 1136-1138. HEAD LIFTING MANEUVER PURPOSE To strengthenmusclesof the neck in order to facilitate opening of the bottom of the throat (e.g.- upper esophageal sphincter) for food passage. APPLICABILITY Patientswhoexhibitreducedupperesophageal sphincteropening and who demonstrate food residue in the pyriform sinuses. SUPPLIES
None INSTRUCTIONS Part one: Sustained Hold 1. Lie flat on your back with no pillow under your head. 2. Lift your head to look at your toes. 3. Keep your shoulders flat on the floor / bed. 4. Hold this position for ___ seconds. 5. Release. Repeat 3 times and rest 1 minute between repetitions. Part two: Lift and Lower (same starting position as sustained hold) 1. Lift your head and look at your toes. 2. Let your head go back down with control. 3. Repeat 30 times.
4. Rest in between as needed. 5. Repeat 3 times a day. WARNING Patients with neck problems (e.g.- arthritis) may not be able to perform this exercise. References Easterling, C., Kern, M., Nitschke, T., Grande, B., Kazandjian, M., Dikeman, K., Massey, B.T., & Shaker, R. Restoration of oral feeding in 17 tube fed patients by the Shaker Exercise. Dysphagia, 15: 105, 2000. Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E., Hoffmann, R.G., Arndorfer, R.C., Hoffmann, C., & Bonnevier, J. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. AJR, 272: G1518-1522, 1997. JAW-OPENING EXERCISE PURPOSE
To improve upper esophageal sphincter (UES) opening during the swallow. APPLICABILITY Patients that have poor hyoid elevation and/or poor UES opening as a result of the decreased hyoid elevation. SUPPLIES Mirror if biofeedback is needed. INSTRUCTIONS 1. Hold the jaw in the maximally opened position for 10 seconds. 2. Rest for 10 seconds. 3. Repeat 5 times. 4. Do two sets a day. WARNING: When the jaw is closed, the superior head of the lateral pterygoid muscle maintains contraction in order to properly position the articular disk. When the jaw is fully open, however, the
superiorheadiscontrolledinarelaxedposition.Thus,thisexercise is probably safer when patients open their jaw to the fullest extent. However, dislocation of the mandibular joint could occur if aging has caused some wear of the articular fossa or condyle, or degeneration of the articular disk. Accordingly, patients with a history of mandibular joint dislocation should not perform this exercise (Wada, et al 2012). References Satoko Wada, Haruka Tohara, Takatoshi Iida, Motoharu Inoue, Mitsuyasu Sato, Koichiro Ueda, Jaw- OpeningExercise forInsufficient Opening of Upper Esophageal Sphincter, Archives of Physical Medicine and Rehabilitation, Available online 10 May 2012, ISSN 0003-9993, 10.1016/j.apmr.2012.04.025. TONGUE MOVEMENT EXERCISES PURPOSE To improve tongue control for food and liquid bolus manipulation, mastication, and front to back bolus movement. APPLICABILITY Patients who exhibit reduced tongue range of motion.
SUPPLIES Mirror INSTRUCTIONS FORWARD / BACKWARD MOVEMENT Stick your tongue out as far as you can and hold for 5 seconds. Relax. Try to keep your tongue in the middle. Use a mirror for visual feedback. Pull your tongue back as far as you can. Hold for 5 seconds. Relax. SIDE-TO-SIDE MOVEMENT Put the tip of your tongue in your right cheek, as far back as you can, and hold it. Relax. Repeat with the tip of the tongue in the left cheek. Smile. Put the tip of the tongue in the corner of your lips on the right, then move it to the left. Perform the exercise(s) ___ times a day, ___ repetitions each time. References
Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition. Logemann, J.A., Pauloski, B.R., Rademaker, A.W., & Colangello, L. (1997). Speech and swallowing rehabilitation in head and neck cancer patients. Oncology, 11(5), 651-656, 659. TONGUE RESISTANCE EXERCISES PURPOSE To improve tongue strengthandendurance forfoodandliquidbolusmanipulation,mastication,andfront to back bolus movement. APPLICABILITY Patients who exhibit reduced tongue strength. SUPPLIES Tongue depressor or spoon INSTRUCTIONS
Stick your tongue out as far as you can and push a tongue depressor / spoon against the tip of your tongue. Hold for 5 seconds. Relax. Stick your tongue out as far as you can. Place a tongue depressor / spoon along the side of the tongue. Push against it with your tongue. Hold for 5 seconds. Relax. Perform the exercise(s) ___ times a day, ___ repetitions each time. References Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition. Logemann, J.A., Pauloski, BR, Rademaker, AW, & Colangello, L. (1997). Speech and swallowing rehabilitation in head and neck cancer patients. Oncology, 11(5), 651-656, 659. CLOSURE OF THE LARYNX PURPOSE To improve airway closure and prevent aspiration. APPLICABILITY
