Approaches to Treating

Dysphagia in Patients
With Brain Injury
Wendy Avery-Smith, Donna M.
Dellarosa
Key Words: modalities, occupational therapy
Dysphagia and its treatment in patients with brain in-
jury are multifactorial. Treatment provided should
address each deficit area releuant to d]'sphagia and
should be consistent with current trends and knowl-
edge. This article describes the subskills thm compose
the abilitv to swallow and their treatment in patients
with brain injurjl. The available literature describing
treatment and its eDicacy relevant to each subskill
area is reviewed Specific areas/or documenting elJi'-
cacv of occupational therapy interventions are
described.
Wendy Averv-Smith, .'15. OTR. is Clinical Supervisor. Occupa-
lional Therapy Department. Shaughnessy-Kaplan Rehabilica-
tion Hospital. S"lem, Massachuseccs. and Professional Associ-
ace, Department of Rehabilitation Medicine. The New YOI-k
Hospit"I-Cornell Medical Center. New York, New YOJ'k.
(Mailing "c1dress: 18 Kelsev Road. Boxford. Massachuseccs
01921)
Donn" M. Dellarosa, OTll. is Senior Occupational Therapist.
Departmenr of Rehabilicacion Medicine, The New York Hospi-
tal-Cornell Medical Cenrer, New York, New York.
This article t.eas accepted/or pub/iuilion Ooo!;er .38. /993.
The American journat o/Occupaliona/ Therapy
D
ysphagia, or difficulty swallowing, is a common
problem in patients with brain injury, which
may include open or closed head injury, en-
cephalitis, subdural hcmatoma, or bilateral stroke. In one
acute care setting, 51% of patients admitted with severe
hcad injury showed pharyngeal problems affecting swal-
lOWing, and 31% showed behavioral problems affecting
eating (iv[ackay & Morgan, 1992). In a rehabilitation set-
ting, 26% of adult patients with a head injury were notcd
to have dysphagia (Cherney & Halper, 1989). Outcome
studies have suggested that dysphagia rehabilitation in
this population shows promising results. Beneficial out-
con,es include decreased length of hospital stay (Ro-
senthal & Boggis, 1983), reduced aspiration (Kaprisin,
Clumeck, & Nino-/v!urcia, 1989; Rosenthal & Boggis,
1983). and improved ability to eat and swallow (Neu-
mann, 1993)
For dysphagia rehabilitation to be effective. thera-
pists need current information on treatment methods.
This article describes the subskill areas that influence
swallOWing in the presence of dysphagia in brain injury
and reviews the existing intervention literature for each
subskill area.
Components of Dysphagia in Brain Injury
Brain injuries may lead to deficits of oral and pharyngeal
sensation and movement that influence swallOWing
(Kaprisin et ai, 1989; Lazarus & Logemann, 1987). Brain
injurv-related changcs in poscure and self-feeding also
can affect swallowing abilit)'. Cognitive-perceptual and
behavioral disorders have been implicated as contribut-
ing to swallOWing disorders (Cherney & Halper, 1989:
Tippett, Palmer. & Linden, 1987). These many potential
deficit areas wan-ant comprehensive treatment for dys-
phagia. Avery-Smith, Dellarosa, and Rosen (1992) de-
scribed the subs kill arcas that should be addressed in any
adult with dysphagia: alertness and orientation; cogni-
tive, perceptual, and behavioral status: positioning and
proximal control: self-feeding; mal and pharyngeal sensa-
tion; and oral and pharyngeal movement. The influence
of these areas on swallOWing in the patient with brain
injury and relevant research are described in the follow-
ing sections.
