Pretreatment Swallowing Exercises

For patients undergoing chemo-radiation for head and neck cancer

What Is Normal Swallowing?

Swallowing is made up of four phases: 1. Oral preparatory phase the food is chewed (masticated), mixed with saliva, and formed into a cohesive ball (bolus) 2. Oral phase the tongue directs food as it breaks down and pushes it back to the back of the throat. 3. Pharyngeal phase the food enters the upper throat area (above the voice box) and the soft palate elevates. The epiglottis closes off the trachea, as the tongue moves backwards and the pharyngeal wall moves forward. These actions help force the food downward to the esophagus. 4. Esophageal phase the food bolus enters the esophagus (the tube that transports food directly to the stomach). The bolus is moved to the stomach by a squeezing action of the muscles of the esophagus.

What are some of the swallowing side-effects due to chemo-radiation?

- Decrease in muscle strength. - Need to swallow many times to clear food from mouth or throat. - Gurgly, wet sounding voice after swallowing. - Coughing or choking. - Pain or dryness while swallowing. - Stiffening of the soft tissue. - Reduced tongue range of motion. - Laryngeal elevation is decreased. - Narrowing of the throat. - Incoordination in the swallowing process. - Thick, ropey secretions.
There are many long term effects of chemo-radiation treatment even after treatment is successfully Please consult with your speech-language pathologist ifimportant you experience pain and/or to be proactive completed. It's for patients extreme discomfort during these exercises. to maintain quality of life, especially 5, 10, 15+ years post successful treatment.

Swallowing and Strengthening Exercises

For patients undergoing chemo-radiation for head and neck cancer

Tongue hold (the Masako Maneuver)

The Masako Maneuver may result in a greater forward motion of the back wall of the throat (pharynx) so it can contact the base of tongue. It is effective for patients with reduced movement of back of the tongue to contact the back of the throat which causes problems with moving the bolus (ball of food or liquid) past the tongue base. It generates stronger pressure in the throat than normal swallows. This exercise should be practiced with saliva only or very small (o.5ml) amounts of water. Using food or liquids with the Masako maneuver can result in coughing or throat clearing (aspiration). Masako Maneuver Instructions: 1. Stick out your tongue. 2. Gently hold your tongue between your teeth/lips. 3. Swallow while holding the tip of your tongue between your teeth/lips. 4. You can let go of your tongue between swallows. Masako Maneuver Video: http://vimeo.com/54665010

What are some of the potential benefits of swallowing exercises?

-Swallowing exercises can help strengthen connective tissue. -They could help with the better preservation of swallowing muscle size and less atrophy occurring due to nonuse. -Swallowing exercises could minimize tissue contraction and fibrosis (stiffening) resulting from radiation. -They could help increase hyoid elevation -They could help increase pressure generation in the back of the oral cavity.

Tongue retraction
The tongue retraction strategy may improve tongue strength and endurance for food and liquid bolus manipulation, chewing, and front to back bolus movement. It may be effective for patients who exhibit reduced tongue strength. 1. Retract tongue, touching the back of your tongue to the roof of your mouth. (as if producing /k/) 2. Hold for 1 to 3 seconds. 3. Relax and Repeat 5 times

Please consult with your speech-language pathologist if you experience pain and/or extreme discomfort during these exercises.

Tongue resistance
This exercise may help improve tongue strength and endurance for food and liquid bolus manipulation, mastication, and front to back bolus movement. It may be effective for patients who exhibit reduced strength. Exercise 1 1. Stick your tongue out as far as you can 2. Push a tongue depressor/spoon against the tip of tongue 3. Hold for 5 seconds 4. Relax Exercise 2 Stick your tongue out as far as you can 1. Place a tongue depressor/spoon along the side of the tongue 2. Push against your tongue 3. Hold for 5 seconds 4. Relax Exercise 3 Stick out your tongue and use a tongue depressor as resistance to push down (a) on tip of the tongue and (b) on the entire body of the tongue.

