In this post, you’ll find swallowing exercises and compensatory strategies. As always, we throw in some extras, including the signs of dysphagia—and how to treat them—and a fully illustrated swallowing exercises handout.
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* Treating dysphagia requires high levels of training and skill; this article is intended for Speech-Language Pathologists or other qualified therapists with the appropriate training and competency to work with adults with dysphagia.
More Dysphagia Articles:
- How to Palpate a Swallow
- Oral Mechanism Examination
- Liquid and Solid Trials
- Swallowing Examination Recommendations
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
When To Recommend a Swallow Evaluation
Many patients will benefit from completing at least one instrumental swallowing evaluation. This can be a Modified Barium Swallowing Study (MBSS) and/or Fiberoptic Endoscopic Evaluation of Swallowing (FEES).
The results of an instrumental evaluation can help a lot when choosing goals, exercises, and strategies.
If you suspect laryngeal penetration or aspiration, you may need to refer the patient for an instrumental evaluation.
Also, consider ordering an MBSS or FEES when upgrading a patient from thickened liquids to thin liquids.
Until these evaluations are completed, you can monitor the patient’s lung sounds, educate on overt signs and symptoms of aspiration, and train in the use of safe swallowing strategies, exercises, and modified diet textures.
Swallowing Exercises
Dysphagia Handouts, Illustrated Exercises, and Treatment Guides
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. Read ahead for a checklist of aspiration risk factors.
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 patients and caregivers about the signs and symptoms of aspiration. See the aspiration risk factors below.
- 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.
Aspiration Risk Factors for Dysphagia
* Educate EVERY patient with dysphagia and their caregivers about the risk of aspiration.
- Dysphonia – “different” vocal quality
- Dysarthria – slurred speech caused by muscle weakness
- Abnormal cough
- Coughing and voice change after swallowing
- Needing help with feeding
- Needing help with oral care
- Resisting feeding
- Poor dentition
- History of smoking
- Feeling full very quickly
- Weight loss
- Taking extra effort/time to complete meals
- Dehydration
- History of respiratory infections/pneumonia
- Taking multiple swallows every bite or sip
- Tongue pumping
- Impulsive eating behaviors
- Recurrent sore throat
- Chest congestion
- Shortness of breath
- High grade temperature
Adapted from UC San Diego School of Medicine, 2006
Swallowing Exercises Handout
The Swallowing Exercises Handout comes with 11 illustrations of common swallowing exercises. Use these images along with the instruction in this article to help your patients learn their swallowing exercises.
Or, check out our shop for print-and-go dysphagia handouts, illustrations, and treatment guides.
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