QUICK REFERENCE FOR DYSPHAGIA REHABILITATION GENERAL THERAPEUTIC GUIDELINES FOR PROFESSIONALS. KUNNAMPALLIL GEJO JOHN, SPEECH LANGUAGE PATHOLOGIST / THERAPIST PREPARED THIS REFERANCE BOOKLET FOR SPEECH THERAPIST AND OTHER PROFESSIONALS.

1. QUICK REFERENCE FOR SWALLOWING THERAPY
QUICK REFERENCE FOR DYSPHAGIA REHABILITATION
&
GENERAL THERAPEUTIC GUIDELINES FOR PROFESSIONALS
PREPARED BY : KUNNAMPALLIL GEJO JOHN,
BASLP, MASLP
SPEECH LANGAUGE PATHOLOGIST / THERAPIST

2. MENDELSOHN MANEUVER
Aim of this maneuver: To improve swallowing by raising the larynx
and opening the esophagus during swallowing to prevent food and
liquids from entering the airway.
Step 1: Place and press gently your middle three fingers (index,
middle, ring) on your Adam’s Apple (the skin in front of your neck
beneath your chin).
Step 2: Swallow once to practice. Feel your Adams Apple slide
upward and (downward) as you swallow.
Step 3: Swallow again and when your Adam’s Apple gets to its
highest position in the throat, squeeze your throat muscles and hold
it as highest point as you can.
Step 4: Hold it for as long as your doctor/speech therapist has
directed for this exercise (or as long as you can if you can’t hold it
for that long).
Step 5: Swallow and hold the throat as high as possible using the
laryngeal muscles, not the fingers/hands, for 8- 10 seconds.

3. MASAKO MANEUVER
Aim of this maneuver: To improve the contact between the
posterior pharyngeal wall and the base of the tongue, strengthen
the base of the tongue, and reduce food/fluid residues in the
oropharyngeal region.
Step 1: Stick your tongue out of your mouth.
Step 2: Hold your tongue between your teeth or hold your tongue
with a piece of cloth.
Step 3: Bite down gently on your tongue to keep it in place.
Step 4: Swallow while holding your tongue between your teeth.
Step 5: Release your tongue. Then, repeat this procedure for 10-15
times as indicated by a speech therapist/doctor.

4. EFFORTFUL SWALLOW
Aim of this maneuver: To improve the lip seal (Orbicularis oris
muscle) and control saliva using effortful swallowing, also improve
the movement of the tongue base and pharynx (throat).
Step 1: Gather the saliva in your mouth in the middle of your
tongue.
Step 2: Keep your lips closed and tight together.
Step 3: Swallow all the saliva at once like you’re swallowing a grape
or a pill.
Step 4: Squeeze as hard as you can with your throat muscles. Do
it 5-10 times per day.

5. YAWNING
Aim of this maneuver: To help the upward movement of the larynx
(voice box) and the opening of the esophagus.
Step 1: Open jaw as far as you can
Step 2: Yawn and when you get into a big stretch,
Step 3: Hold that position for 10 seconds
Step 4: Do 5 repetition for 2 times per day

6. TONGUE BASE RETRACTION EXERCISE
Aim of this exercise: To improve the movement of base of the
tongue and Strengthening
Step 1: Use a tongue depressor and place it in the center of the
tongue. .
Step 2: Squeeze the tongue and then push it back against the
posterior wall of the pharynx,
Step 3: Making a lot of effort and holding it there for a few seconds.
Step 4: You can start with 10 seconds, and 2 times per day, (the
duration will increase according to your ability and stability).

