Flashcards: Dysphagia Lecture 4

Diagnosis: Specific diagnosis guides treatment plan.

Prognosis: Expected outcome informs treatment goals.

Reaction to Compensatory Strategies: Assessing response to strategies informs management approach.

Severity of Dysphagia: Evaluating severity determines interventions and support needed.

Cognitive Status: Assessing cognitive abilities aligns with capabilities. Respiratory Status: Evaluating respiratory function influences treatment plan. Caregiver Support: Considering available support determines intervention feasibility.

Patient Motivation and Interest: Assessing motivation impacts treatment planning and engagement.

The decision between oral and nonoral feeding is typically made by a team:

Physician: Assesses the patient's medical condition, prognosis, and overall health to determine the appropriateness and feasibility of oral feeding.

Dietitian: Evaluates the patient's nutritional needs and recommends feeding methods considering swallowing abilities, dietary restrictions, and nutritional requirements.

Family: Provides insights into the patient's daily care, preferences, and support system, considering the potential risks and benefits of different feeding options.

Patient: Their wishes, desires, and goals regarding feeding method are crucial, considering comfort, willingness, and ability to participate in oral feeding.

- Nasogastric Tube (NG Tube): Temporary tube through the nose to deliver nutrition and medication to the stomach.

- Orogastric Tube (OG Tube): Similar to NG tube, inserted through the mouth to deliver nutrition and medication to the stomach.

- Percutaneous Endoscopic Gastrostomy (PEG): Surgical procedure for long-term feeding, inserting a tube through the abdomen into the stomach.

- Open Gastrostomy Tube (G-tube): Surgical feeding tube placed directly into the stomach through an abdominal incision, can be temporary or long-term.

- Jejunostomy Tube: Similar to PEG tube, inserted into the jejunum for feeding when stomach feeding is not possible or safe.

- Total Parenteral Nutrition (TPN): Intravenous method for delivering complete nutrition when the digestive system cannot be used.

Indirect therapy in swallowing rehabilitation involves exercises programs or swallows of saliva (dry swallows) without actually giving food or liquid to the patient.

Direct therapy in swallowing rehabilitation involves presenting food or liquid to the patient while providing specific swallowing instructions.

An example of indirect therapy is performing exercise programs or practicing swallows of saliva (dry swallows) without giving any food or liquid to the patient.

Food or liquid should always be given in small amounts during therapy sessions to ensure safe swallowing practice and minimize the risk of aspiration.

- Increasing spoon pressure on the tongue: More pressure improves sensory input, enhancing awareness and control during swallowing.

- Sour bolus: Sour foods enhance oral sensory stimulation, increasing awareness of swallowing.

- Cold bolus: Cold foods stimulate oral sensitivity, improving oral awareness during swallowing.

- Chewable bolus: Chewing challenging foods enhances oral sensory awareness by engaging muscles and providing feedback.

- Larger volume bolus: Gradually increasing food or liquid volume challenges swallowing muscles, improving sensory awareness.

- Thermal-tactile stimulation: Alternating warm and cold stimuli enhances oral sensory awareness and swallowing function.

- Modifying Volume and Speed of Food Presentation: Adjusting the volume and rate at which food or liquid is presented to the patient can help improve their swallowing coordination and reduce the risk of aspiration. This may involve providing smaller or larger boluses and adjusting the pace of feeding.

- Food Consistency/Diet Changes: Altering the texture or consistency of food and liquid can make swallowing easier and safer for individuals with swallowing difficulties. This may involve modifying the diet to include softer or pureed foods, thickened liquids, or using thickening agents to adjust the viscosity of liquids.

- Intraoral Prosthetics: Intraoral prosthetics, such as palatal obturators or lingual palatal aids, may be used to provide structural support or improve swallowing function in individuals with specific anatomical or functional impairments. These prosthetic devices are custom-made and designed to address individual needs.

