Swallowing Disorders: Neurogenic

Presentation of Neurogenic Disorders  Acute Injury Conditions occur suddenly Some recovery expected  Degenerative Conditions Gradual deterioration over time

Established Diagnosis  CVA Cortical (cortex)  R or L hemisphere Subcortical Brainstem  Hemorrhage  Cancerous Process Tumor growth  May be an initial sign  Traumatic Brain Injury

Clinical Manifestations  Oral/Pharyngeal symptoms Decreased awareness/sensation Drooling Impaired mastication Trouble with initiating a swallow Nasal regurgitation Coughing Choking Difficulty moving bolus through the pharynx Difficulty with secretions Throat clearing Gurgly voice

Clinical Manifestations  Esophageal Symptoms Sticking in the chest Regurgitation Heartburn Chest discomfort Globus sensation Chronic sore throat  Rule of thumb Poor timing/coordination Decreased awareness Increased risk of silent aspiration

Secondary Complications  Weight loss  Malnutrition  Dehydration  Laryngospasm  Bronchospasm  Aspiration (pneumonia)  Asphyxia  Loss of appetite, desire to eat  Social withdrawal

Dysphagia with Diagnosis  Review all symptoms Esophageal Structural Neurological  Know the symptoms well enough for differential diagnosis  Comprehensive evaluation must be completed

“Silent” Symptoms  Pt compensates for difficulty  Cough reflex is reduced or absent  Cognitive impairment

Specific Neurologic Diagnoses  Many symptoms occur in more than one type of neurologic disease process or insult

Cerebrovascular Accident (CVA)  Right hemisphere CVA Characteristics  Left pocketing/weakness  Poor insight  Neglect  Impulsivity  Silent aspiration  Reflex delay 3-5” Treatment  Positioning  Liquid/diet modification  Tray/meal set-up  Oral motor exercises; TTS; maneuvers  Longer recovery time vs. L CVA

Cerebrovascular Accident (CVA)  Left hemisphere CVA Characteristics  Right pocketing/weakness  Oral motor apraxia; swallow apraxia  Reflex delay 2-3”  Silent aspiration  Reduced comprehension Decreased ability to follow treatment strategies Treatment  Positioning  Liquid/diet modification  Oral motor exercises  Multimodality input to facilitate comprehension  Increase pressure with spoon; TTS

Cerebrovascular Accident (CVA)  Brainstem CVA (low – medullary) Characteristics  Significant impairment; May affect swallow centers of the brain  Significant reflex delay 10-15” or absent reflex  Reduced laryngeal elevation  TVF paralysis  Pharyngeal paresis  Compromised respiration  Fatigue  UES dysfunction Treatment  Usually return to po intake (eating out of mouth) within 3 weeks  Exercise for weakness  Positioning Head turn to weaker side (while swollowing)  Mendelsohn maneuver (swallow and hold laryx up)  Liquid/diet modifications  Thermal stimulation

Cerebrovascular Accident (CVA)  Brainstem CVA (high – pontine) Characteristics  Hyperspasticity  Delayed or absent swallow reflex  Unilateral pharyngeal wall paresis  Decreased laryngeal elevation Treatment  Similar to previous slide  Massage prior to exercises/feeding trials may be helpful

Cerebrovascular Accident (CVA)  Subcortical CVA Characteristics  3-5” delay in OTT and pharyngeal reflex  Decreased laryngeal elevation Treatment  3-6 weeks recovery time  TTS  Exercises for oral ROM, BOT, and laryngeal movement

Cerebrovascular Accident (CVA)  Multiple CVAs (can lead to vascular dementia) caused by multiple strokes Characteristics  Delayed pharyngeal reflex  Reduced laryngeal closure  Pharyngeal weakness  Decreased attention and language comprehension Treatment  Similar to other treatments for CVAs, depending on exact disorders

Traumatic Brain Injury  Characteristics Decreased level of arousal Impulsivity Cognitive deficits Decreased sensation Weakness of the oral-motor structures Abnormal oral reflexes (Abnormal reflex such as,biting and sucking, rooting relex) Delayed swallow reflex Decreased laryngeal elevation Tolerate prolonged aspiration  Treatment Compensations Diet/hydration modification Thermal stimulation; exercises for oral muscles Longer period of spontaneous recovery; assess yearly

Guillain-Barre  Characteristics Rapid onset paresis – tracheostomy – vent Generalized weakness of oral and pharyngeal musculature Recovery slow Respiration unstable  Treatment Gentle ROM and resistance exercises Increase effort with improvement – slowly! Supraglottic swallow; Mendelsohn maneuver

Progressive Neurologic Disease  Amyotropic lateral sclerosis Characteristics  Progressive weakness Oral, pharyngeal, laryngeal, and respiratory  Progression of symptoms Aspiration  Tongue fasciculations  VPI Nasal regurgitation Treatments  Counsel regarding long-term feeding options  Diet/liquid modification  Controversy regarding tx

Progressive Neurologic Disease  Parkinson’s Disease Characteristics  Progressive disease  Marked variability in med cycles  Weak oral motor muscles  Delayed initiation  Reduced pharyngeal contraction  High percentage of silent aspiration in later stages. Treatments  Manipulation of drug cycles  Diet/liquid modification  Enteral feeding options

Progressive Neurologic Disease  Multiple Sclerosis Characteristics  Periods of exacerbation/remission  Symptoms vary dependent upon site of lesions Treatments  Typically necessary during periods of exacerbation  Compensatory strategies Postural Behavioral  Diet/liquid modification

Progressive Neurologic Disease  HIV-AIDS Characteristics  Weakness of the laryngeal elevators and other oral motor structures  Pharyngeal weakness Treatments  Compensatory strategies Postural  Diet/liquid modifications  Advise on long-term feeding options

Progressive Neurologic Disease  Myasthenia gravis: Characteristics  Rapid fatigue Can affect all phases of the swallow Treatment  Frequent small meals  Compensatory strategies Overcome short-term symptoms

Progressive Neurologic Disease  Huntington’s Chorea Characteristics  Choreiform movements  Difficulty with coordinated movements of manipulating and moving a bolus  Increased risk of aspiration/airway obstruction Treatment  Modified diet/hydration  Positioning  stabilization

Cerebral Palsy  Characteristics Abnormal oral reflexes Difficulty with cohesive bolus hold Disorganized A-P tongue movement Delayed triggering of pharyngeal reflex  Treatment Oral exercises TTS Diet changes May need chronic/ long-term therapy