Alertness and Orientation
Backgroundliterature. After brain injurv, decreased
arousal. confusion. and loss of circadian rhythms can af-
fect hunger and appetitc. An adequate degree of alertness
is necessary to eat safelv (Groher, 1992; Silverman & 1-
fant, 1979). Using the Rancho Los Amigos Hospital Adult
Levels of Cognitive Functioning Scale (RIA), M3ckay and
Morgan (1992) rated patients with head injury who were
able to participate in oral intake. They found that, on the
average. patients at RLA Level 4. at which they are con-
fused and agitatcd, are ready to begin eating. However,
235
full oral intake does not occur until RiA Level 6, at which
patients remain confused but display more aprropriate
behavior (Mackay & Morgan, 1992), in our clinical prac-
tice, we find that the therapist may be able to begin
prefeeding aC[iyitic5, including snacks, at RLA Level 3, at
which patients show localized responses to stimuli,
Intervention literature, Multisensory stimulation is
often used as a precursor to functional eating activities to
improve overall alertness (Farber, 1982; Groher, 1992),
During eating, however, a quiet environment is helpful in
avoiding overstimulation (Farber, 1982), Self-feeding may
improve attention span to eating activities (Groher,
1992), Orientation to an eating activity can be accom-
plished by facilitation of hand-to-mouth responses,
through oral stimulation, and through the presentation of
distinctive food odors, tastes, and temreratures, such as
ice pops (Farber, 1982),
Cognitive Impairments and Behavioral Dysregulation
Background literature. Once alertness and atten-
tion span have improved, other areas of cognitive and
behavioral impairment such as poor memory, limited in-
sight, impulsiVity, agitation, inflexibility of thought, poor
judgment, and unilateral inattention may become more
apparent, These problems, along with communication
defiCits, compound the physical causes of dysphagia
(Cherney & Halper, 1989). This wide range of deficits can
interfere with the eating process and may cause aspira-
tion, even in the absence of a physiologic cause for dys-
phagia. Cherney and Halper (1989) noted in a rehabilita-
tion population that severe cognitive and communication
disorders tended to go hand in hand with severe oral
intake problems. Cognitive and behavioral deficits can
limit the ability to use or participate in compensatory
techniques (Tippett et ai., 1987). Neumann (1993) found
that attcntional deficits had a greater negative effect on
dysphagia therapy outcome than did memory deficits in a
group of patients with neurogenic dysphagia, including
those with bilateral brain injury, As noted above, Mackay
and Morgan (1992) found that patients at RiA level 6, at
which they were more aware of eating, had more success-
ful eating experiences.
Intervention literature. The literature includes sev-
eral programs for improving eating in the presence of
cognitive and behavior problems. Tippett et al. (1987)
described the treatment of a patient between 2 and 8
months after sustaining a closed head injury who demon-
strated poor attention span, poor memory, and impulsiV-
ity, along with a fairly normal oral and pharyngeal exami-
nation. Behavior modification techniques, a structured
eating environment, and intensive use of verbal cuing
techniques allowed progression from tube feeding to a
full oral diet (Tippett et aI., 1987). Yuen and Hartwick
(1992) described the treatment of a patient with an acute
closed head injury who had sustained behavior changes
after a craniotomy for a subdural hematoma 20 years
rrevious]y and had no basis for dysphagia except for
memory and judgment deficits. This ralient refused to
cat any textures but purees offered in a glass with a straw,
Using ane:dr transfer or ~ l l s approach, the patient pro-
gressed within 6 days from eating purees to eating
chopped food, first from a glass and then from a plate
with proper utensils. Yuen (1992) described another pa-
tient 3 years post closed head injury with poor attention
span, memory defiCits, and impulsivity, who gorged her
food and showed overall poor food intake. The use of
paced prompting (presenting one bite at a time with
intensive verbal cuing) and reauditorization (haVing the
patient reiterate instructions) facilitated improved atten-
tion span, socially acceptable behaviors, and weight gain
after 2 months of intervention. Behavioral strategies are
also useful in the presence of unilateral inattention; tactile
and verbal cuing, setup to attend to the neglected side of
the food tray, and cues to orally manipulate the food on
the neglected side of the mouth may be helpful (Groher,
1992).
Positioning and Proximal Control
Background literature. In brain injury, abnormal
muscle tone, reflexes, and sensory deficits result in pos-
tural problems that affect the ability to assume and main-
tain a seated upright position. Proper positioning and
body alignment during eating assist with maximum air-
way protection, oral and pharyngeal function, and ease of
self-feeding (Boggis, 1985; Farber, 1982; Groher, 1992;
Silverman & Elfant, 1979). Rood conceived of proXimal
stability as a prerequisite to distal mobility (Trombly,
1989) Once the trunk is in a stable position, distal mobil-
ity may then be addressed, along with tasks like self-
feeding that require grasp anu reach (Trombly, 1989).
