Four main methodologies that comprise the core components of rehabilitation exercise: comprehensive medical management, the activity-function-structure relationship, therapeutic learning, and the assistive system
The activity-function-structure relationship refers to the fact that function and structure are adjusted based on the activity level. Basically, immobilization or disuse syndrome leads to deterioration of many body functions and the development of various diseases. In contrast, encouragement of activity with early rehabilitative intervention helps to prevent disuse syndrome and gain functional ability by the overload principle. A greater load than normally experienced on the body can enhance the ability of activity-dependent elements (e.g., muscle strength, range of motion ) that are used for daily activities and contribute to functional improvement (Fig. 7.2).
The assistive system comprises instrumental aspects (e.g., modified dysphagia food, swallowing chair , dental prosthesis) and environmental aspects (e.g., social resources, family support, environment). To achieve the reconstruction of life in rehabilitation medicine , instruments and the environment are utilized effectively. Therapeutic learning is the motor learning process in which target behavior is achieved by utilizing activity-dependent elements and the assistive system.
7.1 Successful Rehabilitation Strategies Based on Motor Learning in Patients with Swallowing Disorders
Motor learning refers to how motor performance is improved and subsequently maintained. Motor learning is defined as a set of processes that are associated with practice or experience and that lead to relatively permanent changes in the capability for skilled performance . The principle of motor learning is based on a limb movement system emphasizing kinematic assessment through feedback during training. It integrates activity-dependent factors and environment to learn new activities using critical tasks.
7.1.1 Evaluation of Rehabilitation Strategies Based on Motor Learning
A motor learning curve is a graphical representation of the increases of learning skill (vertical axis) with exercise (horizontal axis). The plot shows a patient’s motor improvement while performing a task repeatedly. A large number of individual trials during training eventually increase the task proficiency and result in a skillful experience to recovery of the patient’s functional capacity (Fig. 7.3).
Motor learning curve indicating the patient’s ability and exercise dose
A motor learning curve, especially with respect to skill proficiency, displays three phases of performance changes associated with task difficulty:
Too difficult: If a task is too difficult (or the ability of the patient is too low to perform the task), the rehabilitation progress is very slow. The performance training may fail, and the patient is unable to become proficient. Consequently, the patient may experience loss of motivation and lethargy during the training program.
Adequate: The ability of the patient to approach the optimal level of task performance is helpful for rapid progression in training. The possibility of success in this phase is around 70%. A proper task difficulty level allows the patient to further improve his or her motor skill.
Too easy: Once a patient practices a too-easy task for which he or she has already reached a certain level of motor skill, the progress plateaus within the learning curve.
The most effective way to achieve successful performance in motor learning must be considered. The principle of motor learning comprises four key factors.
Transferability (task specificity)
Transferability refers to the probability that the patient can transfer from performance of a training task to achievement of the final targeted area or function. Similarity between the training task and target task is important.
Motivation (psychological driving force)
Motivation should be considered situation-dependent, and the patient should receive reinforcement from either intrinsic or extrinsic resources.
Performance change (behavioral modification)
There are three major components to acquiring relatively permanent motor skills:
Feedback is composed of knowledge of results and knowledge of performance; both influence the motor learning process:
Knowledge of results is feedback regarding the results, indicating limit-difficulty tasks and the success of activity with respect to overall performances (e.g., the result of VF study showing penetration , aspiration, or pharyngeal residue ).
Knowledge of performance is feedback that provides specific information regarding the performance strategy, such as food modifications, postural modification, and the effect of swallowing maneuvers . This feedback can reinforce exercise training or the application of the swallow maneuver for dysphagia treatment.
Quantity (amount/frequency of exercise)
High numbers of repetitions (repetitive tasks) are essential to the success of motor learning . The number of repetitions performed in a given exercise protocol is based on the progression and regimen used in training. Repetition is a very important key for improvement. According to the overload principle, when the threshold of the target intensity is reached, the patient will gain both activity-dependent elements and skill acquisition.
Difficulty of exercise
Difficulty should be kept in mind when choosing the appropriate task to ensure that an exercise is effective, as mentioned in the description of the skill proficiency curve. The task that fits the patient’s level (not too easy and not too difficult) can be transferable to the target.
Three essential components to overcome task difficulty are:
Task selection (proper bolus consistency and volume depending on the patient’s pathophysiological disorders)
Instrumental usage (e.g., assistive devices)
Rehabilitation techniques (e.g., facilitation techniques, swallowing maneuvers )
These components will be further clarified in the discussion of treatment.
