Treatment of Dysphagia in Adult Dysphagic Patients

Treatment is the natural continuation of the evaluation of swallowing in cases where difficulties are found. In terms of swallowing and oral feeding, two key concepts should be considered: safety and nutritional effectiveness. By safety, we refer to the neutralization of the risk that the bolus may enter the airways, increasing both the risk of choking, according to its size, and the risk of lung infection. Nutritional effectiveness, on the other hand, refers to the ability of the ingested bolus to meet the nutritional and hydration needs of the individual. The treatment of dysphagia is strongly bound by these two concepts, which determine the methods of execution and the limits of applicability. The goal of treatment is functional swallowing, that is, a para-physiological mode of swallowing with no aspiration, even if the transit times of the bolus in the oropharyngeal canal may be longer than normal and minimal residues may remain in the oral cavity (Schindler 1990) (Table 4.1). Historically, the treatment of dysphagia has been based on two different approaches: compensation and re-education. The compensatory approach includes all strategies that, while not modifying the physiology of the swallowing act, ensure the safety and functionality of swallowing. The rehabilitative approach, on the other hand, includes all strategies that affect the physiology of swallowing, achieving stable changes. In the first phase of its young history, speech therapy treatment was mainly based on the search for compensation, but today, there are techniques and tools, and above all theories, that have given a significant boost to the use of re-educational techniques. A preventive approach is also spreading, reserved for those individuals who must undergo treatments, for example, chemoradiotherapy, in which the onset of dysphagia is the expected consequence of the planned treatments. The choice of the type of approach is closely linked to the outcome of the evaluation, which is responsible for identifying the dysfunctional traits of swallowing. The use of one of the two approaches is almost never alternative, but most of the time, the rehabilitator uses both, with a different coefficient of use of the rehabilitative or compensatory approach on the basis of the phase of the rehabilitative path. In the early stages of taking charge of the dysphagic patient, the approach is predominantly compensatory, whereas during the course of therapy and with the progress of rehabilitative goals, the use of compensation is gradually reduced. Compensatory strategies, in fact, produce an immediate effect, thus quickly solving the patient’s swallowing problems. The rehabilitative approach, on the other hand, produces results that are spread over time, but are more stable. Furthermore, the functional improvement, obtained via a compensation technique, is strictly dependent on the use of the technique itself; the rehabilitative approach, on the other hand, produces improvements that, at a certain point, are independent of the exercise itself (Schindler et al. 2011).