Rehabilitation Interventions

Rehabilitation interventions involve applying principles of neuroplasticity and motor learning to improve the physiology of swallowing behaviour.

Oral sensorimotor interventions aim to develop awareness, strength, coordination, range of movement, and endurance of the lips, cheeks, tongue, and jaw (Sjögreen, et al., 2018).

Direct oropharyngeal exercises include exercises involving the oropharyngeal musculature with the aim of changing participant swallowing physiology (e.g. strength-based exercises, respiratory coordination exercises, and skill-based programs). At present, the feasibility and effectiveness of using swallowing exercises with children remains inconclusive (Halfpenny, Stewart, Kelly, Conway, & Smith, 2021).

Best evidence reinforces dysphagia rehabilitation approaches that include motor learning factors such as intensity, duration, task specificity, and generalization.

At present, the strength of recommendations relating to oral sensorimotor interventions for children with dysphagia secondary to congenital or early-acquired disabilities is moderate due to lack of control groups, however, significant positive results are reported (Sjögreen, et al., 2018). Clinicians should always consider functional therapy tasks that directly impact eating and drinking ability and/or safety and closely parallel the desired task. See Table 8.

Table 8: Compensatory, Rehabilitative, and Habilitative Techniques for Dysphagia Management

MANAGEMENT	STRATEGY	EXAMPLE		OBJECTIVE
COMPENSATION
	Pacing		Moderate the rate of intake by controlling or titrating the rate of presentation liquid or food provided, moderating the rate of presentation of food or liquid, and the time between bites or swallows	Encourage breathing (infants) Discourage overfilling the oral cavity (children)
	Modify texture		Offer moist, cohesive consistency	Reduce piecemeal deglutition, reduce choking risk
	Modify liquid viscosity		Thickened liquids consistency	Reduce risk of aspiration
	Modify position		Elevated side-lying positioning or semi-prone (for infants)	Maximize control of muscles for deglutition, reduce bolus flow, improve integration of suck-swallow-breathe sequence, reduce airway obstruction
	Provide head or face posture support		Provide jaw, lip, or cheek assist	Reduce risk of aspiration
	Use alternative equipment		Trial slow flow nipples	Reduce risk of aspiration
	Use adaptive equipment		Trial flexible cut-out cup	Reduce risk of aspiration
	Increase oral sensorimotor awareness		Alter food taste, temperature, tactile quality	Stimulate receptors of the tongue and oropharynx Provide additional sensory input for swallowing
REHABILITATION
	Practice biting and chewing		Offer transitional foods which quickly dissolve	Improve underlying oropharyngeal physiology
	Refine bolus control and swallow		Offer small sips of water	Improve underlying oropharyngeal physiology
	Practice swallowing Strengthen the jaw, lips, cheek, and tongue		Dry swallow or effortful swallow	Improve underlying oropharyngeal physiology (e.g. strengthen jaw, lips, cheek, and tongue)
	Trial dysphagia exercises or maneuvers		Modified Shaker exercise, Effortful swallow, Masako Maneuver, Jaw Thrust* *This list is not exhaustive	Change the timing or strength of movements of swallowing Improve underlying oropharyngeal physiology (e.g. modified Shaker exercise improves the amplitude of pharyngeal muscle contraction)
	Trial biofeedback		Use surface electromyography, ultrasound, or nasendoscopy	Interpret visual information and make physiological changes during the swallowing process
	Trial electrical stimulation		Use an electrical current to stimulate the peripheral nerve	Improve underlying oropharyngeal physiology (e.g., increase the velocity of hyoid bone movement and reduce the pyriform sinus stasis)
HABILITATION
	Support the development of oral sensorimotor skills that have yet be mastered		Offer oral stimulation with tastes, or time and volume limited oral feeding Begin with foundational skills and practice within the infant or child’s zone of proximal development	Elicit the skills that emerge in the typical oral sensorimotor skill sequence
	Responsive feeding— Focus on the caregiver-and-child dynamic		Attempt to understand and read a child’s cues for both hunger and satiety and respect those communication signals	Emphasize communication rather than volume
	Behavioural interventions based on principles of behavioural modification		Trial techniques such as antecedent shaping, prompting, modelling, stimulus fading, and differential reinforcement of alternate behaviour	Increase relevant actions or behaviours—including increasing compliance—and reduce maladaptive behaviours related to feeding and swallowing