Bulow M, Olsson R, Ekberg O. Supraglottic swallow, effortful swallow, and chin tuck did not alter hypopharyngeal intrabolus pressure in patients with pharyngeal dysfunction. conversation about goals of care. Brain Impair. Bisch EM, Logemann JA, Rademaker AW, Kahrilas PJ, Lazarus CL. 1993;104:136–9. 2nd ed. Arch Phys Med Rehabil. Dysphagia. This article is a recent literature review of exercise-based therapy for swallowing disorders, including a particular focus on transcutaneous electrical stimulation. Fourth, it has been suggested that post-stroke oromotor features of dysphagia differ from those following TBI [23••, 32]. Arch Otolaryngol Head Neck Surg. 2008;63:499–508. The Modified Evans Blue Dye Test uses blue dyed food and fluid instead [70, 72]. Brady SL, Hildner CD, Hutchins BF. a VFSS (videofluoroscopic swallow study)? Higher level cognitive impairments involving organizational and sequencing skills may cause difficulty for patients undertaking appropriate strategies [8, 9, 40]. Sometimes, if they see the patient is really miserable, painful swallowing, lots of coughing, finding the Memory issues may result in patients forgetting about safe food consistencies [8, 9, 40], or when/how much they last ate , increasing aspiration risk and over/under-eating, respectively. For example, Winstein  reported that 94 % of dysphagic patients progressed to full oral feeding within 5 months post-injury. Dysphagia. J Speech Hear Res. Normalization of temporal aspects of swallowing physiology after the McNeill Dysphagia Therapy Program. goals are very important. The truth is, I don’t […] Controlling stimuli and the meal-time environment is also important for patients with agitation and combativeness. Studies of ‘neurogenic dysphagia’ typically include heterogeneous subject groups, including subjects with cerebrovascular accident (CVA), progressive neurological diseases, brain tumors as well as TBI [19, 20]. 2005;20:283–9. Am J Speech Lang Pathol. 2010;136(8):784–9. However, CVA and TBI populations are quite different. A thorough premorbid and current medical history including the nature and severity of the TBI are obtained from the medical file. Part of Springer Nature. 2001;20:124–30. However, to be effective the patient must have sufficient behavioral control and cognitive-communication skills to attend to, comprehend and recall and sequence commands consistently [8, 9, 40]. 2007;21(13–14):1411–7. [6, 8, 9, 33, 41, 42] For example, lower admission scores on the Ranchos Los Amigos (RLA) scale are a risk factor for dysphagia [41, 42] and that as cognitive function improves, so do functional oral feeding skills, [6, 29, 41, 42] such that RLA scores represent the most significant independent predictor of the time to return to full oral feeding . Trauma patients may experience injury-related physical damage to their head and neck. the process), I let the doctor know, document the informed decision the family is Supervised meals with a caregiver who cues to the patient to other issues such as speaking with the mouth full, may be required [8, 9]. In a recent live chat, ASHA online dysphagia conference presenters Brenda Arend and Kate Krival talked about dysphagia in palliative care. If there are strategies to help, use them. Do you have any approaches or suggestions for educating Current Dysphagia Therapy Techniques 1. N Engl J Med. Brain Inj. Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence. [8, 9, 33, 40]. When Dr. James Coyle, PhD, CCC-SLP, BCS-S discussed this issue at the Dysphagia Research Society’s annual meeting in 2017 (session with Dr. Martin Brodsky titled: Evaluation and Treatment of Dysphagia in the ICU – see Evidence-based systematic review: oropharyngeal dysphagia behavioral treatments. of the doctors, and will just straight-up tell them I think the patient has hit a Determining whether a patient would benefit from large or small bolus volumes illustrates the importance of accurately identifying the nature of their swallowing disorder. but is choosing to accept these risks for comfort and QO), especially in the context Further research into the effect of long-term training is indicated . 2002;17:139–46. Electrical stimulation and dysphagia: what we do and don’t know. Similar oromotor presentations have been found in pediatric TBI patients [10, 44, 45]. I will often ask the occupational therapist or physical therapist or social worker Robbins J, Kays GA, Gangnon RE, et al. education. Second, population demographics are different, with CVA more common in older patients with degenerative co-morbidities. J Head Trauma Rehabil. Patterns and predictors of swallowing resolution following adult traumatic brain injury. Studies suggested that even in the absence of neurological conditions, patients with tracheostomies risked dysphagia . Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. Dysphagia. Long-term tracheostomies can cause physical injuries such as tracheostenosis, tracheomalacia, and/or granuloma [49–52]. Outcomes and costs of acute treatment of traumatic brain injury.  found that isometric tongue exercises improved tongue strength and swallowing function in patients post-CVA. This can also be a useful strategy for patients with limited attention spans . Electrical neuromuscular stimulation in dysphagia: current status. The role of fiberoptic endoscopy in dysphagia rehabilitation. making, and continue with trying to work on any compensatory strategies that may help, Terre R, Mearin F. Effectiveness of chin-down posture to prevent tracheal aspiration in dysphagia secondary to acquired brain injury. Available in English and Español. 