Post-Stroke Dysphagia: Difficulty Swallowing And Rehabilitation Techniques

Dysphagia, or difficulty swallowing, is a common condition that affects over 40% of stroke survivors. It can be caused by impaired control of the muscles in the throat responsible for swallowing, or damage to the parts of the brain that control these muscles, such as the motor cortex or brain stem. Dysphagia can lead to serious complications such as malnutrition, dehydration, choking, and aspiration pneumonia, which occurs when food or liquid enters the lungs instead of the stomach. It is important for survivors with dysphagia to work with a speech-language pathologist to learn how to eat and drink safely and to practice swallowing exercises that can help improve oral motor control and promote neuroplasticity. While dysphagia often improves within the first two weeks after a stroke, some individuals may experience swallowing difficulties for longer periods, and it is important to seek treatment to prevent further complications.

Dysphagia: a swallowing disorder that affects over 40% of stroke survivors

Dysphagia is a common condition that affects more than 40% of stroke survivors. It is characterised by difficulty swallowing, which can range from minor difficulty to a complete inability to swallow. Dysphagia is often caused by impaired control over the muscles in the throat and can have serious complications if left untreated. These complications include malnutrition, dehydration, choking, and aspiration pneumonia.

Causes of Dysphagia

Dysphagia is often caused by stroke-related damage to the parts of the brain that control the throat muscles, such as the motor cortex or brain stem. This damage can inhibit the brain's ability to send and receive information from the throat muscles, leading to impaired control over these muscles and difficulty swallowing.

Treatment and Management of Dysphagia

Dysphagia is typically treated by speech-language pathologists, who may recommend rehabilitative exercises, compensation techniques, and complementary treatments. Rehabilitative exercises aim to improve communication between the brain and the muscles involved in swallowing, promoting neuroplasticity and the formation of new neural connections. Compensation techniques, such as eating soft foods or drinking thick liquids, can help minimise the risk of choking or aspiration during the recovery process.

Complementary treatments, such as electrical stimulation, acupuncture, and swallowing maneuvers, can also be used in conjunction with other therapeutic techniques to improve swallowing function.

Outlook for Stroke Survivors with Dysphagia

Most individuals with dysphagia after a stroke are able to regain their swallowing function within the first two weeks. However, recovery time varies depending on the severity and location of the stroke. Severe strokes may lead to more persistent dysphagia, and in some cases, feeding tubes may be required initially to prevent malnutrition. Speech-language pathologists play a crucial role in diagnosing and treating dysphagia, and it is important for survivors to work closely with them to ensure safe eating and drinking practices.

Aspiration: when swallowed substances enter the lungs, which can lead to pneumonia

Aspiration is a common problem for people who have had a stroke. It occurs when swallowed substances enter the lungs instead of the stomach. This can happen when the epiglottis, a flap of tissue that blocks food and drink from entering the trachea, fails to function properly.

Aspiration can be dangerous because the mouth contains high numbers of bacteria. If these bacteria enter the lungs, they can cause an infection known as pneumonia. Pneumonia is a serious condition that requires immediate medical attention. It causes fluid to build up in the lungs and can even be fatal if left untreated.

Signs of aspiration include coughing or choking when eating or drinking, bringing food back up, feeling that food is stuck in the throat, and repeated episodes of pneumonia. However, some people who aspirate do not exhibit any symptoms, a condition known as silent aspiration.

If you suspect that you or someone you know is experiencing aspiration, it is important to seek medical attention as soon as possible. A speech-language pathologist can evaluate your swallowing ability and recommend strategies to reduce the risk of aspiration, such as changing your diet or using special swallowing methods.

Treatment options: swallowing exercises, electrical stimulation, acupuncture, and swallowing maneuvers

Treatment Options

Swallowing Exercises

Swallowing exercises 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 bolus flow. Some maneuvers may serve as a compensatory strategy and also function as rehabilitative exercises, such as the effortful swallow, supraglottic swallow, super-supraglottic swallow, and Mendelsohn maneuver.

The effortful swallow is used for patients who present with clinically significant residue in the valleculae and/or pyriform sinuses, as well as for patients who may have decreased airway closure. The Mendelsohn maneuver is used for patients with decreased hyolaryngeal excursion and/or decreased duration of upper esophageal sphincter (UES) opening.

Other exercises are not compensatory and are meant to solely improve swallowing physiology, such as the Shaker exercise and Masako (tongue hold) maneuver. The Shaker exercise is used for patients with decreased UES opening and weakness of the suprahyoid muscles. The Masako (tongue hold) maneuver is used for reduced tongue base and pharyngeal wall contact.

Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is a treatment where electrodes are placed on the anterior neck and an electrical current evokes a muscle contraction. There are mixed views and research findings on incorporating NMES into dysphagia management practices. Some studies have found that NMES, when used in conjunction with traditional swallowing treatment, can significantly improve swallowing function. However, other researchers have questioned the use of NMES for the treatment of dysphagia, as it can decrease swallow function by lowering hyolaryngeal elevation and increasing the risk of penetration and/or aspiration.

