Compensatory Strategies

 
 

Compensatory strategies are sometimes necessary when a safe swallow isn’t necessary. The following range from simple products that can be purchases and implemented, to strategies requiring surgery.
There are a few techniques to compensate for deficits and use during therapeutic feedings
(by staff or family). These strategies are used to change the timing or strength of swallowing . The patient should always be at a 90 degree angle when these strategies are implemented. The 90 degree angle allows the patient to control whatever is in the oral cavity with a minimal impact of gravity to reduce the risk of aspiration.

 
 

Multiple Swallows

Some patients will require a cue for a second (or third or fourth) swallow to get rid of residue from the valleculae and pyriform sinuses.

Food Placement Considerations

Most patients do best when food is placed at the midline of the tongue. However, some patients do better when you place the food on their stronger side (especially if the food requires mastication).


Supraglottic Swallow

The supraglottic swallow is used to protect the patient’s airway. The patient is instructed to hold his or her breath right before swallowing (which will close the vocal folds). Immediately after the swallow, the patient should produce a volitional cough and then swallow again right after the cough.


Chin-down positioning Swallow

The chin-down position is appropriate for patients with decreased back of tongue control. Research suggests this positioning may increase oral and pharyngeal control of the bolus for patients who have food falling over the back of the tongue. This helps the patient gain volitional control for propulsion of the bolus in their mouth and can also widen the patient’s valleculae which allows for collection of material without spill to the pyriform sinuses or into the trachea. It protects the trachea opening from aspiration by tucking the airway beneath the tongue base and epiglottis.

Head Tilt Swallow

The posterior head tilt is not usually recommended, but it may be appropriate for a patient who displays decreased ability to propel the bolus posteriorly to initiate a swallow (for example, a patient who has undergone a partial or total glossectomy or laryngectomy or patients with tongue scarring). This allows for gravity to propel the bolus posteriorly to initiate the swallow response. In order to use the posterior head tilt, the patient must have intact cognition & patient must display an efficient, strong response to penetration into the airway.

The lateral head tilt, on the other hand, may be appropriate for patients who exhibit hemiparesis of the tongue and pharynx. The bolus is directed to the side of the oral cavity with greater muscle tone.


Head Rotation Swallow

A head rotation is appropriate for patients who have unilateral pharyngeal paresis or paralysis. This maneuver decreases the pharyngeal space by 50 percent. You instruct the patient to rotate his or her head all the way toward the damaged side which closes the pyriform sinuses on the weak side, increasing vocal fold closure, and reducing resting tone in the cricopharyngeal muscle.


External Pressure to Cheek

Placing pressure on a symptomatic cheek can be helpful for patients with oral cavity weakness. Research suggests it can decrease how much material falls into the weaker lateral sulcus and assists the tongue in forming a cohesive bolus. It is hypothesized that it serves as a tactile cue helping the patient check the lateral sulcus or buccal pocket for any food that may have fallen into there.

Oral Sensitivity Training

Oral sensitivity training can be used for patients who are not orally eating. Typically these patients express reduced sensitivity to anything in the oral cavity. Use a swab or toothette to moisten the oral cavity and have the patient swish and spit some liquid from his or her mouth.


Labial and Chin Support

This provides assistive support at the chin and lip by placing your finger under the patient’s chin or lip to assist in closure of the mouth. If a patient has a labial droop, this fingertip support may provide enough lip closure to keep material in the oral cavity. This technique is particularly useful for the maintenance of thin liquids. For patients who are severely impacted, it may provide support to compensate for both labial and jaw weakness. In this case, you would place the thumb along the mandible with your index finger below the lower lip and your middle finger below the patient’s chin.

Carbonation and other Chemesthesis

A study in 2006 found moderate sucrose, high salt, and high citric acid evoked greater lingual swallowing pressures compared to pressures generated by water. High salt and citric acid evoked chemesthesis mediated by the trigeminal nerve. They developed the hypothesis that chemesthesis may play a critical role in the physiology of swallowing. If this hypothesis is true, patients with dysphagia may profit from trigeminal irritants like carbonation.


Sour Bolus

A sour bolus, like lemon juice, can also be used to improve the onset of the oral and pharyngeal phase of the swallow. Lemon glycerin swabs can be used for patients who can not take any food orally. These are not effective in improving oral hygiene as lemon reduces oral pH below the normal level and dehydrates the tissue. The acid in citrus can also cause pain, tooth decay, and decalcify teeth.


 

Products

  • Wedge Cup: Adjustable flow control to limit intake

  • Oralflo: Combines medications and liquid for easier swallowing by placing the pill in the mouthpiece

  • Dysphagia Cup: Weighted with an oval shape

  • Nose Cut Out Cup: Has a cut out for patients who can’t tilt their head or use a straw

  • Divided Plates: Have different sections to separate the food

  • Plate Guards: Snap to the edge of the plate to help patient get food onto utensils

  • Utensils: With bigger handles or are shallow

 

PEG Tubes (Percutaneous Endoscopic Gastrostomy), Ng tubes (Nasogastric)

A PEG is a soft plastic feeding tube going into your stomach. Liquids, including formulas and medicines, are put through the PEG tube to provide nutrients. If you have one, you can eat the same feeding time as everyone else or throughout the night. Sometimes PEG tubes are used to take air and fluid out of the stomach. An NG tube is very similar to a PEG tube, except it carries liquid from the nose to the stomach.