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Swallowing Disorders - Fact Sheet

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Brain injury effects

Swallowing Disorders - Fact Sheet

The seemingly effortless process of swallowing can be impaired following a serious brain injury. Despite the ease with which people complete this fundamental process, the act of swallowing involves complex and coordinated neural activity paired with the accurate execution of 31 muscle groups (Dodds, Stewart, & Logemann, 1990; Donner Bosma, & Robertson, 1985; Nelson &Castell, 1988).

 

Brain diorders such as Traumatic Brain Injury can damage this neural network or the associated muscles and lead to Dysphagia. Dysphagia is a disorder resulting from damage in any of the normal stages of swallowing (Morgan & Ward, 2001). Dysphagia invariably has some impact on an individual's nutrition and on their quality of life (Morgan & Ward, 2001).

 

The Five Stages of Swallowing

In order to understand the consequences of dysphagia following ABI, it is necessary to describe the normal swallowing process (Kennedy & Kent, 1988), which comprises five stages (Morgan & Ward, 2001).

 

1. The Pre-Oral Anticipatory Stage 

Commencing before food has entered the mouth, this initial stage involves: 

  • Emotional cues or individual memories relating to the meal,
  • Visual and sensory stimulation,
  • Oral sensations, such as temperature or texture, and
  • Directed attention.
    (Leopold & Kagel, 1983, 1997).


Impairments at this level can lead to dysphagia, due to poor attention or lack of judgement (Siebens, et al., 1986).

  

2. The Oral Preparatory Stage 

This stage is under voluntary control, and involves the manipulation of food and liquid in order to shape a cohesive ball, or bolus, which is suitable for swallowing (Morgan & Ward, 2001). Important to this phase are the actions of: 

  • Chewing
  • Combining of the food with saliva
  • Formation of a bolus that is of an appropriate size for transport into the pharynx and oesophagus (i.e. the tube that runs from the throat to the stomach, also known as the food pipe) (Derkay & Schechter, 1998).

 

Difficulties during this phase may result from limited range of motion of the jaw, poor lip seal, or impaired action of the saliva glands (Logemann, 1983, 1988).

  

3. The oral phase

Once again, this phase of the swallow is under voluntary control, and begins with the propulsion of the bolus by the tongue, to the back of the mouth (Morgan & Ward, 2001). The key structures involved include various muscles of the tongue, such as those that allow the bolus to sit centrally on the tongue, and those that control the front-to-back pumping action of the tongue (Arvedson, Rogers, & Brodsky, 1993; Derkay & Schecter, 1998; Logemann, 1988; Ramsey, Watson, Gramiak, & Weinberg, 1955).

 

Difficulties at this stage may be due to poor lip seal, as well as reduced movement of the tongue, cheeks and jaw. This can result in oral spillage or pooling of food residue in the sides of the mouth. Reduced oral sensitivity may be seen, with a patient showing decreased awareness of food residue on the face or mouth. Once the bolus has reached the back of the tongue, the swallow reflex is triggered (Morgan & Ward, 2001).

 

4. The pharyngeal phase 

The pharyngeal phase starts with the initiation of the swallow reflex, which sets off a sequence of different events. Taking approximately one second (Derkay & Shechter, 1998), yet involving 26 muscles and six cranial nerves, the pharyngeal phase consists of various involuntary actions (Wolf & Glass, 1992) that aim to: 

  • Close off the nasal passages to avoid food or fluid escaping through the nose (Kennedy & Kent, 1988).
  • Protect the airways by closing off the passage to the lungs
  • Transport the bolus to the entrance of the oesophagus (Kennedy & Kent, 1988).


If the swallow reflex is delayed or absent, or the nasal cavity is not adequately closed, a patient is said to have pharyngeal dysphagia. This may result in food escaping up through the nose, collecting in the pharynx, or entering the airways resulting in aspiration.

 

5. The oesophageal phase 

During this involuntary final phase, the bolus will travel the length of the oesophagus in approximately six to 10 seconds (Dodds, Hogan, Reid, Stewart, & Andorfer, 1973; Ingelfinger, 1958) by means of rhythmic contractions known as peristalsis (Morgan & Ward, 2001). The oesophageal phase of the swallow ends when the bolus has reached the opening of the stomach (Derkay & Schecter, 1998). Impairments at this level result in the bolus being pushed back up the tract from the oesophagus into the pharynx, which is commonly referred to as reflux (Arvedson, Rogers, & Brodsky, 1993).