7. RESISTIVE TONGUE EXERCISE
Aim of this maneuver: To improve tongue strength and control of
food and drink.
Step 1: Push tongue hard against roof of mouth.
Step 2: Push tongue hard against each cheek.
Step 3: Push tongue hard against a tongue depressor or spoon.
Step 4: Hold it for 5 seconds, (the duration will increase according
to the stability)

8. ISOKINETIC (DYNAMIC) SHAKER
Aim of this maneuver: This will help upward movement of the
larynx and to improve the movement of the epiglottis and
strengthens the opening of the esophagus, to reduce food particles
in the pharynx.
Step 1: Lie down on a flat surface. Do not use a pillow.
Step 2: Keep your shoulders flat and lift your chin towards your
chest so you can see your toes for one minute
Step 3: Lower your head back down to the surface.
Step 4: Repeat it 30 times. Then rest for 2 minutes. Repeat as many
times as indicated by a doctor/ speech therapist
(It is not recommended to use this exercise for patients who suffer
from heart problems or problems in the spine, except after
consulting a specialist doctor only under the supervision).

9. ISOMETRIC (STATIC) SHAKER
Aim of this maneuver: This will help upward movement of the
larynx and to Improves the movement of the epiglottis and
strengthens the opening of the esophagus, to reduce food particles
in the pharynx.
Step 1: Lie down on a flat surface. Do not use a pillow.
Step 2: Keep your shoulders flat and lift your chin towards your
chest so you can see your toes
Step 3: Hold your head for as long as, then set your head down
and rest
Step 4: Repeat it 5 repetition for 2 times per day. Then rest for 1
minutes. Repeat as many times as indicated by a doctor/ speech
therapist
(It is not recommended to use this exercise for patients who suffer
from heart problems or problems in the spine, except after
consulting a specialist doctor only under the supervision).

10. SUPRAGLOTTIC SWALLOW MANEUVER
Aim of this maneuver: It will improve the protection of the airway
during swallowing by closing the vocal cords before and during
swallowing to prevent food from entering lungs. . A cough helps
remove any food particles in the larynx or pharynx after
swallowing.
Step 1: Perform this exercise if and only if directed by your
clinician.
Step 2: Your clinician should also provide direction as to the
position of your head (tucked, right, left, straight).
Step 3: Collect a small amount of saliva in your mouth.
Step 4: Take a deep breath and hold your breath (if the vocal folds
are not closed then try to inhale and say ah, turn off your voice
and hold your breath).
Step 5: Keep holding your breath while you swallow.
Step 6: Immediately after you swallow, cough. Practice with saliva
prior to food or liquid.

11. SUPER-SUPRAGLOTTIC SWALLOW MANEUVER
Aim of this maneuver: It will Helps to protect the airway during
swallowing by closing the vocal cords before and during swallowing
to prevent food from entering lungs. . A cough helps remove any
food particles in the larynx or pharynx after swallowing.
Step 1: Perform this exercise if and only if directed by your
clinician. This maneuver is not recommended for patients with high
blood pressure / hypertension (HTN)
Step 2: Your clinician should also provide direction as to the
position of your head (tucked, right, left, straight).
Step 3: Collect a small amount of saliva in your mouth.
Step 4: Swallow with double effort by tightening the muscles while
holding your breath.
Step 6: Cough immediately after swallowing. Practice with saliva
prior to food or liquid.

12. THERMAL TACTILE / SENSORY STIMULATION
Aim of this maneuver: To improving the feeling/ sensitivity in the
mouth area, stimulating oral cavity and surrounding areas muscles
during swallowing process.
Step 1: Place an oral care sponge in an ice cup for 10 minutes. .
Step 2: Dry the sponge from water drops.
Step 3: Wipe the back area of the roof of the throat (starting from
the center to the right and then from the center to the left 3-5
times on each side).
Step 4: Ask the patient to swallow. Repeat this exercise for 5-10
minutes and 3 times per day.
Note: Change the sponge after each time if the patient has
problems with oral health, Some patients might be feel Nausea or
vomiting.

13. LOLLIPOP SWALLOWING
Aim of this exercise: This exercise will help you build swallowing
Step 1: Place a sugarless lollipop in your mouth and lick.
Step 2: Lick three times and then do an effortful swallow with your
lips firmly pressed together.
Step 3: Swallow as hard as you can.
LIP RANGE OF MOTION
Aim of this exercise: This exercise will help to strengthen lip and
cheek muscles
Step 1: Pull your lips into a smile and hold the stretch
Step 2: Then, open your jaw widely
Step 3: Then stretch your lips into a smile and hold for 30 to 60
seconds
Step 4: Relax, repeat this exercise for 5 time per day.

