As a speech-language pathology professional, you are the expert on dysphagia.

But sometimes it can help to have that knowledge summarized—in plain language—as you treatment plan for your patients.

In this post, you’ll find dysphagia treatment options for adult patients. You’ll also find helpful links, step-by-step patient instructions, and specific exercises and strategies to make your job easier.

Feel free to copy and print the instructions to make your own handouts. Or check out our shop for premade handouts!

* Treating dysphagia requires high levels of training and skill; this information is intended for Speech-Language Pathologists or other qualified therapists with the appropriate training and competency to work with adults with dysphagia.

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Dysphagia Treatment Options

You’ve completed the bedside swallowing evaluation, including the oral mechanism examination and food and/or liquid trials.

You’ve completed/referred out for an instrumental assessments, as needed.

You know the patient’s chewing and swallowing strengths and weaknesses.

You’ve made goals based on those weaknesses and on the patient’s wants and needs.

Now it’s time to treat! Let’s go over the dysphagia treatment options.

1. Diet Modifications

Diet modifications are making modifications to the texture of foods and viscosity of liquids. Taste (e.g. sour, spicy) and temperature may also be modified.

Where to Start

In many cases, your patient’s first modified diet will be the food textures and liquid consistencies that they can safely consume 80% or more of opportunities.

The International Dysphagia Diet Standardisation Initiative (IDDSI) Framework is now the gold standard for determining diet textures for dysphagia. See their site for food/drink lists, helpful images, and testing methods.

2. Oral Hygiene for Dysphagia

This involves patient and caregiver training to keep the oral cavity clean, including education about how good oral hygiene can help prevent aspiration pneumonia and thrush, in addition to improved comfort and self-esteem.

Where to Start

Patient Instructions

• Use a clean toothbrush with soft bristles and toothpaste
  
  
• Brush your teeth and tongue once in the morning and once in the evening (Some patients may need to brush more often)
  
  
• Perform oral care before eating or drinking to avoid bacteria entering the airway.
  
  
• Remove dentures to properly clean gums and palate. Properly clean dentures.
  
  
• Floss before you go to bed
  
  
• Use alcohol-free and sugar-free mouthwash, if you choose to use mouthwash
  
  
• Visit the dentist for a cleaning & check-up every 6 months
  
  
• Treat xerostomia (dry mouth) by sipping water throughout the day. Consider a mouthwash to reduce bacteria.
  
  
• For patient who are are NPO, lean forward over the sink/basin to catch oral secretions.
  
  
• Avoid alcohol, caffeine, and sugary drinks

3. Swallowing Exercises & Devices

Swallowing exercises aim to strengthen the tongue, lips, jaw, soft palate, pharynx, larynx, and/or respiratory control muscles to improve swallowing.

Exercise devices have the same aim. Examples include oral screens such as the Muppy® that may help with lip strengthening. Expiratory muscle strength training and incentive spirometers also aim to strengthen some of the muscles involved in swallowing.

Where to Start

See the bonus section below for exercise ideas, or see our Swallowing Exercises post, which includes a free illustrated handout.

How to Think about Exercises: Strength Training!

Strength training programs have long been associated with physical rehab and exercise science, though there is a growing interest in strength training for dysphagia treatment (Burkhead et al., 2007; Zimmerman et al., 2020).

Strength training uses intense, specific, and transferrable tasks to improve a system’s functioning. In this case, the system is swallowing.

Strength Training, Neuroplasticity, and Motor Learning: An Overview

1. Ask yourself these questions:
   
   -Is the patient alert and able to follow directions?
   -Is there underlying weakness?
   -Will exercise increase strength?
   -Will strength improve functioning?
   
   If the answer is YES to all, then move to the next step!
   
   
2. Always work at the patient’s level. You want to push the patient’s ability a little, but not too much. Safety comes first.
   
   
3. Make sure that the exercises are salient. Eating is innately salient. But you can maximize neuroplasticity by increasing the meaningful factor! Work towards a birthday dinner. Or an outing with a beloved grandchild. Make your treatment session as comfortable and fun as possible.
   
   
4. Be specific. Teach the movement you want them to improve. To improve swallowing, the patient must swallow!
   
   
5. Focus on the correct technique. Practice doesn’t necessarily make perfect! If a patient has poor form when swallowing, take the time to teach the correct form. Strengthening bad form is counterproductive.
   