Oral Control and Oral-Pharyngeal Range of Motion (ROM) Exercises: These exercises focus on strengthening and improving the coordination of the muscles involved in swallowing. They target specific movements and functions of the tongue, lips, and jaw to enhance oral control and improve swallowing efficiency.

Sensory-Motor Integration Procedures: These procedures aim to improve the integration of sensory and motor functions in the swallowing process. They involve exercises and activities that stimulate the sensory receptors in the oral cavity, promoting better sensory awareness and integration during swallowing.

The changes observed were:

Reduced swallow onset time.

Reduced oral transit time.

Reduced pharyngeal delay time.

Reduced pharyngeal transit time.

Increased oropharyngeal swallow efficiency.

Some postural techniques used as compensatory strategies include:

Chin-down

Chin-up

Head rotation

Chin down and head rotation

Head tilt

Lying down

The chin-down postural technique is used to help prevent aspiration during swallowing by closing off the airway and directing the food or liquid toward the esophagus.

- helps remove residue

The chin-up postural technique may be used to improve airway clearance during swallowing by opening up the airway and facilitating the movement of food or liquid into the pharynx.

- may be good for people who have trouble manipulating the bolus

- make sure they have adequate airway closure

Head rotation is a postural technique that can help direct the bolus (food or liquid) to one side of the mouth or throat, which may facilitate swallowing and reduce the risk of aspiration.

The chin down and head rotation technique is often used when individuals need both the benefits of chin-down positioning (to close off the airway) and head rotation (to direct the bolus). This combined technique can help improve swallowing safety and efficiency.

The head tilt postural technique aims to change the alignment of the head and neck during swallowing to facilitate the movement of food or liquid through the pharynx and into the esophagus.

Lying down may be used as a compensatory strategy in individuals who have difficulty swallowing in an upright position. This position can help control the flow of the bolus and reduce the risk of aspiration.

The chin tuck and head rotation to the weak side were found to be the most effective postural techniques in preventing aspiration.

The lying on the side technique was the least successful, as it only eliminated aspiration on smaller boluses (1-3 mls). It was used on only 4 patients.

Some swallowing maneuvers used in dysphagia management include:

Effortful swallow

Mendelsohn maneuver

Breath hold

Supraglottic swallow

Super-supraglottic swallow

The effortful swallow maneuver involves intentionally exerting more effort during the swallowing process. It aims to increase the strength and coordination of the swallowing muscles, helping to improve bolus propulsion and clearance.

- increases bot and posterior pharyngeal wall movement

The Mendelsohn maneuver is a swallowing maneuver where the individual prolongs the elevation of the larynx during the swallow. This maneuver is used to improve the coordination and timing of the swallowing mechanism, specifically targeting the opening and closure of the upper esophageal sphincter (UES).

- reduced laryngeal elevation

- increase cricopharyngeal contraction for UES opening

- have them hold their laryngeal elevation which gives the UES more time to open

The breath hold maneuver involves briefly holding one's breath before and during the swallow. It aims to temporarily suspend respiration to prevent aspiration and facilitate coordination between breathing and swallowing.

- hold their breath before they swallow, then swallow

- for patients with aspiration or penetration during the swallow

The supraglottic swallow maneuver involves the individual taking a deep breath, closing the vocal folds tightly, and holding their breath while swallowing. This maneuver helps to close off the airway at the level of the vocal folds, reducing the risk of aspiration during the swallow.

- for people with poor airway closure

- gets more airway closure than a breath hold

The super-supraglottic swallow maneuver is an advanced version of the supraglottic swallow. In addition to closing the vocal folds and holding the breath, it also involves a forceful effort to swallow and a strong cough immediately after the swallow. This maneuver is used in cases where there is a high risk of aspiration and aims to further protect the airway.

Some instructions to encourage an effortful swallow include:

"I want you to swallow but squeeze very hard with your tongue and throat throughout the swallow."

"Imagine you are trying to swallow a ping pong ball."

"Push your tongue against the roof of your mouth as you swallow hard."