Patients who exhibit laryngeal aspiration with liquids and foods during the swallow. INSTRUCTIONS Breath Hold / Valsalva Maneuver Take a breath. Bear down and hold your breath. You should not hold your breath with your lips, but in your throat,like youdoif you are tryingto liftsomethingveryheavy.Holdfor ___ seconds. Relax. Repeat ___ times, ___ a day. Push Pull with Breath Hold Place one or both hands under your chair and pull as if you are trying to lift your chair up with you in it. (You can also do it by standing up and pushing against the wall). Hold your breath tightly. Relax. Repeat ___ times a day. Head Rotation with Phonation Turn your head to the left / right. Hold your breath tightly. Let go of your breath and say ahh. Perform this exercise ___ times a day, ___ repetitions each time. References
Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition. Logemann, J.A., Pauloski, B.R., Rademaker, A.W., & Colangello, L. (1997). Speech and swallowing rehabilitation in head and neck cancer patients. Oncology, 11(5), 651-656, 659. BASE OF TONGUE EXERCISES PURPOSE To improve base of the tongue movementandstrengthinordertobetterpropel the bolus(food/ liquid). APPLICABILITY Patients who exhibit reduced tongue base / pharyngeal wall movement and vallecular residue. INSTRUCTIONS Gargle with Water / Pretend to Gargle Look uptoward the ceiling.Gargle for___ seconds. Relax. Repeat ___ times. Gradually increase duration of gargling time. Perform the exercise ___ times a day ___ repetitions each time.
Pretend to yawn Open your mouth wide. Start to yawn. You will feel all the muscles open wide in your throat. Relax. Repeat ___ times throughout the day. Tongue Base Retraction Pull the back of your tongue asfar back as you can. Pretendyouare tryingto scratch the back wall of your throat with the back of your tongue. Hold for ___ seconds. Repeat ___ times, ___ times a day. References Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. Pouderoux, P., & Kahrilas, P.J. (1995). Deglutitive tongue force modulation by volition, volume, and viscosity in humans. Gastroenterology, 108, 1418-1426.

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Ahsan

  • 1. Name: Ahsan Jamil Male Age: 8 years Diagnosis: Phonological Processing disorder Secondary to hearing impairment Date: Child with cochlear implant (unilaterally) Concern of speech clarity and acquirement of Age appropriate language Ahsan was brought to the hospital one year ago. Initially childs speech was presented with lot of articulation errors .high rate of speech and poor eye contact accompanied with behavior problems. Ahsan is cooperative and an active child. Communicates verbally. Can speak 4 words sentences confidently with intelligibility of speech in own language 90% of time. Behavior problems are decreasing as the expressive language increasing. Childs reluctances regarding verbal response decreasing. Child can realize his mistakes and tries to correct them immediately Able to follow two stage directions. Enjoys games, active in socialization. Reciprocity in conversation and games intact. Attention span is good. Auditory understanding intact A: Childs strengths and weakness were assessed according to Blank level of questions. Child performs level 1,2, 3 withoutanydifficultybut level 4 takes much time. Why questions are difficult to answer, however able to repeat and remember the answers with prompting. P: child needs regular speech therapy in order to improve spontaneous speech. Yasmin Naqvi: Speech Pathologist/Psychologist/Educationist Shifa International Hospital Islamabad. Pakistan
