The Magic Mirror: And a potential code to swallowing success

SLPs have the hardest jobs in the entire rehab department. Why? Because we are flying blind at the bedside. Physical therapists can see the patient’s gait. Occupational therapists can see their fine motor grasp. But SLPs? We are asking patients to manipulate muscles they can’t feel… inside a space they can’t see. 

This is all while we cross our fingers and offer nothing but obscure cues, simply hoping that they’re doing it right:

“Swallow harder.”

“Swallow faster.”

“Swallow… better?”

But what does any of this even mean? 

It’s like we’re navigating a dark cave, feeling our way through the twists and turns and listening for sounds that might help us make sense of what’s going on around us. Listening and feeling can be great approaches to navigating the dark abyss, but truly, there’s nothing like a bit of light.

So, how can we turn the lights on?

Biofeedback

According to the mountain of research I’ve just dived into, biofeedback might just be the magic mirror that helps us get out of that dark, damp cave. It could be one of the most effective ways to prime the pump of motor learning, wake up the swallow that fell asleep years ago, and get people prematurely written off with the scarlet letters of NPO status to eat and drink their favorites again.  

What are we doing wrong?

Strengthening requires feedback on what you’re doing in order to adjust and push harder and faster on the next go. We overcome resistance to build muscle and build muscle to overcome resistance. Take weightlifting, for example. If we’re working with a personal trainer, they’ll tell us how much weight to lift, how to stand, and what posture to maintain, and will help determine how much we can and should lift based on how fatigued we look throughout the exercise. 

But swallowing is different. SLPs can’t show their patients how to exercise without a biofeedback device. Without that device, they are relying on "intrinsic" feedback (what they feel), but in neurogenic dysphagia, their sensation is often impaired.

Biofeedback is the "extrinsic" remedy. It uses technology to capture physiological signals (such as muscle electrical activity or breath flow) and convert them into something the patient can see or hear immediately. It creates a bridge between what’s felt and what’s actually done. 

4 Biofeedback Tools:

Here are 4 gadgets we can use to light up the cave and help our patients navigate their way out:

1. sEMG (Surface Electromyography): This is the heavy hitter in the research. You place electrodes under the chin (the submental muscles) to measure electrical activity during swallowing. It turns a swallow into a waveform on a screen.

2. Accelerometry: Think of this as a tiny seismograph for the throat, but instead of measuring the earth’s movements, it measures the vibrations and movement of the hyolaryngeal complex.

3. Tongue Manometry: Here, the patient can press their tongue against a sensor to obtain an instantaneous reading of lingual pressure.

4. Respiratory Sensors: A nasal cannula that visualizes the breath-swallow pattern (so patients can learn that elusive exhale-swallow-exhale pattern).

Why It Works: The "Video Game" Effect

You know how addictive Block Blast is? That’s because of the dopamine hit you get when you see visual progress. Biofeedback does the same thing for the brain. One study used a game where a rabbit climbed a hill to eat a carrot based on the patient's muscle effort. This engages the striatal dopamine release—basically, the brain's reward center—which helps cement new motor pathways. Have you heard of motivation via the carrot or the stick? This is, quite literally, a carrot.

Trick for a Treat

These small accomplishments build up into a rigorous exercise routine with increased resistance over time. Gamifying the task tricks the brain into doing hard work disguised as something fun. It’s a trick for the treat of progress. And maybe an actual treat of eating something they haven’t been able to tolerate before. 

Two Key Terms: 

• Knowledge of Results (KR): This tells the patient, "Yes, you did it." It is motivating and energizing. Think about it as getting to the next level in your favorite game. 

• Knowledge of Performance (KP): This tells the patient how they did it. "See that line? You didn't squeeze long enough." It helps shape the movement and create a more effective, successful swallow.

Here is a story from Bice & Galek (2016) that will give you chills:

An SLP team worked with a 90-year-old woman with severe dementia (GDS Level 6). She was holding food in her mouth, and traditional verbal cueing was doing absolutely nothing.

The therapists hooked her up to sEMG biofeedback. They set up a simple bar graph on a screen. When she swallowed, a big blue bar shot up, and a bell dinged. They told her, "When the bar goes up and you hear the bell, you’re the winner!"

The Result: The visual cue bypassed her cognitive deficits. The bell and bar grabbed her attention. After just five sessions, she went from oral holding to independently consuming a regular diet. All because the task was gamified.

Bigger Isn’t Always Better

We often obsess over making the muscles bigger and stronger, but sometimes we need them to be smarter. This is called skill training.

Instead of just "squeezing hard," Athukoralaet et al. created a task in which patients using sEMG had to swallow so that their muscle waveform hit a specific "green box" on a screen. If they hit it, the box got smaller, and the task progressively got harder. If they missed, it got easier.

This forces the brain to plan and execute with precision, not just brute force. In patients with Parkinson’s Disease, this skill training improved swallowing speed, timing, and quality of life. 

It’s Never Too Late

One of the most encouraging findings I found was for patients with chronic dysphagia—those patients who are months or even years post-stroke and still on PEG tubes. We often think the opportunity for significant recovery is over for them, right?

But studies show that intensive rehab with biofeedback can help patients return to oral diets even years after their injury. One study found a group of patients with chronic dysphagia status post brainstem stroke. Nothing worked for these patients. All attempts at therapy failed. But after an intensive biofeedback program, 8 of 10 returned to full oral intake. Think of how many NPO patients are in your facility. Can you imagine the excitement of getting any of them eating again, let alone 8 out of every 10?

Conclusion

Is biofeedback a magic wand? Not exactly. You still need good clinical judgment, knowledge of evidence-based practices, and skilled, well-targeted treatment plans. Biofeedback may just be the missing piece to better outcomes for your patients and your practice.

But to use it, you first must have access. With that, I’ll leave you with 3 key findings we can use to encourage our administrators without receiving the pushback we typically see. 

Biofeedback has been shown to…

1. Increase hyoid displacement (a key component of airway protection).

2. Improve functional oral intake (FOIS) scores (getting people eating the things they love again).

3. Reduce the time patients spend on feeding tubes (which saves money!).

Whether you are helping a patient execute a perfect Mendelsohn maneuver or helping a patient with dementia "ring the bell," giving your patients a way to see their success might just be the breakthrough they need. 

Complimentary CEU Opportunity! Join Accelerated Care Plus (ACP) on Wednesday, March 18, 2026, from 6:00–8:00 pm ET to learn about Surface EMG Biofeedback in Dysphagia Rehabilitation (0.15 ASHA CEUs). This webinar explores how sEMG is used in dysphagia practice, highlighting the evidence behind its role in assessment and rehabilitation. The course will cover sEMG research, clinical applications, lab demonstrations and will conclude with a 30-minute live expert panel/Q&A. Register here! 

Thank you to Accelerated Care Plus for your partnership. 

References

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