Applying extra effort during a swallow, as in an effortful swallow, can help strengthen the swallowing muscles and improve the movement and coordination of the bolus through the oral and pharyngeal phases of swallowing. It can also aid in clearing the throat and reducing the risk of aspiration.

Practicing an effortful swallow can have several benefits, including:

Strengthening the swallowing muscles.

Improving bolus propulsion and clearance.

Enhancing coordination and timing of the swallowing mechanism.

Facilitating the movement of food or liquid through the throat.

Reducing the risk of aspiration and improving swallowing safety.

Some instructions to perform the Mendelsohn maneuver include:

"I want you to swallow normally with your hand on your throat. Feel your larynx move up and down while you swallow."

"Now, when you feel your larynx lift all the way up, hold it up with your neck and tongue muscles for a few seconds."

Practicing the Mendelsohn maneuver can have several benefits, including:

Enhancing the coordination and timing of the swallowing mechanism.

Improving the opening and closure of the upper esophageal sphincter.

Promoting adequate bolus clearance from the pharynx into the esophagus.

Reducing the risk of aspiration and improving swallowing safety.

Optimizing overall swallowing efficiency and function.

Holding the larynx up with the neck and tongue muscles, as in the Mendelsohn maneuver, allows for a longer duration of laryngeal elevation during the swallow. This can facilitate the opening and clearance of the UES, improving bolus flow and reducing the risk of aspiration.

Pushing the tongue against the roof of the mouth during an effortful swallow helps generate increased pressure and force within the oral cavity. This can enhance the propulsion of the bolus and facilitate the swallowing process.

The instruction for performing a breath hold during swallowing is straightforward: "Hold your breath, now swallow"

Incorporating a breath hold during swallowing can have several benefits, including:

Promoting airway protection by reducing the risk of aspiration.

Facilitating coordination between breathing and swallowing.

Allowing for better control and timing of the swallowing process.

Enhancing the efficiency and safety of swallowing.

Assisting in maintaining respiratory control during swallowing.

The instructions given to perform a supraglottic swallow are as follows:

"Take a breath in."

"Hold your breath."

"Swallow."

"Cough."

"Swallow again."

Taking a breath and holding it during a supraglottic swallow helps prepare the individual by ensuring they have enough air in their lungs before initiating the swallowing process. Holding the breath during the swallow assists in closing the vocal folds and protecting the airway.

Coughing is included in the supraglottic swallow technique to further clear the airway after the swallow. A forceful cough helps expel any potential residue or foreign material that may have entered the throat during the swallow.

Performing a supraglottic swallow can have several benefits, including:

Enhancing airway protection during swallowing.

Minimizing the risk of aspiration.

Promoting the safe and efficient clearance of food or liquid from the pharynx.

Providing an effective mechanism to protect the lungs from potential aspiration-related complications.

The instructions given to perform a super-supraglottic swallow are as follows:

"Take a breath in."

"Hold your breath very tightly while bearing down."

"Swallow."

"Cough."

"Swallow again."

Bearing down while holding the breath tightly during a super-supraglottic swallow enhances the closure of the vocal folds and the protection of the airway. It adds an extra level of force and coordination to ensure the airway remains closed during the swallow.

Performing a super-supraglottic swallow can have several benefits, including:

Maximizing airway protection during swallowing.

Minimizing the risk of aspiration.

Providing an advanced technique for individuals with a higher risk of aspiration.

Enhancing the efficiency and safety of the swallowing process.

Further clearing the airway through the incorporation of a forceful cough after the swallow.

Before the swallow.

Aspiration before the swallow can occur due to two main factors:

Premature spillover into the airway caused by inadequate base of tongue (BOT) and/or soft palate function.

Delayed or absent swallow reflex.

Inadequate base of tongue and/or soft palate function can lead to premature spillover of the bolus into the airway before the swallow is initiated, increasing the risk of aspiration.

A delayed or absent swallow reflex means that the automatic triggering of the swallowing process is delayed or does not occur at the appropriate time. This delay allows the bolus to linger in the oral or pharyngeal area, increasing the risk of aspiration before the swallow reflex is initiated.

