Dysphagia: Etiologies and SLP’s Role in Identifying Patients At-Risk, Evaluation and Treatment Scott S. Rubin, Ph.D. LSUHSC-N.O. SPTHAUD 6218 Summer 2009

Dysphagia: SLP’s Role ASHA Position Statement: …speech-language pathologists play a primary role in the evaluation and treatment of infants, children, and adults with swallowing and feeding disorders. However – telling you - We must work WITH other rehabilitation professionals… know our role and that they do have a role to play. So - what are THEY told about their role??

Dysphagia: SLP’s Role Appropriate roles for speech-language pathologists include, but are not limited to: – Performing clinical feeding and swallowing evaluations. –Performing instrumental assessments that delineate structures and dynamic functions of swallowing. –Defining the abnormal swallowing anatomy and physiology and diagnosing swallowing disorders

Dysphagia: SLP’s Role SLP continued – –Identifying additional disorders in the upper aerodigestive tract and making referrals to appropriate medical personnel. –Making recommendations about management of swallowing and feeding disorders. –Developing treatment plans for individuals with swallowing and feeding disorders.

Dysphagia: SLP’s Role SLP continued – –Providing treatment for swallowing and feeding disorders, documenting progress, and determining appropriate dismissal criteria. –Teaching and counseling individuals and their families about swallowing and feeding disorders.

Dysphagia: SLP’s Role SLP continued – –Educating other professionals regarding the needs of individuals with dysphagia, and the speech-language pathologists' role in the evaluation and management of swallowing and feeding disorders. –Serving as an integral part of a multidisciplinary and/or interdisciplinary team as appropriate.

Dysphagia: SLP’s Role SLP continued – Advocating for services for individuals with swallowing and feeding disorders. Advancing the knowledge base on swallowing and swallowing disorders through research activities.

Dysphagia: SLP’s Role You are a primary professional in area! However – telling you - We must work WITH other rehabilitation professionals… know our role and that they do have a role to play. So - what are THEY told about their role??

Dysphagia: SLP’s Role AOTA Position: : OTs to evaluate and provide intervention for clients with dysphagia. OT “practice” in - Individualized compensatory swallowing strategies Modified diet textures Adapted mealtime environments

Dysphagia: SLP’s Role OT continued – –Enhanced feeding skills –Preparatory exercises and positioning to clients –n Reinforcement of mealtime strategies to clients to enhance and –improve swallowing skills.

Dysphagia: SLP’s Role OT continued – Training for caregivers in individualized feeding and swallowing strategies to enhance eating and feeding performance.

Dysphagia: SLP’s Role OT – “occupational therapy practitioners offer input to other dysphagia team members regarding client performance at mealtime and goal accomplishment. Occupational therapy practitioners utilize environmental and behavioral strategies to optimize swallowing performance and provide culturally sensitive interventions to clients with dysphagia”

Dysphagia: SLP’s Role Back to ASHA Statements – the SLP in Evaluation: Swallowing function assessment is provided to evaluate oral, pharyngeal, and related upper digestive structures and functions to determine swallowing functioning and oropharyngeal/respiratory coordination (strengths and weaknesses), including identification of impairments, associated activity and participation limitations, and context barriers and facilitators.

Dysphagia: SLP’s Role Depending on assessment results, intervention addresses the following: –The alteration of lingual and labial resting postures. –Muscle retraining exercises. –Modification of handling and swallowing of solids, liquids, and saliva.

Dysphagia: SLP’s Role Short- and long-term functional goals and specific objectives are reviewed periodically to determine appropriateness. Treatment provides information and guidance to patients/clients, families/caregivers, and other significant persons about the nature of orofacial myofunctional patterns, and the course of recovery and prognosis for improvement.

Dysphagia: SLP’s Role Documentation includes the following: –Written record of the dates, length, and type of interventions that were provided. –Progress toward stated goals, updated prognosis, and specific recommendations. –Evaluation of intervention outcomes and effectiveness within the WHO framework of body structures/functions, activities/participation, and contextual factors

Dysphagia: SLP’s Role ETIOLOGIES

Dysphagia: SLP’s Role Common etiologies of dysphagia include: strokes head injuries cervical spinal cord injuries progressive neurologic diseases head and neck cancer and the surgery or radiation used to treat it congenital syndromes and abnormalities

Dysphagia: SLP’s Role esophageal stenosis- narrowing esophageal motility disorders Achalasia-cause a sphincter to remain closed gastroesophageal reflux disease Antipsychotic drugs that cause extrapyramidal symptoms like tardive dyskinesia may cause dysphagia

Dysphagia: SLP’s Role THE ? S esophageal stenosis aka esophageal stricture –a gradual narrowing of the tube that carries food to the stomach. It occurs when scar tissue builds up in the tube. –muscles behind and in front of the food contract and relax in a rhythmic sequence to force it along toward the stomach.

