*4.1.2 Rehabilitation treatment*

Rehabilitation treatment should be carried out whenever possible so that the patient can maintain an adequate oral intake to a greater or lesser extent. Postural maneuvers should be recommended to protect the airway during swallowing [12]. There is no strong evidence in the literature for dysphagia intervention in patients with ALS. Thus, rehabilitation treatment should be individualized. Aspects that influence the selection of the most suitable technique for each patient should be evaluated, such as the patient's cognitive status, behavioral and emotional aspects, degree of fatigue and family support. Based on these criteria, the most rehabilitative technique will be selected for each patient. Some rehabilitation techniques are postural strategies, sensory enhancement strategies (such as mechanical tongue stimulation, bolus changes in volume, temperature, and flavor, thermal stimulation, and changes in taste or acid flavor), neuromuscular practice, compensatory swallowing maneuvers and facilitation techniques.

Some compensatory swallowing maneuvers have been studied in patients with ALS. The chin-tuck posture was found to be useful in most cases, given that it offers a valuable protection mechanism for the airways by opening the valleculae and preventing penetration into the larynx [43]. The indication of the other maneuvers differs according to the mechanism involved in relation to disease characteristics and progression. Thus, hyperextended head posture is indicated in the absence of tongue pumping. If there is hypertonicity, incomplete release, or premature closure of the UES, head rotation is indicated [43]. However, current clinical guidelines do not suggest specific postural maneuvers [12].

Also, saliva could interfere with the management of dysphagia. However, the current evidence to recommend pharmacological treatments such as antimuscarinics in affected patients is low. There is no evidence linking the treatment of saliva issues with the improvement of dysphagia [12].