  • 2. Please read the disclaimer before reading any of the exercises below. Please work directly with a licensed medical professional before implementing any of the following therapy exercises. This information is for educational purposes only! A Beginning List of Dysphagia Exercises that Have Evidence Base I collectedandtypedthese exercises up from the handouts that we had at work (thanks to Jamie Pulliza for supplyingthem). Also,much thanks to whomever compiled these with references in the beginning. Imindebtedtoyouroriginal hardwork! I want anyone withexperience with these exercises and others that have evidence base (even referenced directly from seminars would be nice) to help add to this list and refine it if you see errors. Thanks for your help! I will alsobe addinga special sectionforexercisesthatuse some sortof device toassist with the swallow. I will even list Vital Stim, when I have a good reference list available. While this one is a polarizing treatmentmethod,Iwill listitbecause there isevidence forandagainstit. Ill letmy readers judge which evidence is more compelling. An additional reference was pointed out by Michelle Skelley Ashford (a fellow SLP), and its a fantastic systematic overview of many of the exercises found below. Check it out here: http://www.rehab.research.va.gov/jour/09/46/2/index.html SUPRAGLOTTIC SWALLOWING MANEUVER PURPOSE To close the airway at the vocal fold level before and during the swallow and to clear residue after the swallow. APPLICABILITY Patientswhohave delayedairwayclosure,reducedairwayclosure,delayedpharyngealswallow,poororal control of liquids with premature loss into the pharynx. Patients who can follow a series of commands. ___ Only saliva swallow ___ Food/Liquid swallow
  • 3. INSTRUCTIONS 1. Take a breath in. 2. Hold your breath after you inhale (lightly cover your tracheostomy tube, if present). 3. Keep holding your breath while you swallow. 4. Clear your throat immediately after swallow before breathing. 5. Swallow again. Perform with each food/liquid swallow. Perform ___ times throughout the day. WARNING Patients with uncontrolled high blood pressure should not use this maneuver; bearing down may raise blood pressure. Talk with your Doctor before beginning any exercise regimen. SUPER-SUPRAGLOTTIC SWALLOWING MANEUVER PURPOSE To close the airwayat the vocal foldlevel before and during swallow, to increase tongue base retraction and pressure generation, and to clear residue after the swallow. APPLICABILITY Patients who exhibit penetration into the airway with aspiration after the swallow. Patients who can follow multistep directions. ___ Only saliva swallow ___ Food/Liquid swallow INSTRUCTIONS 1. Hold your breath very tightly, bearing down (lightly cover your tracheostomy tube, if present).
  • 4. 2. Continue to hold your breath tightly while swallowing. Swallow hard. 3. Clear your throat/cough immediately after swallowing. 4. Swallow again. ___Perform with each food/liquid swallow. Perform ___ times throughout the day. WARNING Patients with uncontrolled high blood pressure should not use this maneuver; bearing down may raise blood pressure. Talk with your Doctor before beginning any exercise regimen. References Martin, B.J.W.,Logemann,J.A.,Shaker,R.,&Dodds,W.J.(1993). Normal laryngeal valvingpatterns during three breath-hold maneuvers: A pilot investigation. Dysphagia, 8, 11-20. Ohmae,Y.,Logemann,J.A.,Kaiser,P.,Hanson,D.G.,& Kahrillas,P.J. (1996). Effects of two breath-holding maneuvers on
  • 5. oropharyngeal swallow. Annals of Otology, Rhinology, and Laryngology, 105, 123-131. HARD / EFFORTFUL SWALLOW PURPOSE To increase tongue base retractionandpressure duringthe pharyngeal phase of the swallow and reduce the amount of food residue in the valleculae of the throat. APPLICABILITY Patients who exhibit residue in the valleculae after the swallow. SUPPLIES ___ Only saliva swallow ___ Food/Liquid swallow INSTRUCTIONS Swallow normally but squeeze very hard with your tongue and throat muscles throughout the swallow. Excess effort should be clearly visible in your neck during the swallow.
  • 6. Perform with each food/liquid swallow. Perform ___ times throughout the day. References Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. Shanahan, T.K., Logemann, J.A., Rademeker, A.W., Pauloski, B.R., & Kahrillas, P.J. (1993). Chin down posture effects on aspiration in dysphagic patients. Archives of Physical Medicine and Rehabilitation, 74, 736-739. TONGUE HOLD EXERCISE PURPOSE To increase the tongue base and throat muscles range of motion. APPLICABILITY Patients who exhibit reduced tongue base/pharyngeal wall movement.
  • 7. SUPPLIES ___ Only saliva swallow ___ Liquid swallow between repetitions INSTRUCTIONS 1. Protrude yourtongue slightlyfromyourmouth. Keeping your mouth moist is helpful for this exercise. 2. Hold the tongue gently with your teeth. 3. Swallow while keeping your tongue protruded. Perform ___ times throughout the day. References Fujiu, M., & Logemann, J.A. (1996). Effect of a tongue holding maneuver on posterior pharyngeal wall movement during deglutition. American Journal of Speech Language Pathology, 5, 23-30.
