Dysphagia Lecture 5 neurologic condition

Dysphagia Lectures : 

Dysphagia Lectures Neurologic Disorders -dysarthria, dysphonia, and dysphagia all coexist commonly in neuro disorders

Slide 2: 

Is the etiology a condition from which I can expect some recovery? Is the etiology a degenerative condition? If recovery expected? What treatment would be most useful? Will patient ultimately manage an oral diet? What other factors may interact with the dysphagia? E.g. what is the influence of fatigue on the swallow? If degenerative? Are there predictable changes to anticipate? How long will the patient maintain an oral diet? What techniques could prolong eating? Key problem in neurologic disorders is loss of sensation, leading to poor sensitivity to aspiration i.e. silent aspiration with no cough

How common? : 

How common? Cherney data – Rehab facility of 307 patient with neurologic swallowing disorders etiologies included: 50% strokes 17% RH stroke 10% LH stroke 19% bilat stroke 5% brainstem stroke 20% TBI 7% spinal cord injury 7% brain tumor 5% progressive disorders 12% acute infectious/toxic conditions (encephalitis, meningitis, Guillian-Barre, anoxia) i.e. in rehab settings, vast majority of cases have a disease from which some recovery is likely

Treatable Neurologic Conditions1) Stroke : 

Treatable Neurologic Conditions1) Stroke unilateral, bilateral, cortical, subcortical, or brainstem all can lead to dysphagia because strokes commonly occur unilaterally, a-p view becomes more important in evaluation sensory loss in larynx/pharynx is common leading to delayed onset of reflex Also see impaired motor activity – including reduced vocal fold mobility (Sellars et al 1999) Kim & Han 2005 – also reported longer oral phase and more chews required; impaired mastication

Treatable Neurologic Conditions1) Stroke : 

Treatable Neurologic Conditions1) Stroke Acutely: (Div 13 FAQs 2006) 55-72% with dysphagia on MBS 38-70% may aspirate (Div 13 FAQs 06) 40-67% silent aspiration Silent aspiration right hemisphere > left hemisphere Stroke-induced neglect associated with nonoral feeding , but aphasia not (Schroeder et al 2006) JCAHO – requires screening for dysphagia in all pts with stroke

Treatable Neurologic Conditions1) Stroke : 

Treatable Neurologic Conditions1) Stroke a) medullary lesions significant swallowing impairment because affects brainstem pattern generator responsible for swallow reflex unilateral Signif dysphagia in medial or lateral unilateral medulla stroke Kwon et al 2000 initially lack swallow reflex, but within a few short weeks can recover substantially but still unilateral pharyngeal and laryngeal weakness bilateral medullary lesion - much worse swallowing prognosis -Robbins et al 1986 showed that cricopharyngeal segment may not relax in these indivs, but Logemann cautions that this may be due to reduced laryngeal elevation

1) Stroke : 

b) pontine, subcortical, right cortical strokes key problem is hypertonicity - i.e. UMN lesion to the swallowing system leads to slowing of motions can result in delayed oral transit, delay or absent in triggering reflex, unilateral pharyngeal weakness, delayed pharyngeal transit, reduced laryngeal elevation and resulting cricophar dysfunction Right cortical strokes: impact of neglect/extinction on swallowing – Berlucchi et al 2004 c) left anterior stroke - can cause swallow apraxia better in automatic eating tasks than in voluntary swallow testing also can see delays in oral transit and reflex 1) Stroke

1) Stroke : 

d) multiple strokes more significant problems especially if strikes motor system bilaterally - pseudobulbar palsy and swallowing problems -Martino et al 2005 overall lower incidence of dysphagia in cortical strokes than in other strokes 1) Stroke

Stroke: lesion location and aspiration riskMcCullough et al 2006 : 