Exercise helps to maintain task performance. Additionally, high variability in task training and the performance of random tasks can improve retention.
Get Clinical Tree app for offline access
7.2 Swallowing Exercises
After completion of treatment-oriented evaluations such as VE and VF , all information must be integrated and analyzed to determine the most appropriate treatment approach based on the individual patient’s pathophysiological considerations. Notably, swallowing treatment is not “one-size-fits-all” therapy. Recognizing patients’ individual pathophysiology allows for effective clinical decision-making in terms of what type of physiology-based exercise (intervention) is the most suitable. The principle of “different physiological disorders, different treatment interventions” is vital to dysphagia management.
When planning dysphagia treatment, clinicians must consider multiple factors:
The definitive or most likely diagnosis
The patient’s general health status (stable/unstable, medical condition, cognitive condition)
The patient’s current swallowing ability and associated problems
The patient’s current nutritional status (type, amount, time)
Previous and most recent evaluation and treatment
Caregiver and social support
This information is helpful for both planning therapeutic interventions and determining the proper time for initiation of swallowing rehabilitation on an individual-patient basis.
Swallowing exercises aim to achieve permanent functional improvement in swallowing through alterations of physiological impairment. In Japan, swallowing treatment is generally classified as indirect and direct exercises . Indirect exercise focuses on exercises performed without food or liquid as a part of the treatment program. In contrast, direct exercise is performed with utilization of food and/or liquid. This classification is introduced from the view of swallowing related to risk.
The Fujita swallowing team classifies the swallowing exercise based on the previously described principle of the four components of rehabilitation medicine as a reconstruction of activity (Fig. 7.1):
Element-based exercises (activity-function-structure relationship)
Behavior-based exercises (therapeutic learning)
The goal of element-based exercises is to increase the functional level of activity-dependent elements such as muscle strength and endurance, range of motion , and coordination of structures. The goal of behavior-based exercises is to integrate activity-dependent elements with swallowing activity through the learning. In this type of exercise, swallowing behavior is more strongly emphasized and performed with a suitable level of difficulty (Table 7.1).
Swallowing exercise -based rehabilitation therapies
Element-based exercise (activity-function-structure relationship)
Behavior-based exercise (therapeutic learning)
Oral element-based exercise
• Lingual range-of-moti on exercise
• Lingual strengthening exercise
• Lingual oromotor control exercise
Facilitation technique (including similar effects)
• Thermal-tactile stimulation
• K-point stimulation
• Balloon dilatation
Pharyngeal elemental-based exercise
• Shaker exercise
• Tongue base exercise
• Tongue-holding exercise
• Swallowing maneuvers
1. Supraglottic swallow
2. Super-supraglottic swallow
3. Mendelsohn maneuver
4. Effortful swallow
• Postural techniques (single, combine): trunk, head/neck
• Diet modifications
Expiratory muscle-strengthening exercise
Decisions regarding therapeutic strategies should be based on accurate evaluation and diagnosis of swallowing disorders, ideally identifying physiological impairments by VF and/or VE study. The following section of text presents the details of each exercise used for dysphagic patients at FHUR.
7.2.1 Element-Based Exercises
Element-based exercises target neuromotor control, which is a prerequisite for swallowing function. Knowledge of the activity-function-structure relationship is fundamental for a comprehensive understanding of the effects of swallowing interventions. The particular structure that corresponds to the targeted function must be considered. An understanding of this relationship will help clinicians to easily determine the most appropriate treatment plan for the patient (Fig. 7.4).
Relationship between structure and function as the basis of element-based exercises
188.8.131.52 Oral Element-Based Exercises
Organs : lower jaw , lip , cheek , and tongue
Functions: bolus intak e , mastication , bolus formation , and bolus propulsion
Training: range-of-motio n exercise, strengthening exercises (resistant and endurance), and oromotor control exercises
The tongue is the key component in oral element-based exercises and plays the most important role in oropharyngeal swallowing, especially in the oral stage, which involves oral preparatory functions and oral transit. The major roles of the tongue are bolus int ake, bolus holding , mastication , bolus formation , and bolus propulsion . Thus, tongue exercises are essential for improvements in the swallowing functional outcome. Many types of exercises are used to improve tongue function and are described below.