  • 8. Fujiu, M., Logemann, J.A., & Pauloski, B.R. (1995). Increase postoperative posterior pharyngeal wall movement in patientswithanteriororal cancer.Prelminaryfindingsandpossible implications for treatment. American Journal of Speech Language Pathology, 4, 24-30. Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. MENDELSOHN MANEUVER PURPOSE To accentuate and prolong laryngeal elevation and thereby increase the extent and duration of cricopharyngeal opening. APPLICABILITY Patients who exhibit reduced laryngeal movement and consequent reduced cricopharyngeal opening.
  • 9. SUPPLIES ___ Only saliva swallow ___ Food/Liquid swallow INSTRUCTIONS 1. Swallow normally. Feel the larynx (voice box) lift during the swallow. 2. On the nextswallow,feel your larynx (voice box) elevating and hold it up with your neck muscles. Do not try to lift the larynx early. Let the larynx lift normally and then hold it up so that it does not drop for ___ seconds. Complete the swallow. Perform with each food/liquid swallow. Perform ___ times throughout the day. References Kahrilas, P.J., Logemann, J.A., Krugler, C., & Flanagan, E. (1991). Volitional augmentation of upper esophageal sphincter opening during swallowing. American Journal of Physiology, 260, G450-456.
  • 10. Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. Logemann, J.A., & Kahrilas, P.J. (1990). Relearning to swallow post CVA: Application of maneuvers and indirect feedback: A case study. Neurology, 40, 1136-1138. HEAD LIFTING MANEUVER PURPOSE To strengthenmusclesof the neck in order to facilitate opening of the bottom of the throat (e.g.- upper esophageal sphincter) for food passage. APPLICABILITY Patientswhoexhibitreducedupperesophageal sphincteropening and who demonstrate food residue in the pyriform sinuses. SUPPLIES
  • 11. None INSTRUCTIONS Part one: Sustained Hold 1. Lie flat on your back with no pillow under your head. 2. Lift your head to look at your toes. 3. Keep your shoulders flat on the floor / bed. 4. Hold this position for ___ seconds. 5. Release. Repeat 3 times and rest 1 minute between repetitions. Part two: Lift and Lower (same starting position as sustained hold) 1. Lift your head and look at your toes. 2. Let your head go back down with control. 3. Repeat 30 times.
  • 12. 4. Rest in between as needed. 5. Repeat 3 times a day. WARNING Patients with neck problems (e.g.- arthritis) may not be able to perform this exercise. References Easterling, C., Kern, M., Nitschke, T., Grande, B., Kazandjian, M., Dikeman, K., Massey, B.T., & Shaker, R. Restoration of oral feeding in 17 tube fed patients by the Shaker Exercise. Dysphagia, 15: 105, 2000. Shaker, R., Kern, M., Bardan, E., Taylor, A., Stewart, E., Hoffmann, R.G., Arndorfer, R.C., Hoffmann, C., & Bonnevier, J. Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise. AJR, 272: G1518-1522, 1997. JAW-OPENING EXERCISE PURPOSE
  • 13. To improve upper esophageal sphincter (UES) opening during the swallow. APPLICABILITY Patients that have poor hyoid elevation and/or poor UES opening as a result of the decreased hyoid elevation. SUPPLIES Mirror if biofeedback is needed. INSTRUCTIONS 1. Hold the jaw in the maximally opened position for 10 seconds. 2. Rest for 10 seconds. 3. Repeat 5 times. 4. Do two sets a day. WARNING: When the jaw is closed, the superior head of the lateral pterygoid muscle maintains contraction in order to properly position the articular disk. When the jaw is fully open, however, the
  • 14. superiorheadiscontrolledinarelaxedposition.Thus,thisexercise is probably safer when patients open their jaw to the fullest extent. However, dislocation of the mandibular joint could occur if aging has caused some wear of the articular fossa or condyle, or degeneration of the articular disk. Accordingly, patients with a history of mandibular joint dislocation should not perform this exercise (Wada, et al 2012). References Satoko Wada, Haruka Tohara, Takatoshi Iida, Motoharu Inoue, Mitsuyasu Sato, Koichiro Ueda, Jaw- OpeningExercise forInsufficient Opening of Upper Esophageal Sphincter, Archives of Physical Medicine and Rehabilitation, Available online 10 May 2012, ISSN 0003-9993, 10.1016/j.apmr.2012.04.025. TONGUE MOVEMENT EXERCISES PURPOSE To improve tongue control for food and liquid bolus manipulation, mastication, and front to back bolus movement. APPLICABILITY Patients who exhibit reduced tongue range of motion.