Stroke: lesion location and aspiration riskMcCullough et al 2006 Location N asp %asp Cortical Right 39 13 33 Left 37 8 22 Bilat 6 1 17 Subcort Right 23 5 22 Left 17 4 24 Bilat 16 7 44 Brainstem Right 11 2 18 Left 10 2 20 Bilat 1 1 100 Cerebellar 4 0 0

1) Dysphagia in Stroke: Recovery : 

Chapman & Price ASHA 1997 n=225 general recovery is good in 90-95% of single stroke patients return to oral intake within 9 weeks, but some remaining problems evident within 4 weeks substantial recovery can be anticipated Smithard et al Dysphagia 1997 n=121 3% with swallowing problems remaining at 6 mos Mann et al 1999 n=128 Onset: 64% with dysphagia At 6 mos: 87% prestroke diet But 16/128 still aspirated on MBS best predictor of poor outcome – poor oral transit 1) Dysphagia in Stroke: Recovery

1) Dysphagia in Stroke: Recovery : 

Chen et al 2004 N=182 strokes Presence of aspiration at onset not predictive of long term survival following stroke Predictors of death: advanced age, recurrent stroke, need for tube-feeding, wheelchair bound 1) Dysphagia in Stroke: Recovery

1) Dysphagia in Stroke: Recovery : 

Schroeder, Daniels et al 2006 n=65 Compared initial testing within 5 days of admission with discharge results 3 days -4 months later Oral intake at onset 63% Oral intake at discharge 75% Presence of 4/6 clinical features (Daniels et al) associated with poor final outcome No clear outcomes associated with lesion location or size 1) Dysphagia in Stroke: Recovery

1) Dysphagia in Stroke: Recovery : 

Daniels et al 2006 Developed normative data for MBS measures – abnormal if Oral transit time (OTT) >1.1 sec Stage transition duration (STD – reflex delay time) > .26 sec Pharyngeal transit time (PTT) > 1,14 sec Pen-Asp score > 2 Residue in valleculae or pyriforms N=9 unilateral stroke pts 5/9 abnormal on multiple measures -most often PTT and STD 1 month post stroke 1/9 resolved dysphagia 4/9 improved on some measures 1/9 no improvement 1) Dysphagia in Stroke: Recovery

1) Dysphagia in Stroke : 

negative concomitants of swallowing ability: -tracheostomy - inflated - reduces laryngeal elevation and allows irritation of vfs and loss of sensory abilities of vfs -medications - such as antidepressants change muscle coordination, others cause dry mouth -concurrent medical problems - prior neuro problems, diabetes 1) Dysphagia in Stroke

1) Dysphagia in Stroke: Treatment : 

Postural adjustments - especially if unilateral stroke head turn toward weak side chin down combined Enhance sensory input to reduce reflex delay volume – increase viscosity – thicker better than thinner brainstem – may need thinner taste- sour is better thermal-tactile stimulation 1) Dysphagia in Stroke: Treatment

1) Dysphagia in Stroke: Treatment : 

ROM exercises for tongue, pharynx, larynx but remember…..the best exercise is to swallow Diet changes – pureed/thickened liquids advancing with recovery toward mechanical soft and thinner liquids Vital stim Myotomy - brainstem strokes that don’t recover and others for whom sphincter doesn’t open 1) Dysphagia in Stroke: Treatment

1) Dysphagia in Stroke: Treatment : 

Nonoral feeding -if no signif improvement in early stages – PEG better than NG tube? Norton et al 1996 no diff between PEG/NG Dennis et al 2005 -then our job is to provide therapy! 1) Dysphagia in Stroke: Treatment

1) Dysphagia in Stroke: Treatment : 

1) Dysphagia in Stroke: Treatment Cochrane Database Systematic Review of dysphagia treatment in acute stroke 1999/updated 2005 - too few RCTS - PEG better outcome than NGt - not enough evidence regarding behavioral therapies FOOD trial collaboration RCT 2005 - PEG vs no PEG – associated with reduced death, better outcomes - PEG vs NGT – associated with increased death and poor outcomes Carnaby et al 2006 RCT - low intensity behavioral tx led to reduced death, dependency and complications - high intensity behavioral tx associated with greater return to normal diet and recovered swallowing