14. JAW THRUST
Aim of this maneuver: To improve upper and lower jaw
movement, adequate mouth opening is essential for eating,
drinking and oral hygiene.
Step 1: Push your lower jaw as far forward as possible,
Step 2: Place your lower teeth in front of your upper teeth.
Note, patients with jaw replacement should use extra caution
before performing this exercise so as not to stress the jaw bone.
(Repeat as many times as indicated by your doctor/ physical
therapist/ speech therapist. For TMJ problem/ bone problem
patients don’t apply this exercise.)
JAW ROTATION / IMAGINARY CHEWING
Aim of this maneuver: To improve adequate mouth opening is
essential for eating, drinking and oral hygiene.
Step 1: Pretend to chew.
Step 2: Rotating the jaw in circular motions in both direction.
Step 3: Start with the mouth closed and gradually open wider.

15. CHIN TUCK SWALLOW
Aim of this technique: This position increases space at the back
of the throat where food and drink can wait before you swallow.
This reduces the risk of it going down the wrong way before you
are ready to swallow/ aspiration.
Step 1: Take a small bite of food/sip of fluids.
Step 2: Hold the food/drink in your mouth, then bend your head
in chin down position, close to your chest as possible
Step 3: Hold the breath for 1 second
Step 4: Swallow the food/drink keeping your chin tucked to your
chest
Step 5: Rest for 30 seconds repeated the technique

16. CHIN TUCK AGAINST RESISTANCE
Aim of this maneuver: This exercise will help to increases space at
the back of the throat where food and drink can wait before you
swallow. This reduces the risk of it going down the wrong way
before you are ready to swallow.
Step 1: Use a 12-cm soft ball or a rolled cotton towel
Step 2: Have the patient push their chin down against the material
which used and hold for one minute
Step 3: Then rest for one minute, and repeat this 3-5 times. (You
can also have the patient push down repetitively 30 times)

17. TONGUE RANGE OF MOTION EXERCISE
Aim of this exercise: This exercise will help to stretch your tongue
muscles for bolus control and swallowing.
Step 1: Stick your tongue out as far as it can go. Hold for 5
seconds.
Step 2: Move your tongue up towards your nose. Hold for 5
seconds
Step 3: Move your tongue down towards your chin. Hold for 5
seconds
Step 4: Move your tongue to the left side. Hold for 5 seconds.
Step 5: Move your tongue to the right side. Hold for 5 seconds.
Step 6: Take a rest for one minute, and repeat this 5-10 times
twice a day

18. ICE MASSAGE
Aim of this maneuver: To improving the feeling/ sensitivity in the
mouth area and oral hygiene.
Step 1: Open mouth and trigger the site for swallowing reflex is
stimulated with cold, eliciting the swallowing reflex
Step 2: Use cotton swab / bud , the cotton ball part of a frozen
cotton bud is commonly used,
Step 3: While using care is required to ensure that the thawed
water does not fall into the pharynx.
Step 4: Repeat this activity 5 times thrice a day with adequate
supervision.
CHEEK EXERCISES
Aim of this exercise: To improving facial muscles coordination and
cheek strengthening.
Step 1: Blow bubbles or puff balls
Step 2: Puff both cheeks with air and hold (3-6 seconds)
Step 3: Puff one cheek at a time and hold air (3-6 seconds)
Step 4: Massage cheeks with two fingers in clockwise and anti-
clockwise direction (6 times

19. HYOID LIFT MANEUVER
Aim of this maneuver: This Maneuver will help you build
swallowing muscle strength and control.
Step 1: Place a few small pieces of paper (about one inch in
diameter) over a blanket or a towel
Step 2: Then place a straw in your mouth and suck one of the
pieces of paper to its tip
Step 3: Keep sucking on the straw to keep the paper attached,
bring it over a cup or a similar container and stop sucking.
Step 4: This will release the paper into the container.
Step 5: Your goal for each session is to place about five to 10
pieces of paper into the container.