  • 15. SUPPLIES Mirror INSTRUCTIONS FORWARD / BACKWARD MOVEMENT Stick your tongue out as far as you can and hold for 5 seconds. Relax. Try to keep your tongue in the middle. Use a mirror for visual feedback. Pull your tongue back as far as you can. Hold for 5 seconds. Relax. SIDE-TO-SIDE MOVEMENT Put the tip of your tongue in your right cheek, as far back as you can, and hold it. Relax. Repeat with the tip of the tongue in the left cheek. Smile. Put the tip of the tongue in the corner of your lips on the right, then move it to the left. Perform the exercise(s) ___ times a day, ___ repetitions each time. References
  • 16. Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition. Logemann, J.A., Pauloski, B.R., Rademaker, A.W., & Colangello, L. (1997). Speech and swallowing rehabilitation in head and neck cancer patients. Oncology, 11(5), 651-656, 659. TONGUE RESISTANCE EXERCISES PURPOSE To improve tongue strengthandendurance forfoodandliquidbolusmanipulation,mastication,andfront to back bolus movement. APPLICABILITY Patients who exhibit reduced tongue strength. SUPPLIES Tongue depressor or spoon INSTRUCTIONS
  • 17. Stick your tongue out as far as you can and push a tongue depressor / spoon against the tip of your tongue. Hold for 5 seconds. Relax. Stick your tongue out as far as you can. Place a tongue depressor / spoon along the side of the tongue. Push against it with your tongue. Hold for 5 seconds. Relax. Perform the exercise(s) ___ times a day, ___ repetitions each time. References Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition. Logemann, J.A., Pauloski, BR, Rademaker, AW, & Colangello, L. (1997). Speech and swallowing rehabilitation in head and neck cancer patients. Oncology, 11(5), 651-656, 659. CLOSURE OF THE LARYNX PURPOSE To improve airway closure and prevent aspiration. APPLICABILITY
  • 18. Patients who exhibit laryngeal aspiration with liquids and foods during the swallow. INSTRUCTIONS Breath Hold / Valsalva Maneuver Take a breath. Bear down and hold your breath. You should not hold your breath with your lips, but in your throat,like youdoif you are tryingto liftsomethingveryheavy.Holdfor ___ seconds. Relax. Repeat ___ times, ___ a day. Push Pull with Breath Hold Place one or both hands under your chair and pull as if you are trying to lift your chair up with you in it. (You can also do it by standing up and pushing against the wall). Hold your breath tightly. Relax. Repeat ___ times a day. Head Rotation with Phonation Turn your head to the left / right. Hold your breath tightly. Let go of your breath and say ahh. Perform this exercise ___ times a day, ___ repetitions each time. References
  • 19. Logemann, J.A., (1998). Evaluation and Treatment of Swallowing Disorders. Austin, TX: Pro-Ed. Second Edition. Logemann, J.A., Pauloski, B.R., Rademaker, A.W., & Colangello, L. (1997). Speech and swallowing rehabilitation in head and neck cancer patients. Oncology, 11(5), 651-656, 659. BASE OF TONGUE EXERCISES PURPOSE To improve base of the tongue movementandstrengthinordertobetterpropel the bolus(food/ liquid). APPLICABILITY Patients who exhibit reduced tongue base / pharyngeal wall movement and vallecular residue. INSTRUCTIONS Gargle with Water / Pretend to Gargle Look uptoward the ceiling.Gargle for___ seconds. Relax. Repeat ___ times. Gradually increase duration of gargling time. Perform the exercise ___ times a day ___ repetitions each time.
  • 20. Pretend to yawn Open your mouth wide. Start to yawn. You will feel all the muscles open wide in your throat. Relax. Repeat ___ times throughout the day. Tongue Base Retraction Pull the back of your tongue asfar back as you can. Pretendyouare tryingto scratch the back wall of your throat with the back of your tongue. Hold for ___ seconds. Repeat ___ times, ___ times a day. References Lazarus, C., Logemann, J.A., & Gibbons, P. (1993). Effects of maneuvers on swallow functioning in a dysphagic oral cancer patient. Head and Neck, 15, 419-424. Pouderoux, P., & Kahrilas, P.J. (1995). Deglutitive tongue force modulation by volition, volume, and viscosity in humans. Gastroenterology, 108, 1418-1426.