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Swallowing Disorders: Neurogenic
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Presentation of Neurogenic Disorders Acute Injury Conditions occur suddenly Some recovery expected Degenerative Conditions Gradual deterioration over time
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Established Diagnosis CVA Cortical (cortex) R or L hemisphere Subcortical Brainstem Hemorrhage Cancerous Process Tumor growth May be an initial sign Traumatic Brain Injury
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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
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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
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Secondary Complications Weight loss Malnutrition Dehydration Laryngospasm Bronchospasm Aspiration (pneumonia) Asphyxia Loss of appetite, desire to eat Social withdrawal
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Dysphagia with Diagnosis Review all symptoms Esophageal Structural Neurological Know the symptoms well enough for differential diagnosis Comprehensive evaluation must be completed
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“Silent” Symptoms Pt compensates for difficulty Cough reflex is reduced or absent Cognitive impairment
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Specific Neurologic Diagnoses Many symptoms occur in more than one type of neurologic disease process or insult
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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