In this article, you’ll learn how to teach swallowing exercises and compensatory strategies to your speech therapy patients with dysphagia.
To make this easier, we include a free, fully illustrated swallowing exercises handout for you to print out.
You’ll learn:
- How to teach swallowing exercises (with videos!)
- Safe swallowing strategies
- The signs of dysphagia and how to treat them
- Risk factors of aspiration
Let’s dive in!
Signs of Dysphagia & How to Treat Them
It’s best practice to recommend an instrumental swallowing assessment before deciding how to treat dysphagia.
Below are examples of dysphagia treatment options. They include compensatory strategies and exercises. Keep reading for how to do each.
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. Regurgitation
Treatment: Small bites and sips, thinner consistencies, Masako maneuver, Mendelsohn maneuver (or effortful pitch glide), head lift or chin tuck against resistance
7. Reduced epiglottic movement
Treatment: Mendelsohn maneuver (or effortful pitch glide), effortful swallow, head lift or chin tuck against resistance
8. Vallecular residue
Treatment: Dry swallow, alternating bites and sips, effortful swallow, Mendelsohn maneuver (or effortful pitch glide), lingual exercises
9. Reduced UES opening
Treatment: Head turn. Mendelsohn maneuver (or effortful pitch glide), head lift or chin tuck against resistance
10. Pyriform sinus residue
Treatment: Dry swallow, alternating bites and sips, head turn, Mendelsohn maneuver (or effortful pitch glide), head lift or chin tuck against resistance, jaw opening exercise
11. Laryngeal penetration
Treatment: Thickened liquids, small bites and sips, alternating bites and sips, bolus hold, chin tuck, Mendelsohn maneuver (or effortful pitch glide), effortful swallow
When To Recommend an Instrumental Swallow Evaluation
Most patients with dysphagia would benefit from an instrumental swallowing assessment. This may be a videofluoroscopic swallowing study (VFSS) or a Fiberoptic Endoscopic Evaluation of Swallowing (FEES).
The results of an instrumental evaluation can help a lot when choosing goals, exercises, and strategies.
Learn more about instrumentals, including when to recommend them.
More Dysphagia Articles:
Swallowing Exercises
Visit our shop for print-and-go dysphagia handouts, exercises, and treatment guides
Below is a list of swallowing exercises.
Choose exercises for your patients based on the results of an instrumental swallowing assessment and the underlying impairments and signs and symptoms they present. Modify as needed.
Model the relevant exercise, 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.
And educate patients and caregivers about the signs and symptoms of aspiration. Read ahead for a checklist of aspiration risk factors.
Pharyngeal Exercises
1. Effortful Swallow
- Sit up straight
- Gather saliva in your mouth or take a sip of water
- Swallow while squeezing your throat as hard as you can (pretend that you’re swallowing a whole grape)
- Repeat to fatigue (or in sets of 5-10 swallows, as appropriate)
Watch How To Do An Effortful Swallow
(Bahia, 2020)
2. Mendelsohn Maneuver
- Place your fingers gently on your throat. Swallow your saliva and feel your Adam’s apple move up and down
- Swallow your saliva again, but halfway through the swallow, hold your Adam’s apple up using the muscles under your chin
- Hold it for 3 seconds. Relax
- Repeat 5-10 times
3. Chin Tuck Against Resistance
- Sit up straight
- Place a rolled-up hand towel lightly under your chin and against your neck
- Push your chin down into the towel and hold for 60 seconds
- Repeat 3 times
- Next, push your chin down hard into the towel and hold for 3 seconds
- Relax briefly
- Repeat the 3-second hold then relax up to 30 times
Watch how to do chin tuck against resistance.
4. Jaw Opening Exercise
- Lightly place the front of your tongue against the roof of your mouth
- Place your fist under your chin, pressing upward
- Slowly press your jaw down into your fist. Continue pressing upwards with your fist. Relax
- Repeat 5-10 times
5. Effortful Pitch Glide (Monkey EEE)
- Glide on the ‘eee’ sound from a low pitch to a high pitch
- Squeeze the muscles in your throat
- Hold the highest pitch possible for 3-5 seconds
- Repeat 5-10 times
6. Super-Supraglottic Swallow
- Take a deep breath and hold it tightly while bearing down
- Continue to hold your breath and bear down as you swallow
- Cough immediately after swallowing but before taking a breath
- Then immediately swallow hard again before taking a breath
- Take a breath
(Vose, 2014)
7. Masako Exercise
- Sit up straight
- Gather saliva in your mouth
- Stick out your tongue and hold it gently between your teeth (Relax your eyes and cheeks)
- While holding your tongue between your teeth, swallow
- Repeat to fatigue (or in sets of 5-10 swallows, as appropriate)
A patient should not do this exercise with food or liquid; only their saliva.
Tongue Strengthening Exercises
Tongue-to-palate resistance training may improve tongue muscle strength and swallow function in patients with dysphagia (Kim, 2017).
You can use a tongue-strengthening device such as the IOPI®, or coach your patients to press their tongue against their palate. Here’s how:
1. 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 5-10 times.
2. 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.