2004;19:192–206. Hospital in Olympia, Washington. Schooling T. Systematic review of oral-motor exercise. Hiss SG, Postma GN. Post-TBI dysphagia is caused and influenced by a number of factors. Dysphagia is causally linked with an increased risk of aspiration pneumonia; [13–16] the incidence of which can be as high as 12 % following severe TBI . 1987;68:79–84. 13, Swallowing and Swallowing Disorders (Dysphagia); and 15, Gerontology. Dysphagia following TBI can be multifactorial, but mainly occurs because of neurological impairment to any or all of the three phases of swallowing (the oral preparatory, the oral and pharyngeal phases) and cognitive-communication and behavioral dysfunction [5–9]. Dysphagia. Betts RH. such as small sips, intake when alert, etc. Terre and Mearin  undertook a longitudinal cohort study of swallowing recovery. Morgan A, Ward E, Murdoch B, Gilmore G, Bilbie K. A study of the resolution of paediatric dysphagia following traumatic brain injury: practical implications for clinicians. All of these potential differences suggest that TBI-specific assessment and management of dysphagia should be recognized, along with the influence of these factors on the clinical management of such patients. 2012;17(5):13, 15. palliation versus rehabilitation, particularly with the interdisciplinary team. J Head Trauma Rehabil. J Speech Lang Hear Res. Chest. Head Neck. Arch Phys Med Rehabil. Robbins J, Butler SG, Daniels SK, Gross RD, Langmore S, et al. Clark H, Lazarus C, Arvedson J, Schooling T, Frymark T. Evidence-based systematic review: effects of neuromuscular electrical stimulation on swallowing and neural activation. However, strategies to target weakness from decreased excitatory input to motor neurons are not well understood  or researched. 2012;24:414–e206. Arch Phys Med Rehabil. Dysphagia following TBI is complex and multiple factors influence how it manifests and is assessed and managed. Carnaby-Mann GD, Crary MA. patient, and he’s so happy eating and drinking, and has fairly low risk parameters Videofluoroscopic swallow studies (VFSS) assesses the speed and coordination of movements during chewing and swallowing in the oral cavity, tongue base, pharynx, hyoid, larynx, and cricopharyngeal region . in a chart note. base we all agreed was pertinent, so that when any of us wrote something about the Behavioural management for oropharyngeal dysphagia. Logemann JA. Ann Otol Rhinol Laryngol. I’d consider a FEES [fiberoptic Swallowing disorders in closed head trauma patients. Dysphagia & stroke 50% of stroke patients have dysphagia in the first few days after the stroke. challenged by the idea of laying out options for our patients. Behavioral dysphagia management techniques targeting swallowing physiology are often divided into ‘compensatory’ and ‘rehabilitation’/direct therapy strategies [65, 75]. The multifactorial nature of dysphagia following TBI, and its far-reaching effects on quality of life, necessitates multidisciplinary management involving the patient, family or caregivers wherever possible. 2009;46(2):195–204. The supraglottic and super-supraglottic swallows are recommended in patients with reduced airway closure and/or a delayed pharyngeal swallow . O’Neil-Pirozzi TM, Lisiecki DJ, Momose KJ, Connors JJ, Milliner MP. sEMG is an adjunctive therapy tool that can increase motor learning via biofeedback during dysphagia treatment tasks [103, 104]. “If the patient was speaking for themselves 20 years ago, what would they have to J Head Trauma Rehabil. In patients where oral feeding is contraindicated due to low responsiveness, sensory stimulation (tactile, olfactory, gustatory, auditory and visual) to has been suggested to improve patient responsivity [8, 9]. Ward EC, Green K, Morton A-L. Stauffer J, Olson D, Pelta T. Complications and consequences for endotracheal intubation and tracheostomy: a prospective study of 150 critically ill adult patients. Duffy JR. Motor speech disorders: substrates, differential diagnosis, and management. I think that the main points are to be very clear that they have choices, and Dysphagia with head injury. Instead, the severe illness necessitating the tracheostomy, whether neurological or not, and/or high dose medications  such as sedatives and neuromuscular blocking agents cause dysphagia, not the tracheostomy itself [37, 38, 58]. 1998;13:208–12. Pharyngeal effects of bolus volume, viscosity and temperature in patients with dysphagia resulting from neurologic impairment and in normal subjects. If the dysphagia manifests in pharyngeal and/or laryngeal deficits, further instrumental assessments may be undertaken [62, 63]. As patients are not irradiated, assessments and implementation of management strategies need not be curtailed; allowing clinicians to assess for pre-swallow pooled pharyngeal secretions [67, 68]. Dysphagia. I absolutely would document the condition of the patient, and that you brought Dysphagia. Treatment is patient-specific, with successful dysphagia ther apies implemented in one patient population not necessarily producing the same results in another population . (cough) are problematic for them, then it is okay to ask if they’ve now changed their Patients’ behavioral and cognitive-communication skills are informally assessed at the bedside . Semin Neurol. If the address matches an existing account you will receive an email with instructions to reset your password. Hansen TS, Engberg AW, Larsen K. Functional oral intake and time to reach unrestricted dieting for patients with traumatic brain injury. the cases in which we as the SLP might be the ones recommending a transition toward Steele CM, Van Lieshout PHM. 2010;25:35–9. Dysphagia & … Increased frequency of obstructive airway abnormalities with long-term tracheostomy. Effortful swallowing training combined with electrical stimulation in post-stroke dysphagia: a randomised controlled study. Swallowing dysfunction in patients receiving prolonged mechanical ventilation. 