Swallowing Rehabilitation: Post-Stroke Recovery And Techniques

A stroke can cause a swallowing disorder called dysphagia, which affects over 40% of stroke survivors. Dysphagia is caused by difficulty controlling the oral muscles responsible for swallowing. It can lead to serious complications such as malnutrition, dehydration, weight loss, and aspiration pneumonia if left untreated. However, most people with dysphagia recover within the first few weeks after a stroke, and rehabilitation methods can help improve swallowing abilities.

Dysphagia: a swallowing disorder that can lead to aspiration pneumonia

Dysphagia is a common condition following a stroke, affecting almost half of people who experience a stroke. It is a swallowing disorder that can have serious consequences if not identified and managed properly.

Dysphagia is caused by difficulty controlling the oral and throat muscles responsible for swallowing. When a stroke damages the parts of the brain that control these muscles, such as the motor cortex or brain stem, the brain cannot send and receive information from them accurately. This inhibits the survivor's ability to control the muscles necessary for swallowing, leading to dysphagia.

The condition can range from minor difficulty with swallowing to a complete inability to swallow. Survivors with dysphagia may require alternative feeding methods, such as soft foods or thickened liquids. In severe cases, a feeding tube may be recommended to ensure adequate nutrition.

One of the most serious complications of dysphagia is aspiration pneumonia. Aspiration occurs when food or liquid enters the lungs instead of the stomach. During swallowing, a flap called the epiglottis moves to close over and protect the airway. However, when a person has dysphagia, food or liquid can enter the trachea and cause aspiration. This allows bacteria to enter the lungs and cause infections, leading to pneumonia.

The risk of pneumonia is significantly higher in patients with dysphagia. In fact, compared to acute stroke survivors without dysphagia, those with the condition are over four times more likely to develop aspiration pneumonia. Other complications of dysphagia include malnutrition and dehydration, as individuals may choose not to eat or drink enough due to their swallowing difficulties.

It is important to identify and treat dysphagia early on to prevent these serious complications. Speech-language pathologists play a crucial role in evaluating and managing dysphagia. They determine the patient's ability to swallow, assess the movement of muscles in the mouth, and evaluate how well the voice box is working. They also recommend suitable food and liquid consistencies and provide swallowing exercises to help improve the condition.

While dysphagia often improves within the first two weeks after a stroke, some individuals may continue to experience swallowing difficulties for weeks or months. Rehabilitation and compensatory techniques are crucial in helping individuals regain their swallowing function and reduce the risk of complications.

Speech-language pathologists: specialists who can determine the best consistency of foods and liquids for you to swallow

Speech-language pathologists (SLPs) are essential in helping stroke survivors recover their swallowing function. SLPs are responsible for screening, assessing, and managing dysphagia, a common condition characterised by difficulty swallowing that affects over 40% of stroke survivors. They work as part of a multidisciplinary team, including medical, nursing, occupational therapy, physiotherapy, and social work staff, to provide comprehensive care for stroke patients.

SLPs play a critical role in identifying and managing dysphagia early on, as it can lead to serious complications such as malnutrition, dehydration, and aspiration pneumonia if left untreated. They perform comprehensive evaluations to determine the patient's ability to swallow, including clinical bedside evaluations and instrumental assessments such as videofluoroscopic modified barium swallow (VMBS) or fiberendoscopic examination of swallowing (FEES). These assessments help SLPs understand the patient's swallowing function and develop an appropriate swallowing management and rehabilitation plan.

SLPs also determine the best consistency of foods and liquids for stroke survivors to swallow safely. They may recommend modifying the texture of food by softening, chopping, or pureeing, as well as adjusting the thickness of liquids. SLPs may initially advise consuming only pureed foods and thickened liquids before gradually introducing more textured foods as the patient's swallowing function improves. Additionally, SLPs provide education and training to caregivers and staff on strategies to support the patient's swallowing and communication needs.

Furthermore, SLPs play a vital role in treating and managing communication disorders associated with stroke, such as aphasia, motor speech disorders, and cognitive communication disorders. They provide assessment, intervention, and rehabilitation services to improve the patient's communication skills and overall quality of life. SLPs work closely with the patient, their family, and the multidisciplinary team to develop and implement effective treatment plans.

Videofluoroscopy: a video X-ray of your mouth and throat while you swallow

Videofluoroscopy is a video X-ray of your mouth and throat while you swallow. It is also known as a Videofluorographic Swallowing Study (VFSS) or a modified barium swallow. The process involves taking X-rays from the front and side of your mouth and throat as you swallow different foods and liquids mixed with a special liquid called barium, which shows up on the X-rays. This procedure allows doctors to see how your swallowing is working and what exercises or treatments might help. It can also show if food or drink is going into your lungs, which can cause aspiration pneumonia.