   
6. Repeat, repeat, repeat. Neural and muscular changes occur only after extensive and prolonged exercise. So have your patient swallow a lot!
   
   
7. Do different types of movement. Do different types of movement to maximize muscle strength. Use exercises that practice the swallow and exercises that hold the swallow for a few seconds.
   
   
8. Gradually make the exercise more difficult through more repetitions, faster speeds, the different exercises, heavier weight such as a larger bolus, etc.
   
   
9. Use the principles of motor learning.

4. Swallowing Maneuvers

Swallowing maneuvers are strategies that aim to change the timing or strength of a particular movements of swallowing.

Where to Start

See the bonus section below for swallowing maneuver ideas.

5. Postural or Positioning Changes

Postural or positioning changes are compensatory strategies that aim to redirect the movement of the bolus during a swallow. This is typically for airway protection or moving the bolus so it can be swallowed.

Where to Start

See the bonus section below for postural and positioning ideas.

6. Bolus Volume/Pacing/Safe Swallowing Strategies

These are strategies that aim to modify the size and speed of movement of the bolus, depending on patients’ needs. It also includes other strategies that support safe swallowing.

Where to Start

See the bonus section below for strategies.

7. Support Respiratory Health for Dysphagia

A big purpose of dysphagia treatment is to protect the airway. We help our patients, in part, by supporting cardiovascular health.

Ways to Support Respiratory Health

1) Incentive Spirometer

Using an incentive spirometer can improve lung health and help patients to take slow, deep breaths. This is important when recovering from certain lung diseases and surgeries.

Patient Instructions

1. Breathe out normally, then place the incentive spirometer mouthpiece between your lips
2. Breath in deeply through your mouth
   • Watch the flow rate guide (usually a blue disc) rise up to the goal level
3. Continue breathing in for as long as your can (or as long as your doctor, therapist, or nurse instructed)
4. Breathe out slowly and relax
5. After 10 repetitions, cough

2) Deep Breathing/ Diaphragmatic Breathing

Practicing deep or “diaphragmatic” breathing can help patients take deeper breaths.

Patient Instructions

1. Place one hand on your stomach and one hand on your chest
2. Breathe in deeply through your nose
   • Push out your stomach when you inhale. Your chest should remain still.
3. Exhale slowly through your mouth
   • Feel your stomach pull in. Your chest should remain still
4. Repeat steps 2-3 for a few minutes

3) Directed Cough

For patients with a weak cough, usually secondary to overall deconditioning or weakness.

Teach patients how to produce a stronger cough in order to clear sputum that may have settled in their lungs.

Patient Instructions

1. Sit up straight
2. Take a deep breath, hold for a second
3. Squeeze your abdominal muscles to cough big
4. Relax and breathe
5. Repeat as needed

4) Conserve Energy while Eating

Teach energy conservation strategies to patients with shortness or breath or who fatigue easily. These strategies can increase safety and help them feel more comfortable while eating.

Patient Instructions

• Eat only when you’ll fully awake and alert
• Reduce distractions while you’re eating: turn off the TV, don’t read a book or magazine, etc.
• Avoid speaking with food in your mouth
• Eat softer foods and avoid tough foods that require a lot of chewing
• Take small bites and sips
• Use smaller utensils to reduce the size of each bite
• Take only one bite or sip at a time
• Place your eating utensils down between bites
• Take small breaks throughout your meal
• Sit upright during and for 30 minutes after the meal
• Eat higher calorie foods that are healthy (avocado, whole milk yogurt, cheese, peanut butter) if your physical-recommended and dysphagia diet allows for it

8. Biofeedback

Biofeedback is the use of sensory feedback (visual, tactile, auditory, etc.) to help patients increase awareness of the physical sensations associated with their dysphagia.

Examples of Biofeedback for Dysphagia

1) IOPI® (Iowa Oral Performance Instrument)

The IOPI is used to increase and measure lip and tongue strength. It features an air-filled bulb on one end and hand-held measurement device on the other. It provides visual biofeedback in the form of a row of lights.

2) sEMG

Surface electromyography uses electrodes placed on the skin of the lower face and/or neck to measure muscle activity. sMEG provides visual biofeedback via a row of lights or a graph on a computer screen. It’s especially helpful for training in the Mendelsohn maneuver and effortful swallow.