Intervention literature. Hulme, Shaver, Acher, Mul-
lette, and Eggert (1987) demonstrated in a population
with developmental disabilities that the use of adaptive
seating devices to correct posture facilitated oral motor
performance and progression from pureed to chopped
food consistencies. The feeding position advocated by
Hulme and colleagues (1987) included at least 90of hip
flexion, 90of knee flexion, a neutral ankle position with
feet supported, and trunk anel head in midline Others
have agreed that this position is essential for safe swallow-
ing in the adult population (Farber, 1982; Groher, 1992;
Silverman & Elfant, 1979). We additionally position the
arms on a tabletop,
Sell Feeding
Background literature. Self-feeding allows the pa-
tient to gain control over the activity, helps to achieve a
basic need, and is often a focus of early occupational
therapy intervention Groher (1992) and Stallons (1987)
March 1994, Volume 48, Number 3
236
noted that efforts to enhance self-feeding, an overly
learned and only partly cortical activity, will stimulate eat-
ing and oral swallowing responses.
intervention literature. In clinical practice, we too
observe that in the presence of similar oral-motor skills,
the patient who can self-feed shows more rapid oral ma-
nipulation of food from the utensil and more efficient oral
bolus manipulation than the patient who must be fed.
However, this finding may he related to the patient's level
of overall neurologic impairment and course of recovery.
Because self-feeding is believed to promote appropriate
oral responses to the bolus, gUided hand-to-mouth move-
ments as opposed to passive feeding arc often recom-
mended for patients with limb apraxias and other limita-
tions in self-feeding (Groher, 1992) Affolter advocated a
"taerile kinesthetic" (1987, p. 165) approach with the use
of hand-over-hand gUiding to promote sensory explora-
tion in eating experiences.
Oral and PharJlngeal Sensorl' Disorders
Background literature. Absent or limited sensation
is thought to be responsible for a poor motor response to
bolus presentation or leftover bolus in thl::' mouth, al-
though inattention of motor deficits may also be implicat-
ed. The resulting neglect of food in the mouth can create
potential for aspiration (Groher. 1992). Abnormal reAex-
ive resronses to oral stimulation. such as a bite reflex.
hyperactive gag reflex, or aversion to touch may be seen.
Different foods possess a wide array of sensory qualities
(Coster & Schwarz, 1987). These sensory quali ties in
combination probably stimulate oral movements and trig-
ger the swallOWing reflex Obliteration of sensation in the
pharynx can drastically impair swallOWing (Pommerenke,
1927). Changing the volume and viscositl' of boluses,
which can be done through the use of different foods, has
been shown to change oral movement responses (Dantas
et aI., 1990; Dodds et al., 1988)
intervention literature. Presentation of boluses with
heightened sensory qualities (heat, cold, flavor) has been
advocated as a way to elicit better sensory awareness of
food in the mouth (Farber, 1982; Groher, 1992; Silverman
& Elfant, 1979) We have also used heavier boluses, that
is, those with a higher graVity, such as pudding
rather than applesauce. Oral desensitization regimes may
help to reduce hyperactive reflexes that interfere with
eating (Farber. 1982; Groher, 1992; Logemann. 1989)
Regular attention to oral hygiene may help to optimize
sensation (Groher, 1992).
Oral and Pharyngeal l'vfovemenl Disorders
Background literature. A wide arrav of oral and
pharyngeal movement disorders, often occurring in com-
bination, are seen after brain injury. In closed head trau-
ma these included limited tongue control, reduced oral
Tbe American Journal of Occupational Tberapl'
and pharyngeal propulsion of the bolus, and a reduced or
absent swallOWing reHex (Lazarus & Logemann, 1987).
Delayed oral tranSit, vocal fold paralysis, and reduced
phalyngeal peristalsis have been seen in patients with
severe traumatic brain injury; difficulty with oral prepara-
tion and transit, delayed swallOWing reflex, and reduced
pharyngeal peristalsis have been seen in patients with
multiple cerebrovascular accident (eVA) injuries (Kapri-
sin et aI., 1989) Apl'axia or motor planning deficits may
also be manifested as a movement deficit during eating,
either orally or pharyngeally.