Videofluoroscopy is considered the gold standard for evaluating swallowing disorders, as it allows doctors to directly visualise the oral, pharyngeal, and oesophageal structures in real time. It can also be used to evaluate the effectiveness of compensatory strategies, such as different head and body positions during swallowing.

The procedure is typically performed by a speech-language pathologist and a physician, such as a physiatrist or radiologist. Before the procedure, the patient will be asked to swallow a very small amount of water, followed by foods and liquids of different consistencies, to determine their ability to swallow safely. This initial evaluation is crucial to developing a treatment plan.

Videofluoroscopy has several strengths, including the ability to directly visualise structural movements and bolus flow during swallowing. It also allows for the immediate evaluation of compensatory strategies and the direct visualisation of cricopharyngeal function (opening). However, one limitation is that obese patients or those with contractures may have limited space for positioning during the procedure.

Fibreoptic endoscopic evaluation of swallowing: a small camera attached to a thin tube and inserted into your nose to check your swallow

A Fibreoptic Endoscopic Evaluation of Swallowing (FEES) is a procedure used to assess your ability to swallow. It involves inserting a thin, flexible tube called an endoscope, which has a light and a small camera attached to it, into your nostril and down your throat. This allows a speech-language pathologist (SLP) or a neurologist to examine your throat and identify any issues that may be causing difficulty in swallowing.

During the procedure, the endoscope is carefully inserted through your nose and positioned above the epiglottis, a flap of tissue that covers your trachea during swallowing to prevent food or liquid from entering your lungs. The SLP will observe how well you swallow saliva and identify any structural abnormalities in your throat. The second part of the test involves introducing different textures and sizes of food and liquid, which may be dyed to make them more visible on the screen. You may also be asked to adopt different positions to evaluate your swallowing function.

The FEES test is particularly useful for individuals who have trouble swallowing, a condition known as dysphagia, which can be a common effect of a stroke. Dysphagia can lead to serious complications such as aspiration, where food or liquid enters the airway and lungs, which can cause pneumonia. Therefore, it is crucial to identify and treat dysphagia promptly. The FEES test can help SLPs determine the specific causes of dysphagia and develop appropriate treatment plans, such as modifying food types and eating positions, to improve swallowing function and reduce the risk of associated complications.

The FEES test is generally well-tolerated, with mild discomfort reported by some individuals. However, there are risks associated with the procedure, including gagging, temporary closure of the airway, and aspiration. Prior to the test, your SLP may recommend a special diet and provide instructions to minimise these risks. It is important to inform the medical team about any medications you are taking and your medical history, especially any surgeries to the neck, throat, or nose.

Treatment options: rehabilitative exercises, compensation techniques, and complementary treatments

Dysphagia, or swallowing difficulties, can often be improved through rehabilitative exercises. These exercises can help improve communication between the brain and the muscles involved in swallowing. While they may not directly involve the act of swallowing, rehabilitative exercises can help train the associated muscles and improve oral motor control.

Practicing swallowing exercises repetitively can promote adaptive rewiring in the brain through a process known as neuroplasticity. This allows the brain to create and strengthen neural connections related to swallowing, improving oral-motor function and, over time, maximizing the chances of regaining the ability to swallow effectively.

Compensation techniques are also important to minimize the risk of choking or silent aspiration (inhaling food or drink into the lungs without developing symptoms) while the patient is still recovering their swallowing function. These include:

• Eating soft foods, which are easier to chew and can help prevent malnutrition
• Drinking thick liquids, which move slower than thin liquids, reducing the risk of choking or aspirating
• Focusing on sitting up straight, as eating or drinking in a position that isn’t upright increases the chances of choking or aspirating
• Eating slowly to ensure food is sufficiently chewed, reducing the risk of choking
• Avoiding foods of varying consistencies, as these can be unsafe and complicated to chew
• Adding moisture to foods to improve ease of swallowing

It is important to note that a speech-language pathologist will determine what textures of foods and liquids are safe for a patient at any given point in their recovery.

In addition to rehabilitative exercises and compensation techniques, there are several complementary treatments that can be used to enhance improvements:

• Electrical stimulation: Applying gentle electrical impulses to the muscles around the throat can improve the connection between these muscles and the brain, encouraging neuroplasticity.
• Acupuncture: Placing thin needles into specific acupoints on the body can help improve numerous conditions after a stroke, including dysphagia.
• Swallowing maneuvers and/or biofeedback: Practicing specific techniques for swallowing or modifying swallowing techniques based on individualized visual feedback may help survivors relearn how to swallow effectively.

Frequently asked questions