Tongue range-of-motion exercises are fundamental for bolus manipulation in both the oral preparation and transit stages. All directions of tongue movement are important, including elevation from the front to the back, lateralization, protrusion, and pulling back. During tongue movement in each direction, the clinician asks the patient to hold the tongue in a particular position for a few seconds. A gradual increase in frequency and intensity is necessary for functional improvement (Appendix “Tongue Range-of-Motion Exercise”). These exercises also promote tongue strengthening for bolus formation and propulsion, particularly the tongue blade elevation ex ercise. In addition to manual exercises, several devices are used to facilitate tongue strength (Appendices “Tongue Resistance-Strengthening Exercise” and “Devices to Facilitate Tongue Strengthening Exercise”).
Oromotor control exercises are also important for oromotor function. These exercises involve not only the tongue but also other oral structures to promote improved bolus control (Appendix “Oromotor Control Exercise”). The clinician should gradually increase the speed of these exercises when the patient’s ability has improved.
184.108.40.206 Pharyngeal Element-Based Exercises
Organs: tongue base , hyoid bone, pharynx , larynx , and UES
Functions: hyolaryngeal elevatio n, laryngeal closure , pharyngeal constriction , and UES dilatation
Training: Shaker exercise , tongue base retraction exercise, and tongue-holding exercise (Masako maneuver)
The Shaker exercise or head lift exercise is a combination of an isometric and isokinetic non-swallowing exercise to strengthen the suprahyoid muscles (specifically the geniohyoid, mylohyoid, and digastric muscles) and enhance thyrohyoid shortening. The physiologic principle of the Shaker exercise is an increase in superoanterior hyolaryngeal movement by strengthening of the supra hyoid muscles with a resultant improvement in UES opening . One study revealed that the Shaker exercise was effective in patients who required tube feedings because of abnormal UES opening . The data showed a change in swallowing physiology with clinical improvement (reductions in pyriform sinus residue and post-swallowing aspiration) . The Shaker exercise is recommended three times a day for 6 weeks; this results in a significant increase in the UES anteroposterior opening diameter and a decrease in the hypopharyngeal intrabolus pressure, which is a marker of flow resistance  (Appendix “Shaker Exercise”). This exercise protocol should be incrementally adjusted based on the patient’s ability level. In some dysphagic patients with limited ability to perform the Shaker exercise (suc h as those with tracheostomy , severe weakness of head and neck muscles, limitation of neck movement, and/or inability to lift the head), strengthening of the suprahyoid muscles can be facilitated by alternative therapeutic interventions such as the jaw-opening exercise  (Appendix “Jaw-Opening Exercise”).
Tongue Base Retraction Exercise
Tongue base retraction generates pressure with which to drive the pharyngeal bolus. The tongue base drives bolus material through the pharynx by moving back, making complete contact with the pharyngeal wa ll and thus applying pharyngeal pressure to the tail of the bolus. Therefore, tongue base retraction plays a critical role in pharyngeal clearance especially in the vallecula , acting in cooperation with pharyngeal constriction . The tongue base retraction exercise is designed to improve the maximum range of posterior movement of the tongue base , establishing strength to propel the bolus and ensure clearance of the bolus through the pharynx (Appendix “Tongue Base Retraction Exercise”).
For patients who cannot follow the instructions provided by the clinician, the patient can pull the tongue back against the pulling force provided by the clinician at the tip of the tongue. Alternative therapies include voluntary tongue base strengthening exercises to improve impaired tongue base movement (e.g., gargling , yawning ) .
Tongue-Hold Swallow Exercise (Masako Maneuver)
Contraction of the posterior pharyngeal wall coupled with posterior movement of the tongue base during swallowing pro vides the driving force necessary to assist bolus clearance , propelling the bolus through the upper pharynx during swallowing. Upper pharyngeal or vallecular residue is observed when insufficient contact is present between the tongue base and posterior pharyngeal wall .
The tongue-hold swallow exercise focuses specifically on pharyngeal contraction by physiologically increasing the anterior movement of the pharyngeal musculature (the superior pharyngeal constrictor muscle , the muscle fibers of which are in conjunction with the intrinsic muscles of the tongue), thus contributing to improved contact between the tongue base and posterior pharyngeal wall during the pharyngeal stage of swallowing [7–9] (Appendix “Tongue-Holding Swallow Exercise (Masako Maneuver)”). This exercise, therefore, is thought to aim for strengthening the pharyngeal contraction.