20. GENERAL OROFACIAL EXERCISES
Aim of this exercise: This exercise will help you build swallowing
muscle strength and control.
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.
Bilabial closure: Press your lips together tight and produce “MM”
sound, hold for 10 seconds, and put wooden tongue depressor on
between upper and lower lip and press tightly and produce “MM”
sound (don’t bit with teeth), relax your neck.

21. POSTURAL TECHNIQUES (Logemann, 2008)
Aim of this exercise: This exercise will help you to build swallowing.
Five Postures to Improve Swallowing Function
1. Chin Down
Posture
• Helpful for those who have tongue base
retraction issues;
• Mechanism of change widens the valleculae,
allowing the valleculae to contain the bolus in
event of pharyngeal delay
2. Chin Up
Posture
• Helpful for those who have oral tongue
propulsion problems;
• Aids in gaining adequate lingual pressure to drive
the food or liquid out of the mouth and into the
pharynx.
3. Head Turn
(left or
right)
• Involves rotating the head to the side that is
damaged;
• Bolus is then directed through the “normal” safe
side.
4. Head Tilt
(left or
right)
• Head is tilted toward the stronger side, to
promote the flow of food and liquid through that
side.
5. Lying Down  Residual or pooling of food or liquid in the
pharynx is less able to enter the airway as
gravity pulls the bolus towards the posterior
pharyngeal wall and in more easily moved
through to the esophagus (Drake et al.,
1997; Rasley et al., 1993).

22. HEAD ROTATION EXERCISE
Aim of this exercise: This technique / exercise can be used when
the pharynx is paralyzed
Step 1: This technique can be used when the pharynx is paralyzed
to a different extent on the right or left due to conditions like
bulbar paralysis, in order to guide a food bolus to the healthy side
or less paralyzed side.
Step 2: Twist head to weaker side, so weaker side is closed off
and bolus travels to stronger side. Avoids pocketing as well.
Step 3: When compared with a neutral head position, rotating the
head to the left or right increased pharyngeal contraction pressure
at the level of the neck muscles on the side of rotation.
Step 4: Relax
EFFORTFUL PITCH GLIDE
Aim of this maneuver: To improve oral hygiene and voice quality.
Step 1:Say “eee” in as low a pitch as possible
Step 2: Then gradually raise the pitch of your voice until the
highest tone possible.
Step 3.Hold this tone for the length of time directed by your doctor
/ speech therapist

23. INTERNATIONAL DYSPHAGIA DIET STANDARDIZATION
A Description of Four Levels of Diets
Level 1
Soft textured foods – may be pureed or mashed foods. Pudding
may also be given. Use thickener (powder soluble in water and
thickening the water- jelly pattern)
Level 2
Minced and Moist – foods are soft, minced. This may include
cooked cereals, yogurts, curds.
Level 3
Smooth pureed – foods may include soft bananas, ground
meats and fish, cream soups, ice-cream etc.
Level 4 Foods are finely chopped.

24. DYSPHAGIA DIET FLUIDS
Thin Fluids All fluids that are thin at room temperature: water/ice
chips/juices/ tea/liquid nutritional supplements/ regular
or strained soups/ice cream/jelly
Nectar Thick
Fluids
Thin fluids that are thickened to the consistency of nectar
and are sipped from a cup: nectar thick juices, milk,
water, soup.
Honey Thick
Fluids
Thin fluids that are thickened to the consistency of liquid
honey but can be sipped from a cup: honey thick juices,
milk, water, soup.
Honey
Thick/Thin
Fluids
Honey thickened fluids with the addition of thin fluids as
determined in consultation with the patients/ resident/
SDM and the SLP/RD.
Honey Thick
Clear Fluids
Only honey thickened CLEAR fluids are allowed (no
textures): honey thick Apple/orange/cranberry juice and
honey thick water.
Honey Thick
Full Fluid
Only honey thickened FULL fluids are allowed (no
textures): honey thick Juices/water/mild/soup/hot
cereals/custard/pudding/smooth yogurt.
Pudding Thick
Fluids
Thin Fluids that are thickened to the consistency of
pudding and are eaten with a spoon: pudding thick
juices/mild/water/soup/custards, high energy
puddings/smooth yogurt.
Pudding
Thick/Thin
Fluids
Pudding thickened fluids with the addition of thin fluids as
determined in consultation with the patient/resident
/SDM /and the SLP/RD.
Pudding Thick
Clear Fluids
Only pudding thickened CLEAR fluids are allowed (no
textures): pudding Thick/apple/cranberry juices and
pudding thick water.
Pudding Thick
Full Fluids
Only pudding thickened FULL fluids are allowed (no
textures): pudding thick Juices/water/mild/soups: hot
cereals, custard, pudding, smooth yogurt.