9. Electrical Stimulation

Electrical stimulation delivers small electrical currents vis electrodes places on the skin of the face and/or neck. The current causes muscles to contract, which can help during swallowing exercises.

Examples of Electrical Stimulation for Dysphagia

1) VitalStim®

VitalStim is a neuromuscular electrical stimulation device that has been approved by the FDA.

10. Sensory Stimulation

Sensory stimulation is adjusting the sensory experience of a food or beverage to facilitate improved feeding and/or swallowing.

Sensory Stimulation for Dysphagia

1) Hyper or hypo sensitivity when eating

Consider whether your patient is hyper or hypo sensitive to food textures, flavors, smells, etc. Hyper sensitivity can include tactile defensiveness and aversion to certain food textures.

If you suspect hyper sensitivity, be aware of the food and liquid’s texture, flavor, smell, temperature, and bolus size. Work with your patient to find foods and drinks that are not aversive to them.

Hypo sensitivity can be a decreased sensory awareness inside of their mouths. This may result in not noticing pockets of food left in their mouth.

Hypo sensitive patients may need extra sensory cues to increased awareness of boluses in their mouths. Examples are more intense flavors, a cue to sweep their oral cavity with their tongue, etc.

11. Environmental Modifications

Environmental modifications are changes to the environment that support improved feeding and safer swallowing. The goal is to optimize the environment so that your patient can focus on eating.

Many times this means limiting distractions, especially for those with acquired attention deficits or other cognitive deficits. For example, a quiet environment with few distractions (back to the door, TV off, decluttered).

SLP Amber B. Heape’s offers environmental modification tips for patients with dementia, including:

• Optimal lighting (avoid low-lit spaces and avoid glare)
• Placemats that are a contrasting color to the table
• Single-color plates
• Square tables (vs round)
• Clutter-free
• Include familiar sounds, smells, and sights (essential oils, bread machine, etc.)

12. Equipment Modification

Equipment modifications (or “adaptive equipment”) are modified feeding tools that help patients more effectively manage a bolus.

Some adaptive equipment help with bolus volume and pacing. While others compensate for the losses in mobility, strength, motor control, etc. that are common with the dysphagia population.

Our OT buddies are excellent partners for identifying adaptive feeding equipment. They’re especially skilled at finding low cost but effective options for patients with limited resources.

Examples of Equipment Modification for Dysphagia

See page 6 of this article by the American Occupational Therapy Association for details about adaptive equipment and how to use them.

1) Adaptive drinkware. Nosey cups, handled cups, cups with lids, weighted cups, spill-resistant cups

2) Built-up handle utensils and/or weighted utensils

3) Adaptive plates. Partitioned plates, scoop plates, high-sided plates, plate guards

4) Non-Slip Mats. Under wheelchair cushion to support upright posture. Under plates and cutting boards.

13. Other Dysphagia Treatment Options: Prosthesis, Medications, Surgery, Tube Feeding, Etc.

Prosthesis and appliances may be prescribed for patients with structural deficits in the intraoral cavity. Examples include a palatal obturator, palatal lift prosthesis, and palatal plates.

Common medications for dysphagia treatment are anti-reflux medications, prokinetic agents (also for reflux), and salivary management.

Common surgical options for conditions that may cause dysphagia aim to improve glottal closure, airway issues, and pharyngoesophageal segment opening.

See ASHA’s dysphagia practice portal for more details on these options, including guidance on tube feeding.

BONUS! Dysphagia Exercises, Maneuvers, and Strategies

Signs of Dysphagia & How to Treat Them

1. Anterior spillage

Treatment: Thickened liquids, small bites, and sips, labial exercises

2. Inadequate mastication

Treatment: Modified diet textures, small bites and sips, lingual exercises

3. Uncoordinated oral phase

Treatment: Bolus hold, lingual exercises, small bites and sips

4. Oral residue

Treatment: Alternating bites and sips, lingual sweep, lingual exercises

5. Pharyngeal pooling

Treatment: Thickened liquids, small bites and sips, bolus hold, chin tuck, lingual exercises

6. Nasal regurgitation

Treatment: Small bites and sips, thinner consistencies, Masako maneuver, Mendelsohn maneuver, Monkey EEE, Shaker exercise, chin tuck against resistance

