When the swallow isn’t 2007;22:1–10. Few studies have specifically assessed dysphagia following TBI. Dysphagia. [8, 9] This provides training to encourage independent eating [40]. If the dysphagia manifests in pharyngeal and/or laryngeal deficits, further instrumental assessments may be undertaken [62, 63]. Dysphagia. Limited awareness 4. Following further analyses, the authors concluded that RLA was the most important independent predictor of the time taken to achieve full oral feeding [29]. Surface electromyography for speech and swallowing systems: measurement, analysis, and interpretation. If sensory issues are suspected, modifying bolus temperature, taste and carbonation can be trialed to determine if these strategies assist with bolus detection and improve swallow safety [62]. Reducing food/fluid intake volume and speed can help prevent pharyngeal pooling and aspiration in patients with delayed or weak pharyngeal swallows [65]. Crit Care Med. “If the patient was speaking for themselves 20 years ago, what would they have to Terre R, Mearin F. Prospective evaluation of oro-pharyngeal dysphagia after severe traumatic brain injury. 2000;110:641–4. 2003;113:1386–93. Cancers in the mouth, throat or esophagus can make it difficult to swallow. Aspiration they are really at end of life (or needing a tube feeding). routine dysphagia treatment had reached a point where continued progress was not observed (i.e., patients who reached a plateau for at least one month). 2010;18:159–64. Prolonged endotracheal tube (ETT) and ventilation places non-TBI trauma patients at an increased risk of silent and overt aspiration, however, this risk is transient [35], with dysphagia resolving in 2–5 days post-extubation [34, 35, 48]. Howle AA, Nott MT, Baguley IJ. [62] Trialing different consistencies, viscosities and volumes of food and fluid allows optimization of the patient’s swallowing regime. At Cleveland Clinic, we’ve assembled an entire team of all the specialists you need – including gastroenterologists, radiologists, pathologists, thoracic surgeons and swallowing therapists – to offer leading-edge J Rehabil Res Dev. Then if they still want to allow textures the patient will aspirate (and Participant: I sometimes feel that I have more difficulty when educating other SLPs than MDs concerning Management of Dysphagia Following Traumatic Brain Injury, https://doi.org/10.1007/s40141-014-0064-z, Swallowing Disorders (RE Martin, Section Editor). ASHA Lead. Guidance for the family and caregivers regarding adequate communication is important, for example, use of short verbal instructions, simple, written instructions, repetition and avoidance abstract language can be discussed and modeled [9]. Identification and minimization of triggers for verbal or physical outbursts can reduce the likelihood of an outburst occurring during meal-times [9, 40]. Patterns and predictors of swallowing resolution following adult traumatic brain injury. Medications such as sedatives required for intubation may also temporarily depress the swallowing reflex [5, 34]. Presence of a tracheotomy tube and aspiration status in early, postsurgical head and neck cancer patients. However, the authors commented that tracheostomy and longer ventilation were potentially not causative factors for dysphagia, but were indicative of a greater severity of brain injury [42]. Enter your email address below and we will send you the reset instructions. Motor impairment following TBI depends on the site/s of injury and can include spasticity, weakness, ataxia, apraxia and extrapyramidal movement disorders [100]. Nagaya M, Kachi T, Yamada T, Sumi Y. Videofluorgraphic observations on swallowing in patients with dysphagia due to neurodegenerative diseases. Effortful swallowing training combined with electrical stimulation in post-stroke dysphagia: a randomised controlled study. For example, there is very little, if any, data on what constitutes normal tone in the swallowing musculature [91], and abnormal oropharyngeal muscle tone is difficult to identify. Patients can also be at risk of aspiration if they are so distracted they forget to swallow [40]. Leder SB, Joe JK, Ross DA, Coelho DH, Mendes J. In my charting, I say, Limited evidence suggests that sEMG can be an effective adjunct to these exercises [81, 103]. Some of us are CAS  1973;136:68–70. Dysphagia. Nothing by mouth is a medical instruction meaning to withhold food and fluids. Electrode placement can be difficult as the muscles are small and overlapping [105]. Identifying exactly why (at a neurological level) oropharyngeal movements are impaired can be difficult. 2004;19:160–4. Curr Phys Med Rehabil Rep. 2013;1:216–22. Langmore SE, Schatz K, Olsen N. Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. 2012;55:1232–46. Folia Phoniatr Logop. Also, explaining the goals are about quality of life, not Part III—impact of dysphagia treatments on populations with neurological disorders. Studies suggested that even in the absence of neurological conditions, patients with tracheostomies risked dysphagia [56]. Morgan AS, Mackay LE. your session, what would that one key takeaway be? Modifying bolus temperature alone will not alter swallowing physiology; [76, 85] however, application of cold and pressure to the faucial arches can increase the speed of the onset of tongue movement and the pharyngeal phase of the swallow in the short-term [86]. 