1) Dysphagia in Stroke: Treatment : 

1) Dysphagia in Stroke: Treatment Pharmacologic tx for swallowing in stroke: Smithard et al 1998 nifedipine 30 mg -some evidence of reduced swallowing problems compared to placebo

1) Dysphagia in Stroke: Resources : 

Division 13 Frequently Asked Questions on Swallowing Screening: Acute Stroke 1) Dysphagia in Stroke: Resources

1) Dysphagia in Stroke : 

Be careful…. Kingston et al 2001 SLPs identified dysphagia in 25% of pts MDs considered safe swallows Only 50% of MDs correctly identified dysphagia 1) Dysphagia in Stroke

2) Traumatic Brain Injury : 

complicated issue because TBI may be part of more involved injuries longer coma associated with greater dysphagia tracheostomy - often performed emergently and may be less optimum placement too high in neck intubation - also frequently used in these people and can injure larynx 2) Traumatic Brain Injury

2) Traumatic Brain Injury : 

2) Traumatic Brain Injury Incidence of dysphagia in TBI (Morgan et al, JHTR, 2003, Table 1)

2) Traumatic Brain Injury : 

2) Traumatic Brain Injury Incidence of dysphagia in pediatric TBI (Morgan et al, JHTR, 2003) Severe TBI – 68% Moderate TBI – 15% Mild TBI – 1% Higher incidence of dysphagia… Glasgow Coma Score <8.5 ventilator dependent >1.5 days

2) Traumatic Brain Injury : 

variety of problems can be expected (e.g. Morgan et al JHTR 2002) - oral stage probs - related to muscle mobility, abnormal reflexes - pharyngeal stage probs - delayed reflex is most common abnormality; reduced movements – reduced laryngeal elevation; reduced pharyngeal contraction - aspiration: very common – acutely 75% aspirate – mostly silent Leder 1999, 2002 2) Traumatic Brain Injury

2) TBI Recovery of Dysphagia : 

Chapman & Price, ASHA 1997 n=95 Acutely 71% aspirated 84% recovered, most within 90 days only 2 npo at end of rehab important to perform follow-up studies on those not swallowing because may recover some ability 6-12 months later at times recovery will be affected by concomitant behavior problems 2) TBI Recovery of Dysphagia

2) TBI: Dysphagia Treatment : 

Can be difficult to manage with compensatory strategies because of cognitive impairments postural changes enhanced sensory input resistance and ROM exercises diet changes 2) TBI: Dysphagia Treatment

3) Spinal Injury : 

delayed reflex possible and reduced movements once reflex triggers high C1-2 injuries can lose sensation also have complications related to trach or intubation, ventilation, cervical brace treatment: postural changes usually not suitable enhanced sensory input swallowing airway maneuvers – because usually cognitively intact 3) Spinal Injury

3) Spinal Injury : 

Does cervical bracing impact the swallow? Stambolis et al 2003 n = 17 normal individuals – 82% swallowing changes with brace 59% residue 23.5% penetration No aspiration -keep in mind because of bracing in spinal injured pts 3) Spinal Injury

4) neurosurgical brainstem problems : 

4) neurosurgical brainstem problems e.g. tumors - like acoustic neuroma usually unilateral problem Cervical neurosurgery – dysphagia common and persists in many Yue et al 2005 treatment postural strategies – if unilateral problem particularly ROM and resistance exercises Maneuvers repeated practice thru day

5) Guillain-Barre’ Syndrome : 