 

Assessment of Dysphagia from ABI

As part of a multi-disciplinary team, the patient with ABI may be assessed by medical staff, dieticians, occupational and physiotherapists, dentists, social workers and speech pathologists (Logemann, 1994).

 

While still in acute care, a speech pathologist may use a variety of methods to assess the functioning of the swallow and determine any areas of impairment.

 

History of swallowing and feeding

It is important to assess swallowing in the context of a patient's medical, psychosocial and developmental history (Kramer & Eicher, 1993). Several areas of interest to the speech pathologist include the nature of the present or previous swallowing difficulties, eating habits and medications.

  

Bedside examination

Apart from general observations such as the patient's level of alertness or positioning, an oro-motor examination is commonly undertaken (Ward & Morgan, 2001). This will involve assessment of the functioning, structure and co-ordination of the swallow.

 

During this assessment, a patient may be asked to demonstrate tasks, such as poking out their tongue, moving it left and right as quickly as possible, blowing a kiss, or producing successive vowel sounds such as oo-ee-oo-ee. Such an assessment will provide a basis for determining possible damage to the nerves of the face, jaw, tongue and soft palate.

 

Feeding trials

Observing the consumption of food, fluids, or an entire meal provides information about a patient's swallowing competency and co-ordination, as well as allowing for the identification of extraneous factors, such as fatigue (Kramer & Eicher, 1993).

 

In order to evaluate whether a patient is able to receive food orally, a speech pathologist will trial various liquids (Ward & Morgan, 2001). This can range from thin fluids such as water, to those that have the consistency of a honey or nectar such as thickened fluids. Solids may also be trialled in various forms, including puree and minced foods such as a mousse or mashed fruit.

 

Instrumental assessments

Instrumental methods allow for closer observation of the pharyngeal phase, and to note the presence of aspiration (i.e. when unwanted materials enter the lungs) (Ward & Morgan, 2001). Preventing aspiration is important as it can lead to inflammation of the lungs or aspiration pneumonia (Martin, et al., 1994).

 

One commonly used instrumental assessment is the Modified Barium Swallow (MBS), in which radiographic images are taken of a person's swallow (Ward & Morgan, 2001). As a speech pathologist does not assess the oesophageal phase of the swallow, other specialised medical staff are often present during the MBS.

 

Rehabilitation

Swallowing rehabilitation aims to minimise the risk of aspiration and promote safe oral intake, by establishing optimal feeding patterns (Schurr, et al., 1999). An individualised rehabilitation program is devised that considers the patient's physiological, psychological, social and Cognitive strengths and weaknesses (Ward & Morgan, 2001).

 

During acute care, a speech pathologist will encourage compensatory strategies such as correct posture and positioning (e.g., sitting upright, tucking chin downwards), and food modification (Ward & Morgan, 2001). Food modification can include thickened fluids or sensory modifications that change the temperature or texture of the bolus in an attempt to trigger the swallow reflex and ensure safe transit of the bolus (Ward & Morgan, 2001). Rehabilitation strategies may include exercises that aim to improve the functioning of the swallowing mechanisms, as well as teaching strategic swallowing methods (Ward & Morgan, 2001).

 

In addition to these strategies, cognitive and behavioural deficits that Affect safe swallowing need to be considered, particularly in the ABI population (Ward & Morgan, 2001). The presence of attention, concentration or memory deficits may impact the process of rehabilitation, as may the ability to learn new information Ward & Morgan, 2001). Rehabilitation programs may include behavioural modification techniques such as modelling or cueing, as well as environmental changes that limit the amount of distractions during mealtime (Ward & Morgan, 2001).

 

Although dysphagia can occur at any one of the five phases of the swallow following a traumatic brain injury, through the combined efforts of the speech pathologist and the rehabilitation team, successful management is achievable.