- Effortful Swallow: Improve base of tongue (BOT) retraction by squeezing tongue and throat muscles tightly during swallowing.

- Resistive Sucking: Strengthen tongue and improve BOT retraction during sucking with resistive devices or exercises.

- Soft Palate Exercises: Target soft palate muscles to enhance coordination and function in swallowing (phonating)

- /k/ and /g/ Exercises: Articulation exercises to engage and strengthen the back of the tongue for the sounds /k/ and /g/.

- Masako Maneuver: Hold the tip of the tongue between front teeth while swallowing to improve tongue base retraction.

- Supraglottic Swallow: Close vocal folds tightly before and during swallowing for better airway protection and reduced aspiration risk.

- Cold/Sour Bolus: Use cold or sour boluses to speed up swallow initiation and potentially lower aspiration risk.

Two active/rehabilitative treatments for aspiration before the swallow are:

Thermal Stimulation: Thermal stimulation involves using temperature changes, such as cold or hot stimuli, to the oral cavity and pharyngeal areas to elicit a reflexive swallowing response. This can help improve swallowing function and reduce the risk of aspiration.

Deep Pharyngeal Neuromuscular Stimulation (DPNS): DPNS is a treatment technique that involves the application of tactile stimulation to the pharyngeal walls to facilitate the retraining and strengthening of the pharyngeal muscles involved in swallowing. It aims to improve the coordination and efficiency of the swallowing mechanism, reducing the risk of aspiration.

The purpose of thermal stimulation in dysphagia management is to increase sensory awareness in the oral cavity prior to swallowing and to decrease the delay between the oral and pharyngeal swallow.

The technique involves using a laryngeal mirror that has been held in ice water for approximately 10 seconds. The chilled mirror is then quickly rubbed onto the base of the faucial arches (located at the back of the throat) in a rapid fashion. Afterward, the patient is instructed to swallow.

The intended outcome of thermal stimulation is to enhance the individual's ability to perceive sensory information in the oral cavity and improve the timing and coordination of the swallow. By decreasing the delay between the oral and pharyngeal phases of swallowing, it aims to promote safer and more efficient swallowing, reducing the risk of aspiration.

After performing thermal stimulation, a small amount of thick liquid (approximately 1/2 teaspoon) should be presented to the individual.

Thermal stimulation should be repeated 3-4 times daily as part of a regular treatment regimen.

The presentation of a small amount of thick liquid after thermal stimulation allows for the integration of sensory input and the immediate practice of the swallowing response. It provides an opportunity to observe and assess the individual's swallowing function and response following the stimulation.

The results revealed that thermal stimulation improved the triggering of the swallow in 23 out of 25 patients on at least one consistency. The improvements were immediate, observed within two or three swallows following the thermal stimulation.

DPNS stands for Deep Pharyngeal Neuromuscular Stimulation.

The purpose of DPNS is to address pharyngeal dysphagia by utilizing "direct" neuromuscular stimulation to the pharyngeal musculature. It aims to restore muscle strength, endurance, and reflex responses, leading to a restored and coordinated swallow response.

DPNS involves nine techniques that are systematically used to target the pharyngeal musculature and improve its function and coordination.

Studies indicate a high efficacy rate for DPNS in patients with varying neurological etiologies causing pharyngeal dysphagia. It has shown promising results in individuals with different neurological conditions, suggesting its effectiveness across diverse populations.

Aspiration during the swallow most commonly occurs due to decreased laryngeal rise, resulting in incomplete contact of the epiglottis to the arytenoid cartilages, and inadequate vocal fold adduction.

The contributing factors to aspiration during the swallow are:

Decreased laryngeal rise: When the larynx does not elevate sufficiently during the swallow, the protective mechanism of the epiglottis and vocal folds may be compromised.

Incomplete contact of the epiglottis to the arytenoid cartilages: Insufficient closure of the epiglottis and arytenoid cartilages can result in the entry of food or liquid into the airway.