Intervention literature. Different treatments are
used to address oral and pharyngeal movement prob-
lems. Linden (1989) distinguished between indirect ther-
apy, which involves exercises to improve the movement
components to swallowing, such as range of motion and
strength of oral structures, and direct therapy, which
incorporates eating and drinking activities. Sensory stim-
ulation techniques such as icing and stroking, which were
originally devised by Rood (19')6), are now standard treat-
ments to elicit active movement in specific muscles in
patients with brain injury and dysphagia (Farber, 1982;
Groher, 1992; Silverman & Elfant, 1979). Lazzara, Lazarus,
and Logemann (1986) tcsted the efficacy of USlllg cold
to the faucial pillars and found that it stimulat-
ed the swallow reflex in patients with a variety of neuro-
logic diagnoses including brain injury. Other indil-ect
tl'eatments used for oral and pharyngeal movement prob-
lems include active and rassive range of motion for facial
muscles and strengthening of facial muscles and glottic
and velopharyngeal closure. In one patient who had re-
ceived no food bv mouth for' 7 years after a gunshot
wound (0 the head, strengthening of glottic and vclophar-
yngcal closure as well as tongue range of motion and
strength were addressed intensively in therap)! for 9
weeks (Harris & Murry, 1984). Follovving this treatment
regime, the patient was able to safely swallow small
amounts of ru[-eed foods, although tube feedings were
still required (Harris & Murry, 1984). Biofeedback has
been used to incrcase awal'eness of sensation of move-
ment in a patient \vith oral and lymphatic carcinoma (BIY-
ant, 1991). however, its use in the population with brain
injury has nor been explored and may be more difficult
with thiS population bccause gooel cognitive anel percep-
tual skills are required for this technique. Verbal cuing, a
form of behavioral training, is referred to as "indirect
biofeedback" hy Logemann and Kahrilas (1990, p. 1136)
and is used wielelv with patients with brain injury.
Linden (1989) additionally distinguished between di-
reCt therapy techniques that she called com.pensations.
which are physical maneuvers used during swallowing,
and those she called facilitations, which are other
ch::mgeahle variables such as type of utenSil, sizc of the
bolus, and fooel tcmperature. The use of compensations
has becn wideI\' documented in the literature in patients
with neurogenic dysphagia (Groher, 1992; Logemann &
237
Kahrilas, 1990; Logemann, Kahrilas, Kobara, & Vakil,
1989; Linden, 1989) not necessarily due to brain injury.
These include techniques such as holding the breath
while swallowing (Logemann & Kahrilas. 1990) or turning
[he head while Bwallowing (Logema[lD & Kahrilas, 1990;
Logemann et ai, 1989) Logemann (1986) has published a
manual with an accompanying videotape of patient video-
fluoroscopies that demonstrate case by case, on a before-
and-after basis, how different head positions improve
swallowing efficiency and safety. Likewise, facilitations are
noted widely in the literature as standard techniques to
use with those with neurogenic dysphagia (Farber, 1982;
Groher, 1992, Linden, 1989; Silverman & Elfant, 1979).
Again, these references are not specific to brain injury.
Successful facilitation techniques examined in the focal
brain injury population include the use of thickened tex-
tures (Groher, 1987) and the use of adaptive equipment
for eating (Groher, 1992). Apraxia for oral and pharyngeal
stages of swallOWing may best be treated with a self-feed-
ing approach in the context of a meal or snack (Groher,
1992).
Discussion
The review of the treatment and efficacy literature on
dysphagia in brain injury described throughout this arti-
cle strongly indicates a need for more research in all of
the swallowing subskilJ areas. The following are some
specific questions for further inquiry in the subskill areas
identified.
ALertness and Orientation
Is sensory stimulation actually useful in alerting and
arousing patients sufficiently for eating' At what level of
arousal can cating be accomplished safely' What are the
most efficient ways in which to increase attention to the
eating task'
Cognitive impairments and Behavioral JJvsregulation
The single case studies reviewed in this paper suggested
useful strategies for various cognitive and behavioral
problems. How do the difFerent components of cognition
and behavior such as memory, attention span, insight,
impulsivity, agitation, communication, and their interac-
tion influence safe eating and swallowing? What interven-
tion methods For addressing these problems are optima!?
Are facilitations more immediately effective and expedi-
ent than compensations for the patient with brain injury
who has cognitive and behavioral problems hecause they
can be affected hy a caretaker rather than by the patient?
Positioning and ProximaL ControL
Positioning and proXimal control receive considerable at-
tention in treatment, as renecred in the literature re-
viewed. but their effectiveness has not been corroborated
scientifically. What specific mOtor components of swal-
lowing does upright position innuence? What is the rela-
tionship of using [he uppel- limb in feeding [0 efficient
oral and pharyngeal controP Studies that address these
questions might use videofluoroscopic (modified barium
swallow) tests of swallowing efficacy.