5) Guillain-Barre’ Syndrome Acute infectious polyneuropathy weakness and paralysis of swallowing movements which over months resolves often have acute trach or ventilation which can complicate matters occasionally swallowing difficulty is first sign of the disease treatment ROM exercises especially in context of swallowing – this is a lower motor neuron disorder so exercises may actually be warranted Swallow maneuvers when respiratory recovery allows Postures

Degenerative neurological conditions : 

Degenerative neurological conditions 1) Alzheimer’s disease Agnosia and conceptual apraxia Difficulty preparing foods Lose ability to recognize food, so slow to take food in May misprepare foods – e.g. pour liquids on solids fail to realize how to use utensils to self-feed Lose ability to recognize hunger, thirst, temperature Wander – causing weight loss much much later motor abnormalities begin to affect aspects of swallow

Degenerative neurological conditions : 

2) other types of dementia – usually frontal dementias little known, but anticipate problems related to frontal role in behavior e..g. utilization behaviors – may put many things in mouth may overfill mouth with food Treatment for AD and frontal dementias enhanced sensory and motor input – i.e. capitalize on the automaticity keep patient safe from utensils, amount of food prepare for future time when quit eating because don’t know what and how Tube feeding in dementia pts associated with > mortality rate (Alvarez-Fernaqndez et al 2005) Degenerative neurological conditions

Suggested Dementia InterventionsBrush et al ASHA Leader 2006 : 

Suggested Dementia InterventionsBrush et al ASHA Leader 2006 Increase lighting and contrast at table – use placemats to set boundaries for their food versus others’ Use visual and written cues Control distracting noises, glare, odors Serve promptly Limit number of utensils Use cups with handles easier to grasp Serve larger portions at breakfast Add sweeteners, other flavors to enhance consumption Serve one item at a time to reduce distractions Provide culturally appropriate foods Offer liquids throughout day Do not use garnishes/decorations that should not be eaten Place at small table if eat better alone

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease : 

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease 29% dysphagia rate (AHRQ report) major swallowing problems likely over time for those with corticobulbar involvement Yorkston (1988) reported that 25% have dysphagia if more corticospinal involvement may maintain swallowing for greater time but Robbins et al 1986 also noted dysphagia in these patients as well

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease : 

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease initially lingual control problems as tongue becomes weak - Kawai et al 2003 more problem with greater viscosity foods requiring more lingual strength e.g. paste at risk for aspiration before the swallow lip closure and velar movement also become problems over time, tongue base and pharynx become affected so residue in valleculae are likely placing them at risk for aspiration after the swallow eventually reduced laryngeal closure placing them at risk for aspiration during swallow

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease : 

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease treatment compensatory strategies for as long as possible i.e. postures, maneuvers diet changes as disease progresses eventually lose motor abilities and ability to feed, so critical to prepare for future

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease : 

3) Amyotrophic Lateral Sclerosisaka Lou Gehrig’s disease Tube feeding in ALS – Langmore et al Cochrane Review 2006 Systematic review Minimal evidence available comparing enteral feeding and oral feeding in terms of long term outcomes Some cohort studies suggest enteral feedings leads to - longer survival, improved nutrition, and quality of life

4) Parkinson’s disease : 

4) Parkinson’s disease PKN 69.1% dysphagia rate (AHRQ report) abnormalities may affect all stages of swallowing (Stroudley & Walsh, 1991) rigidity, tremor, festination general effect on swallowing is overall slowing of movements oral stage abnormalities rock and rolling tongue movements - tongue base doesn’t go down so bolus rolls back forward pharyngeal stage abnormalities possible delayed reflex triggering over time pharyngeal contraction and laryngeal elevation reduces

4) Parkinson’s disease : 

4) Parkinson’s disease Stroudley & Walsh, 1991 n=24 w/ PKN & dysphagia oral stage abnormalities – 92% pharyngeal stage abnormalities – 54% Aspiration – 46%

4) Parkinson’s disease : 