 

References and further information

  • Arvedson, J., Rogers, B., and Brodsky, L. (1993). Anatomy, Embryology and Physiology. In J. 
  • Derkay, C. S., and Schechter, G. L. (1998). Anatomy and physiology of pediatric swallowing disorders. Otolaryngologic Clinics of North America, 31, 3, 397-404. 
  • Dodds, W. J., Hogan, W. J., Reid, D. P., Stewart, E. T., and Arndorfer, R. C. (1973). A comparison between primary esophageal peristalsis following wet and dry swallows. Journal of Applied Physiology, 35, 851-857. 
  • Dodds, W. J., Stewart, E.T., and Logemann, J.A. (1990). Physiology and radiology of the normal oral and pharyngeal phases of swallowing. American Journal of Radiology, 154, 953-963.
  • Donner, M. W., Bosma, J. F., and Robertson, D. L. (1985). Anatomy and physiology of the pharynx. Gastrointestinal Radiology, 10, 3, 196-212. 
  • Ingelfinger, F. J. (1958). Esophageal motility. Physiological Review, 38, 533-584.
  • Kennedy, J. G., and Kent, R. D. (1988). Physiologic substrates of normal deglutition. Dysphagia, 3, 24-27.
  • Kramer, S., & Eicher, P. (1993). The evaluation of paediatric feeding abnormalities. Dysphagia, 8, 215-224.
  • Leopold, N. A., and Kagel, M. A. (1983). Swallowing, ingestion, and dysphagia: a reappraisal. Archives of Physical Medicine and Rehabilitation, 64, 371-373.
  • Leopold, N., & Kagel, M. (1997). Dysphagia: Ingestion or deglutition? A proposed paradigm. Dysphagia, 12, 202-206.
  • Logemann, J.A. (1983). Anatomy and physiology of normal deglutition. In J.A. Logemanm (Ed.), Evaluation and Treatment of Swallowing Disorders (11-36). San Diego: College-Hill Press.
  • Logemann, J.A. (1988). Swallowing physiology and pathophysiology. Otolaryngological Clinics of North America, 21, 613-623.
  • Logemann, J. A. (1994). Non-imaging techniques for the study of swallowing. Acta Oto-Rhino-Laryngologica Belgica., 48, 2, 139-142.
  • Logemann, J. (1998). Evaluation and treatment of swallowing disorders. Texas: Pro-Ed.
  • Martin, B. J., Corlew, M. M., Wood, H., Olson, D., Golopol, L. A., Wingo, M., and Kirmani, N. (1994). The association of swallowing dysfunction and aspiration pneumonia. Dysphagia, 9, 1-6. 
  • Morgan, A., & Ward, E. (2001). Swallowing: Neuroanatomical and physiological framework. In B.E. Murdoch and D.G. Theodoros, Traumatic Brain Injury: Associated Speech, Language and Swallowing Disorders. (313-329). Australia: Singular Publishing.
  • Nelson, J. B., and Castell, D. O. (1988). Esophageal motility disorders. Disease a month, 34, 6, 297-389.
  • Ramsey, G. H., Watson, J. S., Gramiak, R., and Weinberg, S. A. (1955). Cinefluorographic analysis of the mechanism of swallowing. Radiology, 64, 498-518.
  • Schurr, M. J., Ebner, K. A., Maser, A. L., Sperling, K. B., Helgeson, R. B., and Harms, B. (1999). Formal swallowing evaluation and therapy after traumatic brain injury improves dysphagia outcomes. The Journal of Trauma: Injury, Infection and Critical Care, 46, 5, 817-821.
  • Siebens, H., Trupe, E., Siebens, A., Cook, F., Anshen, S., Hanauer, R., and Oster, F. (1986). Correlates and Consequences of Eating Dependency in Institutionalized Elderly. Journal of the American Geriatric Society (JAGS), 34, 192-198.
  • Ward, E., & Morgan, A. (2001). Dysphagia following traumatic brain injury in adults and children: Assessment and characteristics. In B.E. Murdoch and D.G. Theodoros, Traumatic Brain Injury: Associated Speech, Language and Swallowing Disorders. (331-368). Australia: Singular Publishing.
  • Ward, E., & Morgan, A. (2001). Rehabilitation of dysphagia following traumatic brain injury. In B.E. Murdoch and D.G. Theodoros, Traumatic Brain Injury: Associated Speech, Language and Swallowing Disorders. (369-401). Australia: Singular Publishing.
  • Wolf, L. S., and Glass, R. P. (1992). Feeding and swallowing disorders in infancy: Assessment and management. Therapy Skill Builders; Tucson, Arizona.

 

 

This Fact Sheet was kindly contributed by Samantha Braden, 3rd Year Bachelor of Speech Pathology, University of Queensland - 2007

 

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