Sel/Feeding
Essentially no studies were identified that examined the
relationship between the level of skill in self-feeding and
efficiency or safety of the swallowing mechanism. Does
self-feeding enhance normal sequencing of the feeding
process, selection of food, introduction of food into the
mouth, length of the oral phase, and/or timing of the
swallow? Is self-feeding an efficient way to approach these
deficits? Videofluoroscopic studies could again easily help
to research this area.
OraL and Pharyngeal Sensory Disorden
Sensation is used to optimize movement through facilita-
tion techniques, but the importance of rehabilitation of
sensation per se, through oral sensitization or desensiti-
zation programs, is not well established. Certainly,
heightening or normalizing sensation allows sensolY in-
put to be used to facilitate movement. What are other
reasons to normalize sensation? What are the optimal
techniques to rehabilitate sensation' Arc there measur-
able sensory thresholds for swallowing? What are the
types and amounts of sensOlY input that trigger the
swallow?
Oral and PbaryngectL Movement Disorders
The success of indirect and direct techniques, the latter
including compensations and faCilitations, needs to be
verified in this specific population. Is it more efficient to
work on indirect techniques to improve subs kills of swal-
lowing or simply to proceed to direct therapy? Many tech-
niques, both indirect and direct, can improve the quality
of swallOWing. Are they equally applicable to the patient
with brain injury? Are there benefits to using compensa-
tions versus facilitations in this population? Which tech-
niques are dependent on prerequisite cognitive abiJity
and insight? Is it more efficient to spend time training a
patient with memory deficits to remember to perform a
compensatory maneuver during swallOWing or to have
the caretaker perform a facilitation technique?
Conclusion
An important overall consideration in the population with
brain injury is examination of the interactions between
idareh 1994. votume 48, Number 3
238
different subskill areas, and what effect treatment in one
area has on another. Several of the studies cited in this
review are based on single case studies that evaluate
treatment strategies and their effects on a specific sub-
skill. Traditional scientific method encourages research-
ers to isolate a single problem and its responses to a
single therapeutic technique or a simple combination of
techniques. Perhaps the research on treatment of dys-
phagia for patients with focal brain lesions is more plenti-
ful than that for patients with brain injury, in whom the
clinical picture is more complex, because such research is
easier to conduct. As mentioned, many of the treatments
that therapists use are based on known successful treat-
mentS in patients with focal brain injury. More informa-
tion on the overall effects of all deficit areas commonly
seen in patients with brain injury is needed, including
which of the major deficit areas are most prevalent in
different types of brain injuries; the changes in deficit
areas as a patient begins dysphagia intervention; the typi-
cal progress in different subskill areas and how that prog-
ress affectS functional outcome; the nature of spontane-
ous recovery in the subs kill areas; and how specific
treatment techniques influence the overall performance.
Once this information on typical picture, progress, and
outcome is obtained, then a clinical model for treatment
incorporating the relevant subs kill areas in treatment of
the dysphagic patient with brain injury can be estab-
lished.
References
Affolter, F. D. (1987). Perception, interaction, and lan-
guage. Berlin: Springer-Verlag.
Avery-Smith, W, Dellarosa, D. & Rosen, A. B. (1992). Clini-
cal assessment of dysphagia in adults. Occupational Therapy
Practice, 3(2), 51-SR.
Boggis, T (1985, September). Dysphagia management of
the adult comatose head trauma patient. Physical Disabilities
Special Interest Section Newsletter, 8(3), 1, 4.
Bryant, M. (1991). Biofeedhack in the treatment of a seleer-
ed dysphagic patient. Dvsphagia, 6. 140-144.
Cherney, L. R., & Halper, A. S. (1989), Recovery of oral
nutrition after head injury in adults.joumal o/Head Trauma
Rehabilitation, 4(4), 42-50.
Coster, S. T, & Schwarz, W H. (1987). Rheologv and the
swallow-safe bolus. D)lspbagia, 1, 113-118.
Dantas, R. 0., Kern, M. K, Massey, B. T, Dodds, w. L
Kahrilas, PJ., Brasseur,] G., Cook, I.], & Land.r M. (1990).
Effect of swallowed bolus variables on oral and pharyngeal
phases of swallOWing. American journal of Phvsiologl', 258,
675-681
Dodds, W.], Man, K M, Cook, I.j., Kahrilas, P.]., Stewart,
E. T, & Kern, M. K (1988). Influence of bolus volume on swal-
low-induced hyoid movement in normal subjects. American
journal 0/ Radiology, 150, 1307-1309.