1994;37:1041–9. crossroads of tube-feeding versus palliative swallow. 2008;13(3):8–11. 2004;19(3):226–40. Steele CM, Van Lieshout PHM. After a couple of days of this, I discontinue the order if there is no Krival: Interacting with family and patients is a huge area of discussion in our field, isn’t Krival: I think the very best way is to help them learn to make choices, too. However, in some patients with decreased oral sensation, a small bolus may be insufficient to trigger the swallowing reflex. Dysphagia. AHSA Lead. Correspondence to The association of functional oral intake and pneumonia in patients with severe traumatic brain injury. 1985;66:372–5. Austin, TX: Pro-Ed; 1998. 1999;14(5):486–96. For example, a person with head and neck cancer with chronic dysphagia from late-radiation induced dysphagia may tolerate some aspiration and want to stay on a least restrictive diet. Ann Surg. Factors affecting ability to resume oral nutrition in the oropharyngeal dysphagic individual. Family education programs must explain dysphagia and provide training in feeding techniques and management strategies where appropriate, as increasing the family’s awareness of these potential issues may assist with compliance with therapy and strategies in the home environment [115]. It helps to have family watch my session with the patient. Dysphagia: general. & Brown, L. Management of Dysphagia Following Traumatic Brain Injury. I’d consider a FEES [fiberoptic 2012;121(8):525–32. Logemann JA, Rademaker AW, Pauloski BR, et al. 2007;21(13–14):1411–7. NPO. The cognitive-communication/behavioral issues that influence the ability to safely eat and drink occur across multiple domains, creating challenges for patients attempting to swallow safely and influencing how dysphagia is assessed and managed [9, 40]. Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: its impact on diagnosis and treatment. Despite this, there is a paucity of evidence demonstrating the efficacy of dysphagia management strategies and treatments in this population. (Titled “Careful Hand Feeding: A Reasonable Alternative to PEG Tube Placement in Individuals However, it was unclear whether these results were due to improvements at the ‘muscle level alone or neuroplastic modifications as well’ [93]. However, whether tracheostomies actually cause dysphagia and aspiration remains controversial. [93] found that isometric tongue exercises improved tongue strength and swallowing function in patients post-CVA. Given the scarcity of evidence for many traditional forms of dysphagia management, regular monitoring and assessment of therapeutic strategies for individuals is recommended to maximize efficacy and avoid unwanted outcomes. Dysphagia. Brenda Arend, MA, CCC-SLP, is a speech-language pathologist at Providence St. Peter 2012;93:1173–8. goals are very important. Of those patients, 37% will develop pneumonia. Taken together, these studies support the contention that the presentation of post-TBI dysphagia differs to that following CVA. The effects of lingual exercise in stroke patients with dysphagia. DYSPHAGIA GOALS LONG TERM GOALS - SWALLOWING • Client will maintain adequate hydration/nutrition with optimum safety and efficiency of swallowing function on P.O. Krival: I don’t think there is one perfect response, because the staff issue is so broad. Brain Inj. I have to have a conversation with the doc. 2002;50:430–3. [61] found that duration to the first swallowing assessment (DFSA) was a predictor for achieving normal oral feeding. Edema 2. Excursion of muscles or decreased strength involved in mastication 3. Lancet Neurol. Am J Speech Lang Pathol. With Dementia,”, Palliative Care in Dysphagia and Dementia, American Journal of Speech-Language Pathology (AJSLP), Journal of Speech, Language, and Hearing Research (JSLHR), Language, Speech, and Hearing Services in Schools (LSHSS), Contemporary Issues in Communication Science and Disorders (CICSD). Betts RH. O’Suilleabhain P, Dewey RB. Barquist E, Brown M, Cohn S, Lundy D, Jackowski J. Postextubation fiberoptic endoscopic evaluation of swallowing after prolonged endotracheal intubation: a randomised, prospective trial. Acta Radiol. Hutchins BF. not feel we have to rehab them—and we can focus on quality of life and involve the Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis. Impulsivity may affect patients’ judgment regarding the amount and rate of food/fluid intake, presenting additional choking/aspiration risks, [8, 9, 11, 32, 33, 40] particularly if the patient’s impaired swallowing physiology cannot cope with such a volume and rate of feeding [8, 40]. Controlling stimuli and the meal-time environment is also important for patients with agitation and combativeness. The management of dysphagia following TBI requires a multifaceted, individualized approach that incorporates the contributory and causative cognitive-communication, behavioral, physiological, and pharmacological factors, any concomitant injuries and the pathoanatomic features of the TBI. Position Paper. Participant: To start, if a participant was to remember or put into practice only one idea from Establishing a dysphagia family intervention program for head-injured patients. The first few days after the stroke after extubation in critically ill trauma may. 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