5.7 Management of Dysphagia for Patients with ABI

How is dysphagia post ABI managed?  

  1. Patients undergo a careful clinical assessment and where necessary a VMBS is performed.
     
  2. Patient is kept NPO until swallowing status can be determined.
     
  3. Where the patient is a severe aspirator, a non-oral feeding tube is inserted.
     
  4. Where the patient is a mild to moderate aspirator treatment is determined by the findings of the VMBS.
     
  5. For these patients compensatory treatment techniques are used.

Describe compensatory treatment techniques for dysphagia post ABI.

  1. Postural adjustment of the head, neck and body to modify the dimensions of the pharynx and optimize the flow of the bolus.
     
  2. Sensory stimulation techniques to improve sensory input.
     
  3. Food consistency and viscosity alterations.
     
  4. Modifying the volume and rate of food and fluid presentation.
     
  5. Use of intraoral prosthetics.

The careful management of dysphagia is essential for the successful rehabilitation of acute brain injury patients 38. Ward and Morgan 6described the use of three distinct types of rehabilitation programs for dysphagic patients following head injury, based on the status of swallowing function at the time of admission 39. The nonfeeding program was designed as a stimulation program for very low-level patients, in order to prepare them for later feeding 39.This program includes desensitization techniques, such as stroking, and applying pressure or stretching, to facilitate normal swallowing, sucking and intraoral responses 39. The second program, the facilitation and feeding program, uses small amounts of puree consistency food to assist normal feeding patterns 39. The third program is referred to as a progressive feeding program, where specialized techniques were used to help the patient develop swallowing endurance by systematically increasing the amount of oral intake 39. This progressive feeding program continued until the patient was able to consume a complete meal within thirty minutes without difficulties 39.

For patients who are safe with some form of oralintake, Ward and Morgan 40note that therapeutic strategies utilized in dysphagia management can be divided into two categories: (a) compensatory treatment techniques and (b) therapy techniques 41.

Compensatory treatment techniquesdo not involve direct treatment of the swallowing disorder. Their purpose is to reduce or eliminate the dysphagic symptoms and risk of aspiration by altering how swallowing occurs 41;42. The types of compensatory strategies include: (a) postural adjustment of the head, neck and body to modify the dimensions of the pharynx and improve the flow of the bolus; (b) sensory stimulation techniques used to improve sensory input either prior to or during the swallow; (c) food consistency and viscosity alterations; (d) modifying the volume and rate of food/fluid presentation; (e) use of intraoral prosthetics 41.

Conversely, therapy techniques are designed to alter the swallow physiology 41. They include range-of-motion and bolus handling tasks to improve neuromuscular control without actually swallowing. They also include swallowing maneuvers that target specific aspects of the pharyngeal stage of the swallow. It was noted that medical and surgical management techniques are included in this category 42with these interventions only introduced once trials with more traditional behavioural treatment techniques have proven to be unsuccessful.

Ward and Morgan 40have noted that the efficacy of a large majority of treatments for swallowing disorders have not been studied in the ABI rehabilitation population.  However, many techniques mentioned above have been studied in other adult populations with neurogenic oropharyngeal dysphagia.