What is the role of Physical Medicine and Rehabilitation (PM&R) in managing swallowing disorders?

Role of Physical Medicine and Rehabilitation (PM&R) in Swallowing Disorder Management

Physical Medicine and Rehabilitation specialists play a critical role in the multidisciplinary management of swallowing disorders through comprehensive assessment and implementation of evidence-based rehabilitation techniques to improve swallowing function and prevent complications.

Assessment of Swallowing Disorders

• Initial screening should be performed as soon as a neurological condition (such as stroke) is diagnosed and emergency treatment provided 1
• Patients who fail screening should not receive anything by mouth until a comprehensive assessment is completed, preferably within three days 1
• Comprehensive assessment should include:
  • Bedside evaluation
  • Instrumental examination when clinically indicated (videofluoroscopy or FEES - Fiberoptic Endoscopic Evaluation of Swallowing) 1, 2
• For Parkinson's disease patients, screening is particularly important for:
  • Patients with Hoehn & Yahr stage above II
  • Those with weight loss, low BMI, drooling, or dementia
  • Assessment should be performed during medication ON-phase 2

Rehabilitation Interventions

Evidence-Based Exercises and Techniques

• Swallowing Rehabilitation Exercises (moderate evidence):

  • Shaker Head Lift Exercise - improves suprahyoid muscle strength and upper esophageal sphincter opening 2
  • Expiratory Muscle Strength Training (EMST) - particularly effective for Parkinson's disease patients, improving cough function and swallowing safety 2
  • Oral Motor Exercise Program - increases strength and range of motion of mouth, larynx, and pharynx 2
  • Lee Silverman Voice Treatment - improves neuromuscular control of oral phase 2
  • Mendelsohn maneuver - improves hyoid movement and upper esophageal sphincter opening 1

• Multi-intervention Programs (moderate evidence):

  • Combining modified diet, airway protection strategies, and swallowing exercises has shown benefits for promoting better swallowing and return to normal diet 1
  • Swallowing maneuver training with electromyography biofeedback showed improvement in approximately half of stroke patients 1

Compensatory Strategies

• Postural Techniques:

  • Chin-tuck posture - provides aspiration protection in fewer than 50% of neurogenic dysphagia cases 1, 2
  • Head rotation - useful for specific cases with hypertonicity 2

• Dietary Modifications:

  • Thickened liquids (honey-thick or pudding-thick) significantly improve swallowing safety 2
  • Appropriate diet consistency based on individual assessment 1
  • Fractionating meals to reduce muscle fatigue 2

• Low-risk Feeding Strategies:

  • Self-feeding when possible
  • Reducing distractions during meals
  • Eating from a seated position
  • Ensuring slow feeding rate with small amounts per bite 1

Advanced Rehabilitation Approaches

• Neuromuscular Electrical Stimulation (NMES):

  • Evidence suggests modest effect on both swallowing physiology and feeding status 1
  • Most effective when combined with conventional swallowing therapy 1

• Non-invasive Brain Stimulation:

  • Transcranial direct current stimulation (tDCS)
  • Repetitive transcranial magnetic stimulation (rTMS)
  • Pharyngeal electrical stimulation (PES)
  • Note: These techniques have limited evidence and should preferentially be carried out within clinical trials 1

Monitoring and Follow-up

• Regular reassessment of swallowing function using instrumental assessment is essential to monitor progress and adjust treatment plans 2
• Monitoring for signs of:
  • Aspiration pneumonia (particularly important as it's the most frequent cause of death in Parkinson's disease) 2
  • Malnutrition and weight loss
  • Dehydration
  • Medication intake difficulties 2

Common Pitfalls and Caveats

• Compensatory strategies may provide protection against aspiration but do not necessarily lead to recovery of swallowing ability 1
• Chin-tuck posture may be difficult for some patients due to physical and cognitive issues 1
• Thickened liquids, while effective for preventing aspiration, are associated with higher rates of dehydration, urinary tract infection, and fever 2
• No single intervention works for all patients - individualized assessment and treatment planning is crucial 2
• Surface electrical stimulation and repetitive transcranial magnetic stimulation lack sufficient evidence for routine recommendation in Parkinson's disease 2

PM&R specialists work as part of a multidisciplinary team including speech-language pathologists, gastroenterologists, radiologists, neurologists, dietitians, and nurses to provide comprehensive care for patients with dysphagia, ensuring optimal outcomes in terms of swallowing safety, nutrition, and quality of life 3.