Inadequate vocal fold adduction: If the vocal folds do not close tightly, there is an increased risk of aspiration as the bolus passes through the pharynx.

The consequences of aspiration during the swallow can include:

Increased risk of pulmonary complications, such as pneumonia or lung infections.

Chronic coughing or choking episodes.

Impaired nutrition and hydration due to difficulty in safely ingesting food and liquid.

Reduced quality of life and potential social implications related to swallowing difficulties.

- Chin Tuck: Lower chin to widen vallecula, narrow airway, push back epiglottis, and move tongue base towards pharyngeal wall for airway protection and reduced aspiration risk.

- Head Turn (towards damaged side): Turn head towards weaker side to redirect bolus away from affected area and improve swallowing safety.

- Chin Tuck + Head Turn: Combine chin tuck and head turn for enhanced airway protection and redirection of bolus, reducing aspiration risk.

- Supraglottic Swallow: Deep breath, tightly close vocal folds, hold breath, swallow, and immediately cough. Technique seals off airway and improves swallowing safety.

- Effortful Swallow: Exert increased effort and pressure during swallowing to improve laryngeal elevation and airway protection. Can be used for rehabilitation or as a compensatory technique.

Super-supraglottic swallow: The super-supraglottic swallow is an advanced technique that involves closing the vocal folds tightly, holding the breath, swallowing, and immediately performing a forceful cough. This maneuver improves the anterior tilt of the arytenoid cartilages and adduction of the false vocal cords, providing increased protection to the airway during the swallow.

Breath Hold: The breath hold technique involves briefly suspending respiration by holding the breath before and during the swallow. This maneuver helps prevent the intake of air during the swallow and can contribute to better coordination between breathing and swallowing.

- EMG Biofeedback: EMG biofeedback uses electronic sensors to monitor and provide real-time feedback on muscle activity. It targets and trains specific swallowing muscles, improving function and reducing aspiration risk.

- Falsetto Exercise: Patient slides up the scale to produce a squeaky voice and holds the highest note with maximal effort. Manual assistance may be provided to achieve the desired pitch. This exercise improves laryngeal elevation and control for better airway protection during swallowing.

Aspiration after the swallow typically occurs as a result of residual Upper Airway Penetration (UAP) or residue in the vallecular and/or pyriform sinus areas.

The contributing factors to aspiration after the swallow are:

Residual Upper Airway Penetration (UAP): Incomplete closure or sealing of the upper airway after the swallow, allowing small amounts of material to penetrate into the airway.

Vallecular and/or Pyriform Sinus Residue: Presence of food or liquid residue in the vallecula (space between the base of the tongue and epiglottis) or pyriform sinus areas (recesses beside the larynx in the pharynx).

Chin Tuck

Head Turn

Chin Tuck + Head Turn

Supraglottic Swallow

Effortful Swallow

Some active/rehabilitative treatments for aspiration after the swallow include exercises aimed at increasing laryngeal elevation and vocal fold adduction. These exercises can help improve swallowing function and reduce the risk of aspiration.

Shaker Exercise: This exercise involves lying flat on the back and repeatedly lifting the head to look at the toes, aiming to strengthen the muscles involved in laryngeal elevation.

Mendelsohn Maneuver: The Mendelsohn maneuver is a technique where the individual holds the larynx up with their neck and tongue muscles for a few seconds during swallowing, promoting increased laryngeal elevation.

Chin Tuck Against Resistance: This exercise involves gently applying resistance to the chin as the individual performs a chin tuck maneuver, helping to strengthen the muscles responsible for laryngeal elevation.

Falsetto Exercise: The falsetto exercise involves producing a high-pitched voice or falsetto by sliding the voice up the scale. This exercise helps improve vocal fold closure and adduction.

Laryngeal Adduction Exercises: These exercises focus on targeted exercises to strengthen the muscles involved in vocal fold adduction. They may include exercises such as humming, phonation exercises, or specific vocal exercises prescribed by a speech-language pathologist.

