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
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
- Emotional cues or individual memories relating to the
- 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:
- 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,
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
- 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
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
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.
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.
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,
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
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.
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,
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,
- Logemann, J. A. (1994). Non-imaging techniques for the study of
swallowing. Acta Oto-Rhino-Laryngologica Belgica., 48, 2,
- 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,
- 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
- 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 -