Because of the negative consequences of the tongue-hold maneuver, this exercise should not be performed with a bolus or during meals; it should instead be performed with saliva . Increased pharyngeal residue , a shortened duration of airway closure, and a longer pharyngeal swallow response time have been reported with the use of a bolus in dysphagic patients .
220.127.116.11 Other Exercises
Expiratory Muscle-Strengthening Exercise
The expiratory muscles function in respiration, speech, and voice production. Likewise, they have a potential role in swallowin g function by enhancing the ability to perform a productive cough as a defense mechanism. This prevents material from entering the airway by providing adequate expiratory or subglottic pressure .
The expiratory muscle-strengthening exercise (EMST) is a non-swallowing exercise designed to modify the physiological biomechanisms of expiratory tasks related to swallowing function for airway protection in dysphagic patients. The therapeutic goal of the EMST is to improve the maximal expiratory pressure, cough strength, and subglottic pressure , all of which are associated with the coordination of swallowing function and help to reduce the risk of penetration and aspiration [11, 12]. Therefore, the EMST could translate to functional improvement in coughing and swallowing. At FHUR, we use two types of handheld airway clearance devices: the Portex Acapella® (Smiths Medical Inc., Minato-ku, Tokyo) and the Threshold positive expiratory pressure device (CHEST M.I., Inc., Bunkyo-ku, Tokyo). These devices combin e the resistive feature of a positive expiratory pressure device with the vibratory feature of a flutter valve to mobilize retained airway secretions . Clearing the airway before swallowing training promotes safe swallowing and minimizes the risk of aspiration (Appendix “Expiratory Muscle Strengthening Exercise”).
7.2.2 Behavior-Based Exercises
Behavior-based exercises promote therapeutic learning by integrating all the activity-dependent elements to the actual swallowing behavior by utilizing assistive system . The key of behavior-based exercises involves the task difficulty range. The difficulty of a task is one of the main components in motor learning that influences the possibility of achieving the targeted result. Methods with which to overcome difficult tasks include:
Providing an easier task that can be transferable to the target (e.g., postural techniques, food modifications, swallowing maneuvers )
Changing conditions (e.g., facilitative techniques)
The proper method will provide an adequate range of task difficulty and promote achievement of the desired goal (Fig. 7.5).
Two methods to overcome difficult tasks based on behavioral exercise
The combination of both facilitation techniques and target-oriented exercises ensures the most effective swallowing treatment. For example, postural strategies, diet modification, and/or swallowing maneuvers are manipulated to contribute to the difficulty of a task; this is performed along with stimulation technique during the swallowing exercises, as shown in Fig. 7.6. Once a patient’s condition has improved, the task should be modified toward a higher goal based on the patient’s success rate.
Exercise task with consideration of task difficulty
18.104.22.168 Facilitation Techniques (Including Similar Effects)
Facilitation induces a temporary change in the patient’s ability and encourages successful performance of the swallowing exercise. The three most common facilitation techniques are thermal-tactile stimulation , K-point stimulation , and the balloon dilatation exercise.
Thermal-tactile stimulation is a sensory stimulation technique most commonly used to improve triggering of the pharyngeal swallow in patients with a delayed swallowing reflex and high risk of pre-swallow airway invasion resulting from this delay. The purpose of cold mechanical stimulation is to heighten the oral sensitivity for the swallow and possibly alter central nervous system excitability by stimulus-induced cortical plasticity . Cold application also acts as a sensory stimulus to the brain stem , inducing improvements in the swallowing physiology, which requires the ability to voluntarily swallow without stimulation.
The anterior faucial pillars are particularly recommended for mechanical thermal stimulation because they are one of the most sensitive oral areas for triggering of the swallowing reflex (Appendix “Thermal-Tactile Stimulation”). Thermal-tactile stimulation is performed on both sides in case of bilaterally equal sensitivity. Other areas in the oral cavity are also used to stimulate initiation of the swallow response during training, including the tongue base , posterior part of the tongue, velum, and posterior pharyngeal wall .
K-Point Stimulation 
K-point stimulation is a swallowing facilitation technique developed by Kojima in 2002. The K-point is located on the mucosa lateral to the palatoglossal arch and medial to the pterygomandibular fold at the height of the post-retromolar pad (Fig. 7.7).
