My current role as a Dysphagia Clinical Program Consultant (CPC) for Accelerated Care Plus is one that is energizing, enjoyable, and also challenging at times. It is a role I feel incredibly grateful to have at this point in my career. I often have the opportunity to sit down with Speech Language Pathologists who are the only SLP working in the facility, which can feel like being on an island without a colleague with whom to brainstorm on a case. I can’t claim I have all of the answers to dysphagia questions, but I am happy to combine knowledge from articles I have read, experience I have, and evidenced based assessment and treatment techniques I been trained to utilize to help problem solve with treating clinicians to provide the best clinical care for the patients they serve. I am also fortunate to have a team of SLP CPC colleagues to consult with for perspective and insights on effective dysphagia rehabilitation for tough cases.

Typically, in the SLP’s quest to help the patient return to eating and drinking safely and efficiently one of the initial questions I ask is something to the effect of, “What is wrong with the patient’s swallow?” Or “Where is the breakdown occurring to create dysphagia?” Often, the answer I receive is that the patient aspirated on a certain consistency or is pocketing a particular bolus. While this is helpful information, I am digging deeper to understand which of the 17 physiological processes of the swallowing mechanism is disrupted (Martin-Harris, Dysphagia, 2008). After all, the bolus is only going to go where the body directs it. Therefore, if the bolus is heading toward the lungs, or is creating stasis in the oral or pharyngeal cavity, this is due to the action of one or more of the physiological processes involved in the swallow. Did the base of tongue not provide complete retraction and approximation with the pharyngeal wall?  Perhaps this is why there is vallecular residue. Did the upper esophageal sphincter not open for long enough or a wide enough diameter?  Perhaps this is the reason for the pyriform sinus residue. Was there delayed or no initiation of the swallow due to damage to the Vagus nerve?

In order to obtain this data, we first need to be willing to ask these questions and second utilize standardized, validated, and objective measures for obtaining the answers. This would initially include a comprehensive clinical swallow evaluation for a collection of non-instrumental measures which may include:

• Comprehensive review of medical history
• Medication review
• Patient interview
• Brief cognitive assessment
• Structural examination
• Cranial Nerve exam
• Objective measures/questionnaires
• Trial swallows of liquids and foods (McCullough 2013).

Following this, we may need to obtain results from an instrumental swallow study such as a Modified Barium Swallow Study or Fiberoptic Endoscopic Evaluation of Swallowing if dysphagia is suspected. Per ASHA’s statement in 2000, “An instrumental examination is indicated for making the diagnosis and/or planning effective management and treatment in patients with suspected or who are at high risk for oropharyngeal dysphagia based on the clinical examination.” (ASHA SIG 13 Task Force 2000).

Once we have the answers regarding where the physiological deficit is occurring, we need to formulate a highly individualized, specific plan for the patient. This plan should be focused on rehabilitation of the deficits to provide a functional swallow for the patient, not simply on modifying a diet. Research has moved away from the use of behavioral compensations and maneuvers toward a greater emphasis on exercised-based therapy that emphasizes consistent, active muscle movement. We know that data from new therapies suggests a stronger emphasis on exercise yields positive results that are superior to older ‘‘management’’ techniques of compensations and maneuvers (Carnaby 2013).

Thanks to a great deal of research being produced over the last decade (not only in the dysphagia community, but in the medical and psychological fields as well) on the ability for neuroplastic changes to occur through application of specific principles, we have a greater understanding of how to best rehabilitate a patient’s swallow than ever before and we have the ability to improve the swallow function of patients with chronic dysphagia or chronic illness. Neuroplastic improvements following disease can include:

1. Reorganization of cortical representation
2. Increased efficiency of residual pathways
3. Greater use of alternative descending pathways.