Vallecular residue occurs as a result of inadequate base of tongue (BOT) and posterior pharyngeal wall contact during swallowing. Insufficient contact between the BOT and posterior pharyngeal wall can lead to residue or pooling of food or liquid in the vallecular space.

Spontaneous Subsequent Swallow (double swallow): This technique involves initiating a second swallow immediately after the first swallow to help clear any remaining residue in the vallecula. The double swallow encourages further movement of the base of the tongue and helps clear the vallecular space.

Liquid Wash: Liquid wash refers to drinking a small amount of liquid, typically water, after swallowing to rinse and clear any residue in the vallecula. The liquid acts as a wash to help remove any remaining material from the vallecular space.

Head Turn to Weak Side: Turning the head towards the weak or affected side during swallowing can help close off that side of the vallecula, reducing pooling or residue. By directing the bolus away from the weak side, this maneuver improves clearance and decreases the risk of vallecular residue.

Effortful Swallow: The effortful swallow technique, which involves squeezing the tongue and throat muscles tightly during the swallow, can help improve base of tongue (BOT) retraction. Improved BOT retraction can reduce residue in the valleculae and improve clearance.

Super-Supraglottic Swallow: The super-supraglottic swallow technique, which includes closing the vocal folds tightly before and during the swallow, can also help improve BOT retraction. By enhancing the retraction of the base of the tongue, this technique can assist in reducing vallecular residue.

Resistive Sucking: Using resistive devices or exercises to strengthen the tongue and improve BOT retraction during sucking actions can be beneficial. This can help improve the clearance of residue in the valleculae.

Masako Maneuver: The Masako maneuver involves gently placing the tongue between the teeth and swallowing while maintaining this position. This maneuver can help improve BOT retraction and facilitate the movement of the posterior pharyngeal wall anteriorly, reducing vallecular residue. It is important to note that food trials should not be attempted during the Masako maneuver.

Effortful Swallow: The effortful swallow technique can be used to improve base of tongue (BOT) retraction, which can help reduce residue in the pyriform sinuses.

Super-Supraglottic Swallow: The super-supraglottic swallow technique, involving closing the vocal folds tightly before and during the swallow, can aid in improving BOT retraction and reducing pyriform sinus residue.

Resistive Sucking: Using resistive devices or exercises to strengthen the tongue and improve BOT retraction during sucking actions can be effective in managing pyriform sinus residue.

Masako Maneuver: The Masako maneuver, which involves gently placing the tongue between the teeth and swallowing while maintaining this position, can assist in improving BOT retraction and reducing residue in the pyriform sinuses.

Odynophagia is defined as the sensation of pain or discomfort upon swallowing.

Some common causes of odynophagia include:

Oral candida: An infection caused by the Candida fungus, also known as oral thrush, can lead to painful swallowing.

Pharyngitis: Inflammation of the pharynx, usually due to viral or bacterial infections, can result in odynophagia.

Tonsillitis: Inflammation or infection of the tonsils can cause pain and discomfort during swallowing.

Strep Throat: A bacterial infection caused by Streptococcus bacteria can cause severe sore throat and pain upon swallowing.

1. Cold or warm boluses (preferably liquids): Consuming cold or warm liquids can provide temporary relief by soothing the throat and reducing pain during swallowing.

2. Medical treatment: Depending on the cause, medical treatment may be necessary. For example, antifungal medications are used to treat oral candida, while antibiotics may be prescribed for bacterial infections such as pharyngitis, tonsillitis, or strep throat.

Cricopharyngeal dysfunction refers to a condition characterized by inadequate relaxation of the cricopharyngeal (CP) muscle during swallowing. The CP muscle is located at the upper end of the esophagus and is responsible for opening and closing the entrance to the esophagus during swallowing.

Cervical spinal cord injury with fusion: Fusion surgeries performed on the cervical spine can affect the innervation and function of the CP muscle, leading to hypertonicity and dysfunction.

Brainstem stroke: A stroke affecting the brainstem, specifically the areas responsible for regulating swallowing, can disrupt the normal function of the CP muscle and result in hypertonicity.