The K-point is located on the mucosa lateral to the palatoglossal arch and medial to the pterygomandibular fold at the height of the post-retromolar pad (Reproduced from  with permission)
This trigger point can be stimulated by a soft touch or light pressure applied by the clinician’s finger or a tongue depressor to facilitate swallowing. K-point stimulation mechanically induces a pathological reflex , particularly in patients with pseudobulbar or suprabulbar palsy. The effects of pathological trigger point stimulation at the K-point in patients with pseudobulbar palsy include facilitation of the swallowing reflex with mastication -like movement and easier opening of the mouth in patients with trismus. Although K-point stimulation has a temporary effect, it allows patients to efficiently relearn actual swallowing exercises.
In Japan, a special device called the K-Spoon (Aoyoshi Co., Ltd., Niigata, Japan) is often used for K-point stimulation (Appendix “K-Spoon”). The K-point can be gently stimulated either before or during feeding by placing food from the K-Spoon onto the dorsum of the tongue and then touching the K-point with the tip of the K-Spoon, particularly in patients with a delayed swallowing reflex . The K-point can also be touched during bolus formation if oral movement has stopped while chewing .
Balloon dilatation , first reported in 1997 , is an optional conservative treatment widely used for cricopharyngeal dysfunction , particularly in patients with a large amount of post-swallowing pharyngeal residue in the pyriform sinus [15–17]. This procedure is cost-effective, minimally invasive, safe, and generally well-tolerated. This balloon-expanding procedure works by stretching the cricopharyngeal muscle and surrounding tissues, facilitating the relearned coordinated swallowing process between UES relaxation and pharyngeal contraction, and improving the sensory -motor coordination of the UES [16, 17]. The balloon dilatation technique is demonstrated in Appendix “Balloon Dilatation” (Figs. 7.8 and 7.9).
Pulling of the balloon (arrow) backward through the UES during VF (anteroposterior view)
Lateral fluoroscopic view, (left) before balloon dilatation ; bolus residue is present in the pyriform sinus after swallowing, (right) after balloon dilatation ; no bolus residue is present after swallowing
At FHUR, balloon dilatation is first performed under VF to ensure accurate positioning of the dilated balloon at the UES, determine the immediate effect of balloon dilatation , and obtain biofeedback of the performance. A round balloon is used (Foley, 12–14 Fr). VF is performed twice, before and immediately after balloon dilatation , to evaluate bolus flow through the UES. After confirmation of the tolerability and immediate effects, balloon dilatation is performed at the bedside by SLHTs . The initial volume of air blown into the balloon is 3–4 ml; this is gradually increased to 10 ml based on the patient’s condition. Balloon dilatation is usually performed 5–10 times per set (2–3 sets/day).
22.214.171.124 Target-Oriented Exercises
Target-oriented exercises involve repeated performance of easier, limit-difficulty tasks. Patients can become proficient after repeated practice. There are three aspects to overcoming task difficulty: swallowing maneuvers , postural strategies, and diet modifications.
Swallowing maneuvers involve the application of voluntary controls to a specific movement of the pharyngeal muscles used during swallowing . These maneuvers change the swallow physiology, providing the patient with a new swallowing strategy. Several swallowing maneuvers are available, including the supraglottic and super-supraglottic swallow , Mendelsohn maneuver , and effortful swallow . Most maneuvers are difficult for patients to understand at their first attempt; thus, patients must persist with these exercises to become proficient. Swallowing maneuvers are generally initiated with a dry swallow followed by an actual bolus swallow; they are also used during meals to ensure swallow safety and efficacy. The recommended exercise protocol is usually at least 5–10 times per set, 2–3 sets per day, and 7 days per week. Additionally, VE or VF study can be used for visual performance feedback to enhance learning and examine the efficacy of the maneuvers.
Supraglottic and Super-Supraglottic Swallow
The supraglottic swallow and super-supraglottic swallow are volitional safe swallowing techniques used before and during the swallow for patients who demonstrate reduced airway protection secondary to delayed and/or decreased laryngeal closure . Basically, laryngeal closure during swallowing involves approximation of valves including the true vocal folds , false vocal folds , and aryepiglottic folds as well as epiglottic inversion [18, 19]. Breath holding in both maneuvers facilitates earlier laryngeal closure and improves safe bolus passage. Breath holding prior to and throughout the swallow increases closure of the true vocal folds and medial approximation of the arytenoids , but the super-supraglottic swallow involves extra effort [18–21]. The extra effort involved in breath holding (super-supraglottic swallow ) provides more effective and supplemental function for greater airway protection via closure of the false vocal folds and anterior tilting of the arytenoids toward the base of the epiglottis . Subsequent coughing after the swallow and before breathing again aims to clear any residual material that has entered the laryngeal vestibule during the swallow or material that has been aspirated upon opening of the vocal folds and inhalation (Appendix “Supraglottic and Super-Supraglottic Swallow”).