7. Reduced epiglottic movement

Treatment: Mendelsohn maneuver, Monkey EEE, effortful swallow

8. Vallecular residue

Treatment: Dry swallow, alternating bites and sips, effortful swallow, Mendelsohn maneuver, Monkey EEE, lingual exercises

9. Reduced opening of UES

Treatment: Head turn. Mendelsohn maneuver, Monkey EEE, Shaker exercise, chin tuck against resistance

10. Pyriform sinus residue

Treatment: Dry swallow, alternating bites and sips, head turn, Mendelsohn maneuver, Monkey EEE, Shaker exercise, chin tuck against resistance

* 11. Laryngeal penetration

Treatment: Thickened liquids, small bites and sips, alternating bites and sips, bolus hold, chin tuck, Mendelsohn maneuver, Monkey EEE, effortful swallow

* Educate EVERY patient with dysphagia and their caregivers about the risk of aspiration.

Swallowing Exercises

Below is a list of common swallowing exercises.

Pick and choose for your patients based on the underlying impairment and signs and symptoms they present. Modify as appropriate.

Provide a list of the exercises you recommend. Model each, then have the patient demonstrate it back to you. Encourage daily practice, at least twice a day.

Print out the swallowing exercises handout to help them learn and remember their exercises.

* Educate patients and caregivers about the signs and symptoms of aspiration.

Pharyngeal Exercises

Effortful swallow: Swallow your saliva as hard as you can (pretend that you’re swallowing a whole grape). Repeat 10 times.

Mendelsohn maneuver: Swallow your saliva and feel your Adam’s apple move up and down. Place your tongue tip against the ridge that’s behind your front teeth. Swallow your saliva again, but halfway through the swallow, hold your Adam’s apple up using the muscles under your chin. Hold it for 1-3 seconds. Repeat 10 times.

Monkey EEE: (effortful pitch glide) Say “eee” in your normal voice. Continue saying “eee” as you quickly glide up to your highest pitch possible. Continue saying “eee” as you apply force to make a strong “eee” sound. Take a breath. Repeat 10 times.

Shaker: Lay flat on your back, do not use a pillow. Raise your head to look at your toes (keep your shoulders on the ground) and hold for up to 60 seconds. Breathe through your nose. Relax back down for 60 seconds. Complete two more times. Next, raise your head and hold up for 3 seconds. Relax down. Repeat the 3-second hold (relaxing down between each repetition) up to 30 times.

Chin tuck against resistance: (use in place of the Shaker exercise with patients physically unable to lay flat on their backs. Such as people with chronic back pain). While seated, place a rolled-up hand towel under your chin, pressed lightly against your neck. Press your chin down into the towel and hold for up to 60 seconds. Keep your spine straight. Relax for 60 seconds. Complete two more times. Next, press your chin down into the towel and hold for 3 seconds. Relax then repeat the 3-second hold (relaxing between each repetition) up to 30 times.

Super spraglottic swallow: Take a deep breath and hold it tight. Take a bite or a sip. Continue to hold your breath. Swallow hard. Immediately after swallowing, cough. Breathe.

Lingual Exercises

Masako maneuver: (strengthens the back wall of the throat) Stick your tongue out and hold it gently between your lips. Relax your eyes and cheeks. Swallow and keep sticking your tongue out. Repeat 10 times.

Hawk: (use this with patients who have difficulty completing the Masako, improves movement of the back wall of the throat). Say the word “hawk” in a loud voice, emphasizing the “k” sound. It will sound like “haw-KKH.” Repeat 10 times.

Gargle: Pretend to gargle for 5 seconds. Repeat 10 times.

Straw suck: Place your lips around a straw (regular size or cocktail size). Place the straw in a thickened liquid (honey thick or pudding thick). Suck continuously for 2 seconds or until the liquid reaches your mouth. If the liquid reaches your mouth, swallow it hard. Pause, then repeat for a total of 10 sucks.

Tongue Press Forward: Lift the front part of your tongue (more than just the tongue tip). Press it against the ridge that behind your top front teeth. Hold and press 10 seconds. Relax. Repeat 10 times.

Tongue Press Back: Lift the back of your tongue. Press it against the hard palate, right before it meets the soft palate. Hold and press for 10 seconds. Relax. Repeat 10 times.