Radiation or surgery to the pharynx: Radiation therapy or surgical procedures performed on the pharynx or surrounding structures can cause scarring or damage to the CP muscle, leading to hypertonicity.

Traumatic brain injury (TBI): Trauma to the brain, such as a severe head injury, can impact the neural control of swallowing and result in cricopharyngeal dysfunction.

Head and neck cancers: Cancers in the head and neck region, such as laryngeal cancer or esophageal cancer, can affect the CP muscle and lead to hypertonicity. Tumors or radiation therapy targeting the area may contribute to the development of CP dysfunction.

Idiopathic: In some cases, the exact cause of CP hypertonicity may be unknown or idiopathic. This means that the underlying reason for the hypertonicity cannot be determined.

Head Turn: Turning the head to the weaker or affected side during swallowing can help open up the upper esophageal sphincter (UES) and facilitate the passage of the bolus.

Head Turn + Chin Tuck: Combining head turn with a chin tuck maneuver can further improve UES opening and reduce the resistance caused by CP hypertonicity.

Mendelsohn Maneuver: The Mendelsohn maneuver involves actively prolonging the elevation of the larynx during swallowing. This maneuver helps improve coordination and relaxation of the CP muscle, allowing for better bolus passage through the UES.

Shaker Exercise: The Shaker exercise is a specific exercise targeting the muscles involved in swallowing, including the CP muscle. It involves lying flat on the back and repeatedly lifting the head to look at the toes. This exercise can help strengthen and improve coordination of the CP muscle, promoting better relaxation during swallowing.

The initial position for the Shaker exercise is lying flat on the floor, facing up, with arms at your sides. Keep your feet, back, and shoulders down.

The movement in the Shaker exercise includes raising your head until you can see your toes, pausing briefly, and then lowering your head again. This movement is repeated 30 times.

After completing the 30 repetitions of head raising and lowering, you should take a 1-minute break.

After the break, you should raise your head and look at your toes for 1 minute.

After the long look, you should take another 1-minute break.

The long look and long rest sequence should be repeated two more times.

The entire sequence of the Shaker exercise should be performed three times a day.

Some compensatory/active treatments for Zenker's diverticulum include:

Head Turn: Turning the head to the weaker or affected side during swallowing can help redirect the bolus away from the diverticulum, reducing the risk of aspiration.

Head Turn with Chin Tuck: Combining a head turn with a chin tuck maneuver can further redirect the bolus away from the diverticulum and promote safer swallowing.

Mendelsohn Maneuver: The Mendelsohn maneuver, which involves actively prolonging the elevation of the larynx during swallowing, can assist in promoting better closure of the cricopharyngeal muscle and reduce the risk of backflow or aspiration from the diverticulum.

Shaker Exercise: The Shaker exercise, which involves head raising and lowering exercises, can help strengthen the muscles involved in swallowing, including the cricopharyngeal muscle, and promote better coordination during swallowing.

Cervical reduction of osteophytes is a medical treatment procedure aimed at removing or reducing bony outgrowths (osteophytes) that may be present in the cervical spine. These osteophytes can sometimes impinge on the swallowing structures and contribute to swallowing difficulties.

Cricopharyngeal myotomy is a surgical procedure that involves the division or cutting of the cricopharyngeal muscle (CP muscle) to improve its function. This procedure is performed to treat cricopharyngeal dysfunction or hypertonicity, which can result in swallowing difficulties.

Botox injection refers to the administration of botulinum toxin (Botox) into specific muscles involved in swallowing. The toxin temporarily weakens or paralyzes the targeted muscles, which can be beneficial in cases of muscle hyperactivity or spasticity that contribute to swallowing difficulties.

Dilatation, also known as balloon dilatation or esophageal dilation, is a medical procedure that involves stretching or widening a narrowed or constricted area of the esophagus. It can be performed using a balloon-like device or other instruments to help improve the passage of food or liquids through the esophagus in individuals with swallowing difficulties.