1983;63(12):1992–7. Identifying exactly why (at a neurological level) oropharyngeal movements are impaired can be difficult. O’Suilleabhain P, Dewey RB. Morgan AS, Mackay LE. Am Surg.  found that duration to the first swallowing assessment (DFSA) was a predictor for achieving normal oral feeding. Such dysphagia in trauma patients with prolonged ETT intubation is often multifactorial , resulting from prolonged contact of the ETT with chemo- and/or mechanoreceptors in the pharyngeal and laryngeal mucosae, critical for triggering the swallowing reflex .Physical injury including vocal fold ulceration and laryngeal edema  and impaired laryngeal elevation and/or closure may impede swallowing function . Thus, even when a patient with TBI is decannulated, they are highly likely to remain dysphagic and at risk of aspiration. The Speech Pathology Association of Australia Limited; 2004. p. 9–11. Establishing a dysphagia family intervention program for head-injured patients. If they are looking in distress, stop the meal and try again later. endoscopic evaluation of swallowing] to see. Swallowing disorders in persons with cerebrovascular accident. taking ice chips was not the treatment goal but was viewed as a means of transitioning from an NPO status to oral intake of liquids and food. J Head Trauma Rehabil. Giving small amounts of food or one utensil at a time [8, 9] at a time, cueing to reduce the amount and rate of food intake and to put utensils and cups down between mouthfuls are strategies that may reduce impulsive grabbing and ‘shoveling’ of food. Dysphagia. Sometimes I just ask them myself and will let the doctor know. 2009;21:361–9. Functional and physiological outcomes from an exercise-based dysphagia therapy: a pilot investigation of the McNeill Dysphagia Therapy Program. The benefits of using FEES are multiple, including its simplicity of use at the bedside [67, 68] and in ventilated patients . I have to have a conversation with the doc. Do it away from the immediate pressure of the patient in the room. Dysphagia. In patients with normal or near normal swallowing physiology, these cognitive-communication and behavioral issues actually cause or worsen the dysphagia . some good, collaborative, interdisciplinary education on palliative care, and some 2012;29(4):247–57. Mackay LE, Morgan AS, Bernstein BA. Crary MA, Carnaby GD, Groher ME, Helseth E. Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Barquist E, Brown M, Cohn S, Lundy D, Jackowski J. Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomised, prospective trial. [email protected], Kate Krival, PhD, CCC-SLP, is an associate professor at Edinboro University of Pennsylvania. For example, injuries to the jaw may interfere with chewing;  injury to the neck may impair laryngeal closure and cricopharyngeal opening . However, the principles of neural plasticity to swallowing rehabilitation may blur the line between this traditional divide. regarding wishes, and they state they don’t know or can’t make a decision, are there Oral food trials may reveal whether they can accept being fed without becoming agitated . on tube feedings in dementia. Arch Phys Med Rehabil. It’s not really something that I feel I can accomplish At Cleveland Clinic, we’ve assembled an entire team of all the specialists you need – including gastroenterologists, radiologists, pathologists, thoracic surgeons and swallowing therapists – to offer leading-edge but is requesting them and showing sign/symptoms (i.e., low oxygen, cough)? However, reliability and validity of testing is variable, necessitating the use of stronger assessment methods such as VFSS or FEES wherever possible [70, 73]. Google Scholar. Asia Pac J Speech Lang Hear. Crit Care Med. 2011;12(3):179–86. These can include videofluoroscopic swallow study (VFSS) (modified barium swallow), fiber-optic endoscopic evaluation of swallowing (FEES), fiber-optic endoscopic evaluation of swallowing with sensory testing (FEESST), cervical auscultation, pharyngeal manometry, pulse oximetry and electromyography . Bulow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in healthy volunteers. Dysphagia. As such, the management for dysphagia post-TBI must be multifactorial, team-based and involve the patients’ families and carers. Wheeler-Hegland KM, Rosenbek JC, Sapienza CM. Also, explaining the goals are about quality of life, not Dysphagia. too. the same attention to careful diagnosis and treatment possibilities as our rehab patients. Cherney LR, Halper AS. Techniques to maximize signal detection and avoid misinterpretation of signals are also important . Of these, 1/3 have swallowing difficulties that persist beyond 3 months post-onset. Enter your email address below and we will send you the reset instructions. Traumatic brain injury (TBI) and its complications contribute significantly to mortality and morbidity worldwide. Heterogeneous subject groups, small subject numbers, lack of specificity of transcutaneous NMES at a tissue level  and differences in electrode placement and stimulation parameters are just a few of the reasons why better designed studies are required [94•] before the efficacy of this treatment option will be known. Short-term memory and receptive language deficits may inhibit understanding, learning, recall and ability to generalize dysphagia management strategies [8, 9, 33, 40].