When developing a treatment plan it is necessary to consider neuroplastic principles to maximize treatment impact. These would include:

• Use it or lose it
• Use it and improve it
• Repetition matters
• Intensity matters
• Plasticity is experience specific
• Salience
• Difficulty
• Transference (Kleim, J Speech Lang Hear Res, 2008) (Robbins, J Speech Lang Hear Res, 2008)

Due to the principle of “specificity” listed above, we understand the importance of identifying and basing a specific plan of care on the patient’s individual deficits to make optimal progress in the patient’s swallow ability. This principle indicates:

1. Changes only occur in the neural substrates engaged in the trained behavior
2. The type of training will determine the functional outcome (skill versus strength versus endurance) (Plowman 2016).

There are several evidenced based treatment techniques available that Speech Language Pathologists can utilize to improve swallowing ability. To name a few:

• Lingual resistance exercises (IOPI/MOST)
• Expiratory Muscle Strength Training (EMST)
• McNeill Dysphagia Therapy Program (MDTP) (Carnaby, Dysphagia, 2013)
• sEMG Guided dysphagia therapy to improve strength based, motor based, and skill based learning (Carnaby-Mann, Arch Phys Med Rehabil, 2010) (Athukorala, Arch Phys Med Rehabil, 2014) (Huckabee, Dysphagia, 1999)

There are, of course, many other protocols and exercises that can be employed, but the point is that, as professionals, we are compelled to utilize a systematic approach to thoroughly investigate and diagnose the reason a patient has dysphagia, where the breakdown in the swallowing process is occuring, and then employ neuroplastic principles with evidenced based treatment techniques to address the patient’s deficits to optimize the outcome in rehabilitating the swallow.

Employing the techniques outlined in this blog post is a great roadmap to improving the patient’s ability to eat and drink as before, thereby improving their quality of life!

Refrences:

Martin-Harris, B., Brodsky, M.B., Michel, Y., Castell, D.O., Schleicher, M., Sandidge, J., Maxwell, R., & Blair, J. (2008). MBS Measurement Tool for Swallow Impairment-MBSImp: Establishing a Standard. Dysphagia 23 (4):392-405.

McCollough, G.H., & Martino, R. (2013). Clinical Evaluation of Patients with Dysphagia: Importance of History Taking and Physical Exam. Manual of Diagnostic and Therapeutic Techniques 11 for Disorders of Deglutition, ). R. Shaker et al. (eds.). DOI 10.1007/978-1-4614-3779-6_2, © Springer Science+Business Media New York

American Speech and Hearing Association (ASHA) Special Interest Group 13, Task Force. (2000). Clinical Indicators for Instrumental Assessment of Dysphagia. [ASHA Guidelines]. Rockville, MD: ASHA.

Carnaby, G., Harenberg, L. (2013) What is the ‘usual care’ in dysphagia rehabilitation: a survey of USA dysphagia practice patterns. Dysphagia, 28(4), 567-74. DOI: 10.1007/s00455-013-9467-8

Kleim, J. A., & Jones, T. A. (2008). Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res, 51(1), S225-239. doi:10.1044/1092-4388(2008/018)

Robbins, J., Butler, S. G., Daniels, S. K., Diez Gross, R., Langmore, S., Lazarus, C. L., Rosenbek, J. (2008). Swallowing and dysphagia rehabilitation: translating principles of neural plasticity into clinically oriented evidence. J Speech Lang Hear Res, 51(1), S276-300. doi:10.1044/1092-4388(2008/021)

Plowman, E., “Neuroplastic Principles.” Critical Thinking in Dysphagia Management. Alexandria, Virginia. 19 November 2016

Athukorala R, Jones R, Sella O, Huckabee M (2014) Skill training for swallowing rehabilitation in patients with Parkinson's disease. Arch Phys Med Rehabil. 95(7):1374-82. doi: 10.1016/j.apmr.2014.03.001

Crary, M. A., Carnaby Mann, G. D., Groher, M. E., & Helseth, E. (2004). Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback. Dysphagia, 19(3), 160-164. doi:10.1007/s00455-004-0003-8.

Huckabee, M. L., & Cannito, M. P. (1999). Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. Dysphagia, 14(2), 93-109. doi:10.1007/PL00009593