Acupuncture

Acupuncture is a traditional Chinese medicine practice where needles are inserted into a person's skin, with the aim of balancing their energy, or "qi". Acupuncture has been used routinely in stroke rehabilitation in China and elsewhere in East Asia for over 1,000 years and has been recommended by the World Health Organization as an alternative and complementary strategy for stroke treatment and care.

Several clinical trials and animal studies have shown that the mechanism of acupuncture for stroke includes the regulation of the release of neurotransmitters, cerebral microcirculation, stimulation of neurogenesis and cell proliferation, and regulation of neuroplasticity. Many studies have indicated that acupuncture might be beneficial in the rehabilitation of patients with swallowing dysfunction post-stroke.

Swallowing Maneuvers

Compensatory swallowing strategies are used to prevent symptoms of dysphagia in order to maintain safety and ensure adequate nutrition and hydration. These techniques do not result in long-term physiological changes. They include volume and texture modifications, as well as strategies such as chin tuck, head tilt, and head turn.

The chin tuck, for example, is used for patients with decreased airway protection associated with delayed swallow initiation and/or reduced tongue base retraction. Patients are instructed to "bring their chin to their chest" and maintain this posture throughout the duration of the swallow.

Signs of dysphagia: coughing when eating/drinking, food feeling stuck in the throat, needing extra time to swallow, etc

Dysphagia, or difficulty swallowing, is a common issue after a stroke, affecting more than 50% of stroke survivors. It can cause several problems, including coughing when eating or drinking, food feeling stuck in the throat, and needing extra time to swallow.

Signs of Dysphagia

Dysphagia can manifest in several ways, and it is important to be aware of these signs, especially after a stroke. Here are some of the most common signs and symptoms associated with dysphagia:

• Coughing or choking when eating or drinking: This is one of the most common signs of dysphagia. The coughing or choking may be mild or severe and can occur with both solids and liquids.
• Food feeling stuck in the throat or chest: This sensation is often described as food getting stuck in the throat and not moving down easily. It can be accompanied by a feeling of tightness or pressure in the throat.
• Needing extra time to chew or swallow: Individuals with dysphagia may take longer to finish meals or need more time between bites and swallows.
• Gagging or gurgling when swallowing: There may be sounds or sensations of gurgling in the throat during or after swallowing.
• Drooling or leaking of food or liquid from the mouth: Dysphagia can make it difficult to control the movement of food or liquid in the mouth, leading to drooling or leakage.
• Frequent heartburn or acid reflux: Dysphagia can be associated with gastroesophageal reflux disease (GERD) or acid reflux, causing frequent heartburn.
• Weight loss or dehydration: Over time, dysphagia can lead to weight loss due to reduced food intake and dehydration from difficulty swallowing liquids.

It is important to seek medical advice if you or someone you know is experiencing any of these signs or symptoms, especially after a stroke. A speech-language pathologist or a doctor can assess your swallowing function and provide appropriate treatment or referrals.

Safety tips: avoid using straws, sit up straight when eating/drinking, eat slowly, etc

Safety Tips for Swallowing After a Stroke

If you are having trouble swallowing after a stroke, you may have a condition called dysphagia. This is a common issue, affecting over 40% of stroke survivors. Dysphagia is caused by impaired control of the throat and mouth muscles involved in swallowing. It can lead to serious complications such as malnutrition, dehydration, choking, and aspiration pneumonia, so it is important to take steps to improve your swallowing function and protect your safety. Here are some tips to help you swallow more safely:

• Avoid using straws. Straws can increase the risk of choking and aspiration.
• Sit up straight when eating or drinking. Maintaining an upright posture aids in comfortable and safe swallowing.
• Focus on eating and drinking. Avoid distractions, and give your full attention to the task.
• Eat slowly and chew your food thoroughly. Taking your time reduces the risk of choking and ensures food is broken down into manageable pieces.
• Modify food and liquid textures. Eat soft or pureed foods, and drink thickened liquids. These move more slowly and are easier to control, reducing the risk of aspiration.
• Avoid thin or watery liquids, such as tea, soup, and juice. These are more difficult to control and can easily go down the wrong way.
• Avoid high-fibre foods that don't break down easily, like seafood, root vegetables, and green leafy vegetables.
• Avoid foods with low water content, like bread, potatoes, and cake.
• Avoid sour or vinegary foods, such as pickles or citrus fruits.
• Consult a speech-language pathologist (SLP). They can evaluate your swallowing function and provide personalised recommendations to improve your safety and comfort during mealtimes.
• Work with a dietitian. They can advise on the best foods and liquids to consume, ensuring you get adequate nutrition while managing your dysphagia.

It is important to take dysphagia seriously and seek professional help. With the right support and consistent practice, most individuals can improve their swallowing function and reduce the risk of associated complications.

Frequently asked questions