Dysphagia: Difference between revisions

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== Therapeutic techniques for dysphagia management ==
== Therapeutic techniques for dysphagia management ==
Therapeutic techniques can be divided into those used as :
Therapeutic techniques can be divided into those used as :
* Compensatory strategies ('''Head Rotation''' (Head Turn), '''Chin Tuck''' (Head Flexion). '''Head Til'''t and '''Bolus Viscosity, Texture, and Volume Modifications)'''
* Compensatory strategies ('''Head Rotation''' (Head Turn), '''Chin Tuck''' (Head Flexion). '''Head Tilt''' and '''Bolus Viscosity, Texture, and Volume Modifications)'''
* Exercises ('''Tongue Hold''', '''Shaker Exercise''')   
* Exercises ('''Tongue Hold''', '''Shaker Exercise''')   
* Those used as both compensatory strategies and/or exercises ('''Supraglottic Swallow''', '''Super-Supraglottic Swallow''', '''Effortful Swallow''', '''Mendelsohn Maneuver''')  
* Those used as both compensatory strategies and/or exercises ('''Supraglottic Swallow''', '''Super-Supraglottic Swallow''', '''Effortful Swallow''', '''Mendelsohn Maneuver''')  
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The chin tuck (head flexion) has been a technique used for patients who have decreased airway protection associated with delayed swallow initiation and/or reduced tongue base retraction.<ref name=":4" />  
The chin tuck (head flexion) has been a technique used for patients who have decreased airway protection associated with delayed swallow initiation and/or reduced tongue base retraction.<ref name=":4" />  
* Instruction: '''‘‘bring your chin to their chest and maintain this posture throughout the duration of the swallow".'''
* Instruction: '''‘‘bring your chin to their chest and maintain this posture throughout the duration of the swallow".'''
=== Head tilt ===
The head tilt is used for patients with unilateral oral weakness. <ref name=":4" />
* Instruction: '''‘‘tilt your head like you’re trying to touch your ear to your shoulder.’’'''
=== Bolus Viscosity, Texture, and Volume Modifications ===
* Increasing the volume and/or viscosity for liquids is another technique used to reduce dysphagia symptoms for some patients. Thickening liquids may be used for patients who have poor oral control of thin liquids and/or demonstrate reduced airway protection.
* Increasing bolus volume increases bolus transit time as exemplified by sustained laryngeal elevation and hyoid excursion.
* Some patients may benefit from texture-modified foods.<ref name=":4" />


== References ==
== References ==
<references />
<references />

Revision as of 11:39, 19 April 2020

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Original Editor - Redisha jakibanjar Top Contributors - Redisha Jakibanjar, Kim Jackson and Uchechukwu Chukwuemeka

Introduction[edit | edit source]

Dysphagia is a difficulty in swallowing liquid or solid food due to disruption in swallowing mechanism from mouth to pharynx.[1] Dysphagia leads to severe complications: [1][2]

  • Aspiration pneumonia
  • Dehydration
  • Malnutrition
  • Dehydration

Physiology of swallowing[edit | edit source]

Having a thorough knowledge of anatomy and physiology of swallowing and eating is essential while evaluating and treating disorders of eating and swallowing,[3]There are four stages while describing the physiology of swallowing :

  1. Oral preparatory stage
  2. Oral propulsive stage
  3. Pharyngeal stage : Main feature of this stage are: food passage, propelling the food bolus through the pharynx and UES to the esophagus; and airway protection, insulating the larynx and trachea from the pharynx during food passage to prevent the food from entering the airway.
  4. Esophageal stage

Eating, swallowing and breathing are tightly coordinated during the normal process. Swallowing is dominant to respiration in normal individuals.Breathing ceases briefly during swallowing due to physical closure of the airway by elevation of the soft palate and tilting of the epiglottis and also of neural suppression of respiration in the brainstem. [3]

When drinking a liquid bolus, swallowing usually starts during the expiratory phase of breathing. The respiratory pause continues for 0.5 to 1.5 s during swallowing, and respiration usually resumes with expiration. This resumption is regarded as one of the mechanisms that prevents inhalation of food remaining in the pharynx after swallowing. When performing sequential swallows while drinking from a cup, respiration can resume with inspiration. [3]