Dysphagia: SLP’s Role Achalasia rare disease of the muscle of the esophagus (swallowing tube). The term achalasia means "failure to relax" and refers to the inability of the lower esophageal sphincter (a ring of muscle between the lower esophagus and the stomach)

Dysphagia: SLP’s Role Spastic esophageal motility disorders, including diffuse esophageal spasm (DES), nutcracker esophagus, and hypertensive Lower Esophageal Sphincter Secondary esophageal motility disorders related to scleroderma, diabetes mellitus, alcohol consumption, psychiatric disorders, and presbyesophagus

Dysphagia: SLP’s Role Nutcracker esophagus an abnormality - swallowing contractions are too powerful. –In up to half of patients, this condition is caused by gastroesophageal reflux.

SYMPTOMS OF DYSPHAGIA: Adult and Pediatric

Dysphagia: Symptoms Symptoms in Adults: –Hesitation or inability to swallow –Difficult or painful swallowing –Constant feeling of a lump in the throat –Food sticking in the throat –Food coming up (regurgitation) through the throat or nose –Hoarse voice or recurrent sore throat

Dysphagia: Symptoms Adult Symptoms - continued –Chest pain or discomfort when swallowing –Difficulty swallowing solid foods –Frequent, repetitive swallowing –Excessive throat clearing –"Gurgly" sounding voice after eating

Dysphagia: Symptoms Adult Symptoms - continued –Coughing during or after swallowing –Necessity to "wash down" solid foods –Recurrent episodes of pneumonia –Frequent heartburn –Food or stomach acid backing up into your throat (acid reflux) –Unexpected weight loss

Dysphagia: Symptoms Pediatric Symptoms: –Low interest in feeding or meals –Tension in the body while feeding –Refusal to eat foods that have certain textures –Lengthy feeding or eating times (30 minutes or longer)

Dysphagia: Symptoms Pediatric Symptoms – continued – Food or liquid leaking from the mouth –Coughing or gagging when eating or nursing –Spitting up or vomiting during feeding or meals –Strained breathing while eating and drinking –Poor weight gain or growth

Dysphagia: Symptoms Different General List (anything new?) –Prolonged feeding and/or fatigue –Oral expectoration, nasal regurgitation –Drooling/increased secretions –Coughing/choking/throat clearing –Weight loss or changes in diet –Dehydration, temperature spike, pneumonia –Pocketing of food, mouth odor –Gurgly/wet voice or cry –Rejection of food, food selectivity, gagging

Dysphagia: Symptoms Oral phase deficits characterized by: –inability to successfully masticate –decreased rotary jaw movement –decreased bolus formation with inefficient lingual search –buccal or sublingual residual, anterior food loss –pre-mature leakage of bolus into the pharynx secondary to poor control

Dysphagia: Symptoms Oral pharyngeal transit deficits characterized by: –latent onset of swallow

Dysphagia: Symptoms Pharyngeal deficits characterized by: –reduced pharyngeal contraction –inadequate base of tongue to posterior pharyngeal wall approximation –poor epiglottic deflection –decreased palatal closure

Dysphagia: Symptoms Pharyngeal deficits characterized by: CONTINUED –pharyngeal pooling –asymmetry in swallowing –decreased laryngeal excursion –dyscoordination of swallowing

Dysphagia: Symptoms Cricopharyngeal deficits characterized by: –reduced extent or duration of UES opening –pyriform sinus residual –dyscoordination of swallowing that inhibits UES opening in sync with pharyngeal contraction –asymmetry

Dysphagia: Symptoms Esophageal Dysphagia symptoms include: –Feeling of food stuck in throat or chest –Reflux of food into the throat or mouth –Heartburn –Report of sour taste in mouth, especially in morning.