4) Parkinson’s disease good deal of variability in swallow disorders across PKN patients; some may have little difficulty make sure patient on optimal doses of movement drugs before evaluating and treating swallowing remember that PKN also can be associated with dementia which can complicate the eating picture - i.e. don’t have the frontal lobe initiative to eat Can impact psychosocial factors – report stigma, embarrassment (Miller et al 2006)

4) Parkinson’s disease : 

4) Parkinson’s disease Treatment resistance and ROM exercises – Lee Silverman Voice Treatment – may also affect swallowing Fox, Ramig et al swallow maneuvers - especially effortful swallows Cochrane Database: Deane et al 2000/updated 2006 No RCTs completed at this time

5) Progressive Supranuclear Palsy : 

5) Progressive Supranuclear Palsy similar to PKN Frattali et al 1999 – common swallowing symptoms delayed initiation of swallow Excess lingual gestures Poor bolus transport Piecemeal deglutition Pooling in valleculae and pyriforms Premature spillage Aspiration – 4.5%

6) Multiple Sclerosis : 

6) Multiple Sclerosis effects on swallowing depend on location of sclerotic plaques symptoms likely to wax and wane in course but progressively worse most frequent to see delayed reflex and reduced phar wall contraction good number are asymptomatic, but have dysphagia Terre-Boliart et al 2004 – 80% have dysphagia, 40% silent aspiration

6) Multiple Sclerosis : 

6) Multiple Sclerosis use treatments relevant to problem Make sure medication optimum during eating Enhance sensory input Postural adjustments and maneuvers as appropriate

7) myasthenia gravis : 

7) myasthenia gravis associated with muscle fatigue over time, worsens with use and improves with rest Aspiration, sometimes silent, possible in 35% (Koopman et al 2004; Kigo et al 2005) Also see bolus transport problems Laryngeal elevation problems may be good to evaluate swallow 15-20 minutes after eating

7) myasthenia gravis : 

7) myasthenia gravis Treatment options: Optimum medications Eat small meals and rest during meals Compensatory postures Diet modifications as needed No exercises – just increases fatigue

8) Other progressive neuro diseases : 

8) Other progressive neuro diseases Huntington’s disease 100% dysphagia rate (AHRQ report) Progressive supranuclear palsy 55.6% dysphagia rate

9) dystonias : 

9) dystonias usually affect oral stages as muscles suffer involuntary contortions; aspiration then can be possible but reflexive stages are normal Diet changes so less oral manipulation necessary

nonneurologic degenerative diseases : 

nonneurologic degenerative diseases 1) arthritis aryt movement can be affected at cricoaryt joint so if fail to make laryngeal closure, at risk for aspiration

nonneurologic degenerative diseases : 

nonneurologic degenerative diseases 2) COPD - chronic obstructive pulmonary disease changes in respiratory airflow Coelho found difficulty closing airway and possibility of aspiration in these patients Good-Fratturelli et al 2000 85% with dysphagia 56% with penetration or aspiration

3) muscular dystrophy : 

3) muscular dystrophy myopathy with muscle weakness - hypotonia over time possible for muscle contractures and muscle wasting prolonged contraction of some muscles involved in swallowing is possible, e.g. cricopharyngeal muscle may fail to relax, so sphincter doesn’t open Temp extremes can cause prolonged contractions other types can affect pharyngeal muscles in particular, so pharyngeal constriction to propel bolus downward becomes difficult Can be associated with cognitive decline? Poor initiation, planning

3) muscular dystrophy : 

3) muscular dystrophy Cochrane database Hill et al 2004/updated 2005 No RCTs for treatment of dysphagia in progressive muscular diseases Several case series reported use of myotomy in MD Be careful of temperature extremes during eating Eat slowly

Breathing and Neuro disorders : 

Breathing and Neuro disorders Hadjikoutis et al (Brain, 2000) Showed neuro patients (variety of etiologies, including many with ALS) had abnormal inspiratory breath/swallow patterns compared to normal controls