Tongue Press Out: Gently bite down on a tongue depressor placed between your upper and lower front teeth. Press your tongue against the tongue depressor. You may hold the tongue depressor in place with your hand if it shifts. Continue pressing for 10 seconds. Remember to gently bite down on the tongue depressor. Pause and repeat for a total of 10 presses.

Tongue Press Side: Gently bites down a tongue depressor placed between your upper and lower premolars. Press the side of your tongue against he tongue depressor. You may hold the tongue depressor in place with your hand if it shifts. Continue pressing for 10 seconds. Remember to gently bite down on the tongue depressor. Pause and repeat for a total of 10 presses. Switch sides and repeat steps 1-5.

Orofacial Exercises for Patients on Chemoradiation

Lip Pucker: Purse your lips like you’re about to whistle and hold for 5 seconds. Press your lips against the back of a spoon to add some resistance.

Pucker side-to-side: Purse your lips then stretch your lips over to the right, hold for 5 seconds, and then stretch your lips over to the left, hold for 5 seconds.

Smile: Showing your upper and lower teeth and gums, clench your teeth gently, avoid squinting your eyes or tensing your neck, hold for 5 seconds.

Pucker/Smile: Purses your lips like you’re about to whistle, hold for 5 seconds, then smile wide for 5 seconds. Do not tense your neck muscles.

Cheek puffs: Puff out your cheeks like a blow fish and hold for 5 seconds. Breathe through your nose.

Mmm’s: Press your lips together tight, hold for 10 seconds, relax your neck.

Compensatory Swallowing Strategies

Below is a list of common compensatory swallowing strategies.

Pick and choose around 3-5 strategies for your patients based on the signs and symptoms they present. Provide a list of the exercises you recommend. Model each, then have the patient demonstrate it back to you. Encourage daily practice, at least twice a day.

* Educate all patients and caregivers about the signs and symptoms of aspiration.

• Take a sip of your drink, look down at your lap, then swallow. 
  
• After each swallow, clear your throat and swallow again. 
  
• Hold each bite/sip in your mouth for 3 seconds, then swallow. 
  
• After each bite of food, take a sip of your drink. 
  
• Take small bites, one at a time. 
  
• After each bite, set your utensil down and eat slowly. 
  
• Swallow each bite/sip twice. 
  
• After each bite/sip, turn your head and then swallow. 
  
• Sit bolt upright whenever you eat or drink. 
  
• Sit upright for at least 30 minutes after eating. 
  
• Use a teaspoon or a small fork. 
  
• Swallow hard like you’re swallowing a whole grape. 
  
• Use your tongue to clear out any leftovers in your mouth. 
  
• Avoid straws and drink straight from the cup. 
  
• Use straws to avoid tilting your head back when you drink. 
  
• Place your medications in apple sauce, yogurt, or pudding. 
  
• Cut your pills in half. 
  
• Crush your pills and place them in apple sauce, yogurt, or pudding. 
  
• Avoid speaking while there’s food in your mouth. 
  
• Eat only when you feel awake and alert. 
  
• Reduce distractions while you eat. Do not watch TV or read. 

References

• The Adult Speech Therapy Workbook by Chung Hwa Brewer
• Adult Dysphagia by ASHA
• Summary of the Clinical Practice Guideline by ASHA
• Oral Hygiene and Dysphagia-Care and Complications by John Ashford for ASHA
• Keeping it Clean: Improving Oral Hygiene Practices by Tiffany Oakes for Dysphagia Cafe
• Self-Feeding With the Adult Population Back to Basics by the American Occupational Therapy Association
• Modifying the Environment during Mealtime by Amber B. Heape for speechpathology.com
• Burkhead, L.M., Sapienza, C.M., and Rosenbek, J.C. (2007). Strength-Training Exercise in Dysphagia Rehabilitation: Principles, Procedures, and Directions for Future Research. Dysphagia, 22, 251-265.
• Zimmerman, E., Carnaby, G., Lazarus, C.L., & Malandraki, G.A. (2020). Motor Learning, Neuroplasticity, and Strength and Skill Training: Moving From Compensation to Retraining in Behavioral Management of Dysphagia. American Journal of Speech-Language Pathology, 29, 1065-1077.

More Resources: Dysphagia Treatment Options