25. DYSPHAGIA DIET TEXTURE
Pureed All foods with a pudding type consistency, all entrees to
be pureed, bread with diet syrup. No bananas, cottage
cheese, oatmeal, old cereal, peanut butter.
Pureed with
oatmeal
Oatmeal, foods with a pudding type consistency, all
entree must be pureed.
Pureed Entered
with/
Modified Bread
Oatmeal, foods with a pudding type consistency, all
entree must be pureed, also suggested crustless bread
toast, moist cakes
Minced/Pureed Minced mead and vegetables, mashed potatoes (not
rice), soft casseroles Scrambled eggs, pureed fruits,
strained soups, oatmeal or cream of wheat.
Minced Minced meats, vegetables, mashed potatoes, potato
puffs, scalloped potatoes, cheese, peanut butter
sandwiches, fresh bananas, minced strawberries,
seedless watermelon.
Minced meat /
Modified
Vegetable
Most meats are minced, soft protein items are allowed,
nothing on a bun, no brussel sprouts, florets of
cauliflower or broccoli, no stir fry (mince before serving);
allowed: mashed potatoes, macaroni salads, bananas,
sliced strawberries and seedless watermelon.
Diced Meat /
Modified
Vegetable
Most meats are diced/soft proteins are allowed whole
(meatloaf); also allowed: bananas, watermelon,
strawberries etc); not allowed: raw vegetables, brussel
sprouts, large pieces of cauliflower, whole corn
Ready Same as regular but roast meats are diced.
Regular All items are served unmodified.
Reference: Dysphagia Diet Guidelines, Parkwood Institute, St. Joseph’s
Health Care London, London, Ontario

26. NEUROMUSCULAR ELECTRICAL STIMULATION
(NMES)
Aim of this electrical stimulation: Transcutaneous electrical
stimulation or neuromuscular electrical stimulation (NMES)
focuses on peripheral stimulation of the oropharyngeal muscles to
enhance neuroplasticity and recovery of swallowing function.
It involves the administration of small electrical impulses to the
muscles associated with swallowing in the throat through
electrodes attached to the skin and is usually used in addition to
conventional swallowing therapy. NMES results in greater
muscular recovery than voluntary contraction due to recruiting a
larger proportion of motor units.
Step 1: Place/ stick the electrodes according to the machine
instruction on the throat and neck.
Step 2: On the instrument and increase the simulation according
to patient condition and severity of the problem.

27. RECLINING POSITION
Aim of this positioning: This positioning reduce aspiration, it helps
proper functions of swallowing reflex, helps adequate laryngeal
closure, and help adequate esophagus sphincter closure (superior
esophageal sphincter) and reduce GERD associated with posture.
This 3 types of aspiration: aspiration before swallowing reflex is
engaged (aspiration before swallowing), aspiration that occurs
during swallowing reflex (aspiration during swallowing), and
aspiration after swallowing reflex is completed (aspiration after
swallowing) can control through this reclining position.
When reinforcing a reclining position (almost supine), the front of
the oral cavity is raised and the back is lowered. This force of
gravity makes it easier to bring a food bolus from the oral cavity
to the throat, this method is often used with patients who have
difficulties sending a food bolus into the pharynx. At the same
time, in the reclining position the respiratory tract is raised and
the esophagus is lowered, so that the bolus easily slides down the
posterior wall of the pharynx and can easily enter the esophagus,
which minimizes aspiration. A reclining position in which the head
is raised 30° is often used with patients with severe dysphagia.
The reclining position makes it easy for the neck to extend, so a
pillow must be used to inflect the neck.
To eat without any assistance, the patient must be more than 60°
higher than a supine position; any less and the patient would
require assistance for eating. In many cases, reinforcing a
reclining position lowers the level of consciousness and the patient
may close his/her eyes. In such cases, putting patients into an
almost seated position can often improves the patient’s mental
alertness and make aspiration less likely. Moreover, remaining in
a seated position for 2 hours after eating is said to prevent
gastroesophageal reflux (GERD) and the onset of fever
presumably caused by aspiration.