3. 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. Relax
- Repeat for 5-10 presses
4. Tongue Press Side
- Gently bite down a tongue depressor placed between your upper and lower premolars. Press the side of 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. Relax
- Repeat for 5-10 presses
- Switch sides and repeat
Lingual Range of Motion Exercises
Lingual range of motion exercises may improve tongue movement and oral motor function in people with dysphagia (Hwang, 2019).
1. Tongue Out
- Stick your tongue out as far out as you can
- Hold it for a count of 5 seconds
- Relax
- Repeat tongue-out 10 times
2. Tongue Back
- Retract your tongue as far back as you can
- Like you’re going to say the ‘K’ sound
- Relax
- Repeat tongue-in 10 times
3. Tongue Out-then-Back
- Protrude your tongue out then retract it in
- Hold each for 5 seconds. Relax
- Repeat tongue-out, tongue-in for 5-10 repetitions
4. Tongue Right
- Stick your tongue out as far as you can to the right
- Hold for 5 seconds. Relax
5. Tongue Left
- Stick your tongue out as far as you can to the left
- Hold for 5 seconds. Relax
6. Tongue Up
- Lift your tongue up as far as you can
- Like you’re trying to lick your nose
- Hold for 5 seconds. Relax.
- Repeat tongue-up for 10 repetitions
7. Tongue Down
- Stick your tongue down as far as you can
- Like you’re trying to lick your chin
- Hold 5 seconds. Relax
- Repeat tongue-down for 10 repetitions
8. Tongue Around (Out)
- Stick out your tongue and lick all around your lip in one direction (clockwise). Relax
- Then go around in the other direction (counter-clockwise)
- Repeat tongue-around (outside the mouth) 5-10 sets, in each direction
9. Tongue Around (In)
- Move the tongue clockwise inside your mouth. Relax
- Move your tongue around in the other direction
- Repeat tongue-around (in the mouth) for 5-10 sets, in each direction
Dysphagia Exercises for Head & Neck Cancer
Read Dysphagia Exercises for Head and Neck Cancer to learn what exercises and stretches to recommend before, during, and after head and neck cancer treatment.
Safe Swallowing Strategies
Choose which of the following compensatory strategies your patient needs based on the results of an instrumental swallowing assessment and the dysphagia signs and symptoms you observe.
Model each relevant strategy, then have the patient demonstrate it back to you.
Encourage practice, at least twice daily.
Educate patients and caregivers about the signs and symptoms of aspiration. See the aspiration risk factors below.
Safe Swallowing Strategies:
- 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
Educate every patient with dysphagia and their caregivers about the risk of aspiration.
Below are some of the signs and symptoms that someone is at higher 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 PDF
Swallowing Exercises Handout
Download the free swallowing exercises handout to use with your adult speech therapy patients.
Your Swallowing Exercises Handout comes with 11 illustrations of common swallowing exercises.
Use these images and the instructions in this article to help your patients learn their swallowing exercises.
More Resources
Check out our shop and course for more dysphagia handouts, illustrations, and treatment guides!
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The Starter Pack is 900+ pages of print-and-go adult speech therapy worksheets, handouts, and templates.
Adult Speech Therapy Roadmap Course
The Adult Speech Therapy Roadmap is an online course that teaches you how to assess, treat, and document all major areas of adult speech therapy, from Day 1 to Discharge.
References
- Bahia, M. M., & Lowell, S. Y. (2020). A Systematic Review of the Physiological Effects of the Effortful Swallow Maneuver in Adults With Normal and Disordered Swallowing. American journal of speech-language pathology, 29(3), 1655–1673. https://doi.org/10.1044/2020_AJSLP-19-00132
- Hwang, N. K., et al. (2019). Tongue stretching exercises improve tongue motility and oromotor function in patients with dysphagia after stroke: A preliminary randomized controlled trial. Archives of oral biology, 108, 104521. https://doi.org/10.1016/j.archoralbio.2019.104521
- Kim, H. D., Choi, J. B., Yoo, S. J., Chang, M. Y., Lee, S. W., & Park, J. S. (2017). Tongue-to-palate resistance training improves tongue strength and oropharyngeal swallowing function in subacute stroke survivors with dysphagia. Journal of oral rehabilitation, 44(1), 59–64. https://doi.org/10.1111/joor.12461
- Masako, F., Logemann, J. A. (1996). Effect of a Tongue-Holding Maneuver on Posterior Pharyngeal Wall Movement During Deglutition. American Journal of Speech-Language Pathology. 5(1), 23-30. https://doi.org/10.1044/1058-0360.0501.23
- Park, J. S., & Hwang, N. K. (2021). Chin tuck against resistance exercise for dysphagia rehabilitation: A systematic review. Journal of Oral Rehabilitation, 48(8), 968-977. https://doi.org/10.1111/joor.13181
- Umay, E., Eyigor, S., Ertekin, C. et al. Best Practice Recommendations for Stroke Patients with Dysphagia: A Delphi-Based Consensus Study of Experts in Turkey-Part II: Rehabilitation. Dysphagia 36, 800–820 (2021). https://doi.org/10.1007/s00455-020-10218-8
- Vose, A., Nonnenmacher, J., Singer, M.L. et al. Dysphagia Management in Acute and Sub-acute Stroke. Curr Phys Med Rehabil Rep 2, 197–206 (2014). https://doi.org/10.1007/s40141-014-0061-2