The Mendelsohn maneuver is designed to augment superior and anterior movement of the hyolaryngeal complex and the subsequent increase in the UES opening (both the anteroposterior opening diameter and opening duration) during swallowing [22, 23]. This maneuver also has the potential to improve the timing and coordination of swallowing in the pharyngeal stage with the improvement in pharyngeal clearance [24, 25]. Furthermore, this maneuver can generally be performed to strengthen and enhance hyolaryngeal movement. Clinically, the Mendelsohn maneuver may be difficult for patients to understand and accomplish. The clinician typically shows the patient how to execute the maneuver by palpating the laryngeal elevation during the swallow to augment understanding and detecting the distance and duration of laryngeal movement (Appendix “Mendelsohn Maneuver”).
The effortful swallow was developed to improve the posterior movement of the tongue base [26–29] and increase the degree of pharyngeal constriction during the swallow . It is used for patients in an attempt to improve bolus clearance from the vallecula . Physiologically, the ultimate goal is to increase propagation of the pharyngeal pressure secondary to facilitating bolus flow through the pharynx and UES (Appendix “Effortful Swallow”).
Postural modification involves behavioral interventions to adjust the difficulty of swallowing tasks. Two essential principles of postural management are changes in gravity (e.g., reclining ) and space manipulation (e.g., head rotation , head /neck flexion ) of the bolus path, which thus controls bolus flow (direction and speed) through the pharynx (Fig. 7.10).
Two key principles of postural management
Several postural strategies have been developed to minimize or eliminate the risk of food/liquid aspiration, enhance the efficiency of swallowing function, and maintain safe oral intake. Postural modification is often used in target-oriented exercise to augment swallowing function and is the first technique applied to prevent penetration or aspiration. This enables maintenance of a normal or near-normal diet and accelerates earlier removal of the feeding tube . It is easily utilized in combination with bolus modification to reduce the risk of aspiration. Before prescription of the postural adjustments, instrumental examination (especially VF ) should be performed to precisely determine the efficacy of the postural strategies and the most appropriate texture and consistency of foods and fluids; this will allow the clinician to assess whether these strategies effectively reduce the risk of aspiration. The most common postural techniques used at FHUR, both during instrumental examination and swallowing training, are described below.
The reclining or lying-down position is implemented to ensure a lower risk of aspiration than that associated with the seated-upright position. The reclining position changes the impact of gravity , affecting the bolus pathway and speed of bolus transport.
In the reclining position, with respect to the inclination of the oral cavity, the front of oral cavity is raised, and the back part is lowered. Thus, the bolus is transported easier from oral to the pharynx with the increased effect of gravity in oral cavity. Regarding the inclination of the posterior pharyngeal wall , the slope is getting moderate. Thus, the bolus advances slowly and arrives late at the hypopharynx with the decreased effect of gravity in the pharynx. Moreover, the trachea is positioned above the esophagus, resulting in a decreased incidence of the bolus entering the trachea and increasing the ability to hold the bolus in the pharynx without aspiration. Pharyngeal residue is likely to be held in the pyriform sinus , allowing patients to safely proceed with a second and third swallow and reducing the possibility of post-swallowing aspiration. This postural technique can be used in patients with impaired bolus transportation from the oral to the pharynx (e.g., bilateral reduction in pharyngeal wall contraction). The reclining technique is also useful in patients who have slow pharyngeal response .
The angle of the reclining position can be adjusted based on the patient’s condition. A 30° reclining posture is often used for patients with severe dysphagia ; this angle is then incrementally adjusted to ≥60°, which helps the patient to eat without any further assistance. Additionally, the impact of gravity in oral cavity must be considered. When the patient reclines, the speed of bolus flow in the oral cavity is accelerated. Severe oral phase problems such as poor bolus holding function may lead to premature spillage . Additionally, the head and neck position must be monitored while the patient is reclined to reduce the risk of aspiration secondary to an extended head and neck position. A pillow is thus recommended to maintain a flexed position.