Eating solid food also alters the respiratory rhythm. The rhythm is perturbed with onset of mastication. Respiratory cycle duration decreases during mastication, but with swallowing. The “exhale – swallow – exhale” temporal relationship persists during eating. However, respiratory pauses are longer, often beginning substantially before swallow onset.[3]

Causes that affect the normal swallowing physiology[edit | edit source]

There are various causes for alteration in normal swallowing physiology. broadly it can be categories into two heading :

  1. Structural abnormalities
  2. Functional abnormalities

Structural abnormalities[edit | edit source]

It can be acquired or congenital. Cleft palate, cervical osteophytes, webs or strictures in the passage are some of the examples of the structural abnormalities. The abnormalities might affect in any stage of the swallowing and alter the normal physiology. [3]

Functional abnormalities[edit | edit source]

Impairments affecting the jaw, lips, tongue, or cheek can hamper the oral phase or food processing. Reduced closing pressure of the lips may lead to drooling. In weakness of the buccal or labial muscles, food can be be trapped in the buccal or labial sulci (between the lower teeth and the cheeks or gums, respectively). Tongue dysfunction produces impaired mastication and bolus formation, and bolus transport. These usually result from tongue weakness or in-coordination, but sensory impairments can produce similar effects, including excessive retention of food in the oral cavity after eating and swallowing.

Loss of teeth reduces masticatory performance. Chewing can be prolonged by missing teeth, and particle size of the triturated bolus becomes larger due to lower efficiency of mastication.

Dysfunction of the pharynx can produce impaired swallow initiation, ineffective bolus propulsion, and retention of a portion of the bolus in the pharynx after swallowing. Insufficient velopharyngeal closure may result in nasal regurgitation and reduce pharyngeal pressure in swallow, hampering transport through the Upper Esophageal Sphincter (UES).

Impaired opening of the UES can cause partial or even total obstruction of the food-way with retention in the piriform sinuses and hypo-pharynx, increasing risk of aspiration after the swallow. Insufficient UES opening can be caused by increased stiffness of the UES, as in fibrosis or inflammation, or failure to relax the sphincter musculature.

Esophageal dysfunction is common and is often asymptomatic. Esophageal motor disorders include conditions of either hyperactivity (e.g., esophageal spasm), hypo-activity (e.g.weakness), or in-coordination of the esophageal musculature.Either of these can lead to ineffective peristalsis with retention of material in the esophagus after swallowing. Retention can result in regurgitation of material from the esophagus back into the pharynx, with risk of aspirating the regurgitated material. Esophageal motor disorders are sometimes provoked by gastroesophageal reflux disease, and in some cases, can respond to treatment with proton pump inhibitors[3].

Diagnosing dysphagia[edit | edit source]

There are many bedside and instrumental tools available for the diagnosis and treatment of dysphagia. Dysphagia evaluation tools can be grouped broadly as

  • Imaging (Ultrasound, Videofluroscopy, Fiberoptic endoscopic evaluation of swallowing, and Fiberoptic endoscopic evaluation of swallowing with sensory testing)
  • Non imaging(beside assessment tools, and pharyngeal manometry).[2]

Rehabilitation of dysphagia[edit | edit source]

Rehabilitative exercises changes and improves the swallowing physiology in force, speed or timing, with the goal being to produce a long-term effect, as compared to compensatory interventions used for a short-term effect. Rehabilitative exercises also involve retraining the neuromuscular systems to bring about neuroplasticity, since pushing any muscular system in an intense and persistent way will bring about changes in neural innervation and patterns of movement.[4] Rehabilitation exercise can be broadly divided into :

  • Swallowing exercises
  • Non-swallowing exercises

Swallowing Exercises[edit | edit source]

Swallowing exercises often are used to treat dysphagia with the goal of altering swallowing physiology and promoting long-term changes. Exercises are expected to impact swallowing mechanics and impact bolus flow.[5] Effortful swallow, Mendelsohn, super-supraglottic, Masako are some of the swallowing exercises.Swallowing exercises follow many of the neuroplasticity principles listed below[4]:

  • Use it or loose it
  • Use it and improve it
  • Specificity
  • Transference
  • Intensity

Non-Swallowing Exercises[edit | edit source]

Non-swallowing exercises are those that do not involve the act of swallowing, for example tongue strengthening exercises.Non-swallowing exercises can be

done by patients who cannot eat orally (are tube fed) or those post-surgery who are temporarily restricted from eating orally. Shaker head lift, tongue strengthening, Lee Silverman voice treatment, expiratory muscle strength training are some of the non-swallowing exercises. Non-swallowing exercises follow few neuroplasticity principles and they are[4]:

  • Transference
  • Intensity

Therapeutic techniques for dysphagia management[edit | edit source]

Therapeutic techniques can be divided into those used as :

  • Compensatory strategies (Head Rotation (Head Turn), Chin Tuck (Head Flexion). Head Tilt and Bolus Viscosity, Texture, and Volume Modifications)
  • Exercises (Tongue Hold, Shaker Exercise)
  • Those used as both compensatory strategies and/or exercises (Supraglottic Swallow, Super-Supraglottic Swallow, Effortful Swallow, Mendelsohn Maneuver)
  • Alternate methods (Neuromuscular Electrical Stimulation (NMES), Oral Stimulation and Other Interventions )

Head Rotation (head turn)[edit | edit source]

Head rotation is a compensatory strategy used for patients with unilateral pharyngeal and/or laryngeal weakness as well as reduced UES opening.Head rotation toward the side of impairment effectively redirects the bolus to the side of the pharynx opposite the rotation (the stronger side).[5]

  • Instruction given:‘‘turn your head to the side as if you are looking over your shoulder.’’

Chin Tuck (Head Flexion)[edit | edit source]

The chin tuck (head flexion) has been a technique used for patients who have decreased airway protection associated with delayed swallow initiation and/or reduced tongue base retraction.[5]

  • Instruction: ‘‘bring your chin to their chest and maintain this posture throughout the duration of the swallow".

Head tilt[edit | edit source]

The head tilt is used for patients with unilateral oral weakness. [5]

  • Instruction: ‘‘tilt your head like you’re trying to touch your ear to your shoulder.’’

Bolus Viscosity, Texture, and Volume Modifications[edit | edit source]

  • Increasing the volume and/or viscosity for liquids is another technique used to reduce dysphagia symptoms for some patients. Thickening liquids may be used for patients who have poor oral control of thin liquids and/or demonstrate reduced airway protection.
  • Increasing bolus volume increases bolus transit time as exemplified by sustained laryngeal elevation and hyoid excursion.
  • Some patients may benefit from texture-modified foods.[5]

References[edit | edit source]

  1. 1.0 1.1 Balamurali K, Sekar D, Thangaraj M, Kumar MA. Dysphagia in Patients with Stroke: A Prospective Study. available from:https://www.ijcmsr.com/uploads/1/0/2/7/102704056/ijcmsr_96.pdf
  2. 2.0 2.1 González-Fernández M, Ottenstein L, Atanelov L, Christian AB. Dysphagia after stroke: an overview. Current physical medicine and rehabilitation reports. 2013 Sep 1;1(3):187-96.
  3. 3.0 3.1 3.2 3.3 3.4 3.5 Matsuo K, Palmer JB. Anatomy and physiology of feeding and swallowing: normal and abnormal. Physical medicine and rehabilitation clinics of North America. 2008 Nov 1;19(4):691-707.
  4. 4.0 4.1 4.2 Langmore SE, Pisegna JM. Efficacy of exercises to rehabilitate dysphagia: a critique of the literature. International Journal of Speech-Language Pathology. 2015 May 4;17(3):222-9.
  5. 5.0 5.1 5.2 5.3 5.4 Vose A, Nonnenmacher J, Singer ML, González-Fernández M. Dysphagia management in acute and sub-acute stroke. Current physical medicine and rehabilitation reports. 2014 Dec 1;2(4):197-206.