28. VOCALIZATION EXERCISES
Aim of this exercise: To improve the movement of vocal cords and
articulators, spontaneous response, coordination and flexibility of
tongue.
Patients are asked to produce loudly and repeat meaningless words
by using labial consonants (p and b), alveolar consonants (t and
d), and palatal consonants (k and g) (e.g., paapaapa, taataata,
kaakaaka, or baataaka) (badaaga). This help in the closure and
opening of the lips and the smooth movement of the entire tongue
Step 1: Start by taking a deep breath
Step 2: Open your mouth as widely as you can. Close your mouth
tightly until you cannot see your teeth
Step 3: Push your mouth out as far as you can. Pull your lips back
sideways as hard as possible
Step 4: Stick your tongue right out. Pull it back into your mouth,
Touch both corners of your mouth with the tip of your tongue
(repeatedly), At this point, try swallowing a little saliva
Step 5: Close your mouth tightly and Say “Pa. Pa. Pa. Pa. Pa.”as
loudly as you can.
Step 6: Put the tip of your tongue firmly behind your front teeth
and Say “Ta. Ta. Ta. Ta. Ta.”
Step 7: Open your mouth, place your tongue on floor of the mouth
and Say “Ka. Ka. Ka. Ka. Ka.”

29. LIP MUSCLES STRENGTHENING GENERAL EXERCISES
Aim of this exercises: To improve the lip movements (Lip closure,
protrusion, retraction, and rounding ) and strengthening
Step 1: The mandible opens and closes when lip protrusion and
pulling back are performed as alternating movements, patients are
asked to bite on a bite block or tongue depressor to stop the
mandible from moving.
Step 2: If the patient is unable to close lips, therapist wear gloves
and tap around the patient upper and lower lip, tap from left TMJ to
right TMJ through lower lip and right TMJ to left TMJ through upper
lip (in circular manner) , with index finger gently and gradually
increase the strength of tapping. Repeat it 5 times.
Step 3: The neck moves backward and forward, the therapist may
instruct the patient verbally or block the movement with his or her
hand.
Step 4: The patient is also asked to puff out both cheeks. If they
are capable of doing this, the therapist gently taps both cheeks with
fingers.
Step 5: Patient is asked, lip rounding is performed as if whistling or
blowing on something hot to cool it.

30. SOME RED FLAGS IN AN ADULTS WHO ARE HAVING ORAL-
MOTOR PROBLEMS AND SWALLOWING PROBLEMS NEED
ATTENTION
 Speech sound errors/ inadequate verbal language skills
 Slurring of speech
 Voice sounds excessively nasal
 Tongue hangs out of the mouth
 Drooling/ Excessive saliva secretion
 Tongue or lip deviated to one side
 Spillage of food outside the mouth while eating
 Improper clearance of food in oral cavity prior to swallowing
 Longer meal times
 Difficulty chewing and biting
 Unable to elevate or protrude tongue
 Choking or coughing often while eating/ Aspiration
 Gagging while feeding, Unable to suck, lick, chew or blow
 Preference of specific food texture/ oral sensory issues
 Brainstem Stroke
 Difficulty swallowing oral secretions
 Choking more than once while drinking 50 ml of water
 Weak voice and Wet-hoarse voice quality
 Respiratory issues while swallowing and low vital capacity/
tidal volume
 Pneumonia and Dysphagia