Difficulty swallowing increases patients’ risk for a host of comorbidities and premature death.
Dysphagia is defined by difficulty or discomfort swallowing due to any number of medical conditions, including stroke. After a stroke, the muscles in the head and neck can have decreased strength, range of motion, coordination and/or speed, which can result in dysphagia. The severity of dysphagia ranges from minimal issues to profound impairments, and can at times require the temporary or permanent placement of a feeding tube.
Dysphagia increases risk for aspiration pneumonia, malnutrition, dehydration, depression and premature death.
Complications of dysphagia impair recovery and lead to prolonged hospitalizations, re-hospitalizations, tracheotomies, tube feedings, respiratory support, related nutritional supplements and equipment, resulting in increased healthcare costs.
Aspiration pneumonia is the most common cause of death in individuals with untreated dysphagia, following stroke, accounting for at least 10 percent of deaths occurring within 30 days of the initial hospital admission.
Many stroke survivors have difficulty swallowing different foods and liquids. It is very common immediately after a stroke but some can experience this for longer periods of time.
Stages of Swallowing
The swallowing process is divided into three stages: oral, pharyngeal and peristalsis-mediated esophageal. Dysphagia in stroke patients results from impairments of these oral and pharyngeal stages of swallowing.
During the oral and pharyngeal stages of swallowing, the contraction and inhibition of approximately 50 pairs of muscles are coordinated in the propulsion of a food bolus, solid or liquid, to the esophagus while protecting the airway to the larynx.
Ascending sensory input from the oropharynx and descending motor input from cortical/subcortical brain swallowing centers are integrated in the lower brainstem in a network of neurons known as the central pattern generator (CPG).
The signs and symptoms of swallowing difficulty can vary, and include: coughing and/or choking during or immediately following meals ; runny nose; wet or gurgling voice during or immediately following meals; food spilling from the mouth; watery eyes; throat clearing; liquid or food coming out of the nose; and pocketing food in the cheeks or other mouth areas.
Assessment
To develop an individualized plan of care, a thorough assessment must first be completed, which should consist of non-imaging procedures and imaging studies to identify swallowing disorders. While there are advancements being made in the area of dysphagia assessment, the gold standard continues to be the completion of a Modified Barium Swallow (MBS) Assessment. This is completed to assess, diagnose and visualize all stages of the swallow. It provides clinicians with the ability to develop an individualized treatment plan to assist the patient in their rehabilitation goals.
The MBS study is a dynamic radiographic assessment. Images of the oral, pharyngeal and cervical-esophageal bolus flow are examined during swallowing, and the clinician identifies anatomic and physiologic abnormalities relative to swallowing. Swallowing safety and efficiency are determined by assessing the effects of modifying the size and/or texture of bolus and patient positioning by using compensatory maneuvers and sensory enhancement techniques on bolus flow.
The implementation of the MBS study requires advanced and specific skills in order to make decisions regarding management options during the examination, assess swallowing physiology, make specific functional diagnoses, recommend a safe diet and develop an appropriate treatment plan.
In order to analyze an MBS study, the speech-language pathologist must have a basic understanding of the following:
- normal/abnormal anatomy and physiology related to the swallowing function;
- signs and symptoms of dysphagia;
- procedures involved with the instrumental techniques used to assist in diagnosis and management;
- appropriate documentation;
- qualifications to determine candidacy for intervention;
- process to educate individuals with dysphagia as well as their families/caregivers;
- quality of life issues;
- identification and utilization of appropriate functional outcome measures;
- medical issues related to dysphagia; and
- advantages and limitations of the study.
Speech-language pathologists are ethically responsible for obtaining the appropriate level of training to administer dysphagia assessments, implement treatment plans and provide related services competently.
The MBS study is a clinically useful tool, however, it is a subjective assessment in the sense that universal standards for swallow evaluation terminology, measurement and reporting methods do not exist. In order to standardize the assessment of swallowing impairment, the MBS measurement model is to be constructed and validated. The components of functional swallowing impairment and domains are to be organized into an assessment tool. The intra-rater and inter-rater reliability of the scored components made by the trained clinician are to be established.
Consequently, to increase standardization of the MBS study, the Modified Barium Swallow Impairment Profile (MBSImP) has been developed and tested. The MBSImP is an evidence-based protocol that can be reliably scored, in which reliability is dependent on training. It is the first known study which exhibits the unique contribution of varied volumes and textures to the overall impressions of swallowing impairment. The protocol aims to minimize variation in scoring and interpretation by standardizing the method of training, administration protocol, assessment tool, vernacular, analysis and reporting methods.
Treatment
The treatment approach is typically determined by the etiology of dysphagia, and may include medication, surgery or dysphagia therapy. Speech-language pathologists work aggressively with patients using facilitation and compensatory techniques to address the issue presented.
The techniques that can be used to treat dysphagia are based on the evaluation and clinical presentation of the patient. Speech-language pathologists utilize technology to assist in treatment, as appropriate, paired with traditional techniques. However, not every piece of technology is appropriate for every patient.
After the treatment plan is developed, the speech-language pathologist can develop tips to help alleviate symptoms as well as a diet plan that is safe for the patient during treatment. Recovery time varies based on the severity of the symptoms, and the speech-language pathologist can give an approximate timeline post-evaluation.
Further research is necessary in the area of dysphagia rehabilitation focusing on both the standardization of the swallowing evaluations and the treatment methodologies.
