Managing Dysphagia in Stroke Rehabilitation

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From 28% to 70% of stroke patients suffer from dysphagia, a condition in which the patient experiences difficulty in swallowing so that food does not always move from the mouth to the stomach. One of the dangers of dysphagia is asphyxiation, where food goes down the wrong tube to the lungs. This could lead to infection. Other risks imposed by dysphagia are dehydration and malnutrition.

Diagnosing Dysphagia

Video fluoroscopy is administered by getting patients to swallow various consistencies of contrast material. When drinking a fluid, such as water or juice, it takes multiple rapid swallows followed by a peristaltic contraction to move the liquid to the stomach. Doctors can see how each contrast material moves and evaluate how each muscle functions. Thin liquids and soups can be a challenge for stroke patients, but this can be ameliorated by thickening the liquid with Simply Thick easy mix so that it is easier to swallow.

A fairly new method — capsule video endoscopy procedure — involves swallowing a minute camera in a see-through container that is roughly the size of a vitamin capsule and that can reach the intestines. This camera sends photos to a recorder on a belt worn by the patient. More commonly, traditional endoscopy makes use of a camera fitted to a long tube and passed through the nostril to examine the pharynx. The latter procedure can be carried out at the patient’s bedside.

For stroke patients who can walk, electromyography or manometry are employed.

Transitioning from Hospital to Outpatient or Home

The average time from being admitted to a hospital until discharge in 2012 was 6.8 days in strokes accompanied by complications and 3.1 days where there were no complicating factors. Stroke rehabilitation could take up to ten days. Roughly half of the patients that are discharged continue to need treatment for dysphagia.

The therapist who assists patients with dysphagia must be able to provide compensatory strategies and additional exercises as patients transition from admittance through rehabilitation and to their homes.

Compensatory Strategies

The physiotherapist will use compensatory strategies that enable the patient to avoid aspiration and take in food in the immediate setting but do not contribute to long-term healing. They are useful as the patient regains awareness and can concentrate and follow instructions. But they are of no use if the patient forgets to use them.

Patients who have been cognitively impaired or battle with language after a stroke may have difficulty following instructions related to different positions for optimal swallowing. Compensatory techniques include chin tuck, head turn, volume regulation, breath-holding, and sensory enhancement. Sensory enhancement comprises temperature, carbonation, and sour bolus. These methods have produced mixed results.

Exercises

Exercises require the patient to have sufficient cognitive ability to comprehend instructions or at least mimic the therapist. These are taught outside of mealtimes. Some patients may have to regain or build the stamina needed for the essential number of repetitions.

Lingual resistance exercises strengthen the tongue. Expiratory muscle strength training increases the ability to open a spring-loaded valve. The Masako maneuver assists when the tongue base and wall of the pharynges do not make sufficient contact. Gargling increases posterior tongue movement. The Shaker exercise strengthens the suprahyoid muscles.

Several methods make use of compensatory and exercise components. These are thermal tactile application, effortful swallow, and the Mendelsohn maneuver. Neuromuscular electrical stimulation is also applied.

The therapist plays a key role in the management of post-stroke dysphagia.

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