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Effortful Swallow
The effortful swallow exercise may help increase tongue base retraction and pressure during the pharyngeal phase of the swallow and reduce the amount of food residue in the area just above the vocal cords and below the epiglottis in the throat. It may be effective for patients who exhibit reduced tongue strength. 1. Swallow normally but squeeze very hard with your tongue and throat muscles throughout the swallow. 2. Excess effort should be clearly visible in your neck during the swallow. 3. Perform with each food/liquid swallow. 4. Perform a few times throughout the day. Effortful Swallow Video: http://www.youtube.com/watch?v=_lL7xxew8wo

Please consult with your speech-language pathologist if you experience pain and/or extreme discomfort during these exercises.

Supraglottic Swallow
The supraglottic swallow is designed to help assist in closing your vocal folds during the swallow, to prevent food or liquid entering your airway. 1. 2. 3. 4. 5. 6. Take a small sip of liquid Take a deep breath through your nose and hold it Bear down and swallow hard Cough when breathing out Swallow again Breathe

Supraglottic Swallow Video: http://vimeo.com/54667137

Mendlesohn Maneuver
This technique is designed to help keep the larynx, or voice box, at its highest point. It is used if you have food sticking in your throat which might fall into your airway. May act in a preventative manner to help improve swallowing outcome in head and neck cancer patients when delivered prior to chemo-radiation treatment. 1. Take a small bite of food or sip of liquid. 2. Hold the food in your mouth. 3. Position index finger and thumb around your Adam's apple. 4. Swallow. 5. Feel the upward movement (the elevation) of the Adam's apple (thyroid notch) when you swallow 6. When the Adam's apple (larynx) reaches its highest point of elevation, hold it up with your muscles for 5 seconds. 7. Release. 8. Repeat steps 1-7 with each swallow.

Please consult with your speech-language pathologist if you experience pain and/or extreme discomfort during these exercises.

Online Resources from ASHA (American Speech-Language-Hearing Association): http://www.asha.org/public/speech/disorders/Swallowing-Problems-AfterHead-and-Neck-Cancer/#tx http://www.asha.org/uploadedFiles/public/TESDysphagiainAdults.pdf

References
Carroll, W. R., Locher, J. L., Canon, C. L., Bohannon, I. A., McColloch, N. L., & Magnuson, J. S. (2008). Pretreatment swallowing exercises improve swallow function after chemoradiation. The Laryngoscope, 118(1), 39-43. Kotz, T., Federman, A. D., Kao, J., Milman, L., Packer, S., Lopez-Prieto, C., ... & Genden, E. M. (2012). Prophylactic Swallowing Exercises in Patients With Head and Neck Cancer Undergoing Chemoradiation: A Randomized Trial. Archives of OtolaryngologyHead & Neck Surgery, 138(4), 376. Kulbersh, B. D., Rosenthal, E. L., McGrew, B. M., Duncan, R. D., McColloch, N. L., Carroll, W. R., & Magnuson, J. S. (2006). Pretreatment, preoperative swallowing exercises may improve dysphagia quality of life. The Laryngoscope, 116(6), 883886. Lazarus, C., Logemann, J. A., Pauloski, B. R., Rademaker, A. W., Helenowski, I. B., Vonesh, E. F., ... & Haraf, D. J. (2007). Effects of radiotherapy with or without chemotherapy on tongue strength and swallowing in patients with oral cancer. Head & Neck, 29(7), 632-637.

Exercise Descriptions Dysphagia exercises. Retrieved June 5, 2013, from http://medicalspeechpathology.wordpress.com/swallowing/dysphagia-exercises/ Head exercises for the tongue, lips, and jaw. Retrieved June 5, 2013, from http://www.ucs.louisiana.edu/~ncr3025/roussel/codi531/oralexercise.html

Please consult with your speech-language pathologist if you experience pain and/or extreme discomfort during these exercises.

NOTES

Please consult with your speech-language pathologist if you experience pain and/or extreme discomfort during these exercises.