Farber, S. D. (1982). Neurorehabilitation: A multisensolT
approach. Philadelphia: Saunders.
Groher, M. E (Ed.). (1992). Dysphagia. Diagnosis and
management (2nd ed.). Boston: Butterworth.
Groher, M. E. (1987). Bolus management and aspiration
pneumonia in patients with pseudobulbar dysphagia Dyspha-
The American Journal of Occupational Therapy
gia, 1, 215-216.
Harris, B., & jvlurry, T. (1984) Dysarthria and aphagia: A
case study of neuromuscular treatment. Archives of Phvsica{
Medicine and Rehabilitation, 65, 408-412.
Hulme,]. B., Shaver, J, AcheI', S., MuJlette, L., & Eggert, C
(1987). Effects of adaptive seating devices on the eating and
drinking of children with multiple handicaps. American Jour-
nal of Occupational Therapy, 41, 81-89.
Kaprisin, A. T., Clumeck, H. C, & Nino-Murcia, M. (1989).
The efficacy of rehabilitation management of dysphagia. Dys-
phagia, 4, 48-52
Lazarus, C, & Logemann,] A. (1987). Swallowing disorders
in closed head trauma patients. Archives of Physical NJedicine
and Rehabilitation, 68, 79-84
Lazzara, G de L., Lazarus, C, & Logemann, J. A. (1986).
Impact of thermal stimulation on the triggering of the swallow-
ing reflex. Dysphagia.. 1, 73-77.
Linden, P. (1989). Videofluoroscopy in the rehabilitation of
swallowing dysfunction. Dysphagia. 3, 189-191.
Logemann, J. A. (1986). Manual/or the videofluoroscopic
study of swallowing San Diego: College-Hill.
Logemann, J. A. (1989). Evaluation and treatment planning
for the head injured patient with oral intake disorders. journal
of Head Trauma Rehabilitation,4(4), 24-33.
Logemann, J A., & Kahrilas, P. J. (1990). Relearning to
swallow after stroke-Application of maneuvers and indirect
biofeedback: A case srudy. Neurology, 40, 1136-1138.
Logemann, J. A.. Kahrilas, P.J ,Kobara, M., & Vakil. N. B.
(1989) .. The benefit of head rotation on pharyngoesophageal
dysphagia. Arcbiues 0./ Pbysical iVledicine and Rehabilitation,
70, 767-771.
Mackay, L., & Morgan, A. S. (1992, April). Early swallOWing
disorders with severe head injuries: Relationships between tbe
RIA and the progreSSion ofomI intake. Departments of Reha-
bilitation Medicine and Surgery, St. Francis Hospital, Harrforu,
CT Abstract from the Fourth Mu]tidisciplinalY Symposium on
Dysphagia, The Johns Hopkins SwallOWing Center, Baltimore.
Neumann, S. (1993). SwallOWing therapy with neurologic
patients: Results of direct and indirect therapy methods in 66
patients suffering from neurological disorders. Dysphagia, 8.
150-153
Pommerenke, W T (1927). A study of the sensory areas
eliciting the swallowing reflex. Americanjournal of Physiologv,
81(1).36-41.
Rood, M. (1956). Neurophysiological mechanisms utilized
in the treatment of neuromuscular dysfunction. Americanjour-
nal of Occupational Therapv 10, 220-225.
Rosenthal, J. A, & Boggis, T (1983). Tbe taste o/success
Dysphagia intervention for the adult. Portland, OR: Portland
Center for Hearing and Speech.
Silverman, E. H., & Elfanr, 1. L. (1979). Dysphagia: An evalu-
ation and treatment program for the adult. American journal
of Occupational Therapy. 33, :382-392.
Stallons. K. M. (1987, June). The evaluation and treatment
of swallowing disorders. Physical Disabilities Special Interest
Section Newsletter, 10, 4-5
Tippett,D C, Palmer,]., & Linden, P (1987). Management
of dysphagia in a patient with closed he,ld injury. Dysphagia. 1,
221-226
Trombly, C A. (1989). Occupational tberapyfor physical
dysFunction Baltimore: Williams & Wilkins.
. . Yuen, H. K. (1992). Self-feeding and TBI. Advance/or Oc-
cupational Therapists, 8(37), 9.
Yuen, H. K, & Hartwick,] A. (1992). Case Report-Diet
manipulation to resume regular food consumption for an auult
with traumatic brain Injury. Americanjournal ofOccupational
Therapy, 46. 94.')-945
239