Major focus area

Feeding Therapy -> Swallowing

Short description

Direct management techniques are hands on oral-motor methods used to facilitate jaw, lip, cheek, and tongue stability and mobility to facilitate swallowing (Cherney, 1994).

Long description

Direct management techniques are hands on oral-motor methods used to facilitate jaw, lip, cheek, and tongue stability and mobility to facilitate swallowing (Cherney, 1994).

Jaw Stability and Mobility The jaw is the foundation of support for the tongue, lips, and cheek mobility. If the jaw is unstable with ungraded jaw movement then it is difficult to suck, bite, chew, and swallow. Provide external jaw stability through oral control during bottle feeding, spoon feeding, and cup drinking, biting, and chewing using 2 basic hand positions. Oral control from the side: The SLP may hold the patient or the patient may be positioned in a small seat at the side of the SLP. The SLP uses one hand to hold the utensil/food item and the other arm is positioned around the back of the patient with the hand positioned as follows.

1. The fleshy bottom portion of the midfinger is placed horizontally across the tongue base under the jaw. The midfinger movement is vertical and dynamic allowing for improved jaw gradation. Its dynamic movement may also provide for improved tongue mobility because it is placed horizontally across the tongue base. If the midfinger is placed posteriorly to the tongue base, it may case tongue retraction as it moves against the hyoid. If placed too far forward, this finger would be positioned on the anterior portion of the mandible, usually providing very little support to the jaw.
2. The index finger is placed horizontally across the indentation below the lower lip. Index finger movement is inward and dynamic, allowing for improved lower lip stability and mobility. Movement of the midfinger under the chin and movement of the index finger occur independently of each other.
3. The thumb is tucked away to and does not push on the cheek and forcing the patient’s face to one side. Oral control from the front: The SLP is positioned in front of the patient, fact to face. This position provides less control than the side position, but it is effective in providing improved jaw stability, jaw gradation, and tongue mobility.

1. Index finger is crooked under the patient’s chin, the front portion at the tongue base.
2. The thumb, in a vertical position, is placed at the indentation beneath the lower lip. Inward pressure of the thumb facilitates lower lip stability. Lip-Cheek Stability and Mobility Place hands directly on patient’s cheeks, and provide direct and dynamic inward pressure to the cheeks as the bolus is being moved within the oral cavity. This inward pressure to the cheeks as the bolus is being moved should be varied from the corners of the mouth toward the molar area in a wave-like fashion in response to bolus formation and movement. You can also place the thumb under the patient’s jaw, together with external support to the lips-cheeks.

Tongue Stability and Mobility When providing oral control, stability is added at the tongue base, allowing the tongue to move actively and independently from the jaw. When the jaw is stable you can improve active mobility of other tongue movement patterns including: tongue extension, tongue retraction, and tongue elevation. Using variations of spoon feeding, cup drinking, biting, and chewing you can affect tongue movement. If you use a spoon that has a deep bowl with a patient who has poor lip and cheek activity you will see atypical tongue movements. By using an appropriate sized spoon placed directly on the tongue with slight downward pressure, lateral tongue elevation or tongue cupping can be facilitated. You can also facilitate tongue cupping by slowly sweeping forward with slight downward pressure on the central portion of the tongue toward the lips, using a gloved finger or a swab with a handle. Cup placement for patients requiring greater jaw stability should be placed on the lower lip toward the corners of the mouth. As the patient gains jaw gradation ability you can move the cup forward on the lower lip.