Communication and swallowing disorders are among the most common impairments resulting from various neurologic diseases or injuries. They impose great impact on a patient’s medical condition, psychological health, social integration, and overall quality of life. The pathophysiology, clinical presentation, evaluation, and management of aphasia, cognitive communicative disorders, motor speech disorders, and swallowing disorders are summarized in this chapter and the accompanying eSlides.
Rehabilitation of Patients with Communication Disorders (eSlides 3.1 and 3.2)
Rehabilitation of patients with communication disorders focuses on restorative as well as compensatory strategies and techniques [augmentative and alternative communication (AAC)]. When the attempt is made to restore deficit areas, early implementation of AAC and incorporation of family and caregivers in the treatment plan to ensure participation of the affected individual are essential.
Aphasia (eSlides 3.3 and 3.4)
Common causes of aphasia include stroke (most common, 20% to 40% of people with stroke have aphasia), traumatic brain injury, dementia, and other progressive neurologic disorders. Aphasia types include Broca, Wernicke, conduction, global, transcortical motor, transcortical sensory, anomic, and crossed and primary progressive aphasia. Assessment involves identification of the specific areas of deficit.
Special Considerations: Handedness and Language Dominance
Language control is in the left hemisphere in 99% of right-handed individuals. Of left-handed individuals, 70% have language control in the left hemisphere, 15% have it in the right hemisphere, and 15% have it in both hemispheres. Overall, 97% of the population has language control in the left hemisphere.
Cognitive Communication Disorders
Cognitive communication disorders impair memory, new learning, awareness, problem solving, organizing, planning, and all other areas of executive function. The following sections describe the management of these disorders, which result mostly from right hemisphere strokes, brain injuries, and dementia.
Right Hemisphere Stroke
Common disorders of right hemisphere strokes include impairments in memory, attention, and problem solving; decreased awareness or insight into the severity of the deficits; reduced ability to process and express higher level or abstract language concepts; decreased or flat affect; and impairments in organizing, planning, and other executive functions. The most common deficits are seen in attention, neglect, perception, and learning or memory.
Traumatic and Nontraumatic Brain Injury (eSlide 3.5)
Penetrating injuries often cause focal damage, and closed head injuries often result in diffuse axonal damage. Interventions focus on supporting and optimizing the progressions through different stages; these stages are often described with the Rancho Los Amigos Levels of Cognitive Functioning Scale.
Early Stage of Recovery (Rancho Levels I–III) : The treatment focuses on stimulating or shaping responses for basic communication and identifying the transition to localized responses.
Middle Stage of Recovery (Rancho Levels IV–V) : The treatment initially focuses on structuring the environment to facilitate participation. This stage of recovery is particularly important with regard to speech recovery, and the focus is to increase orientation, insight, memory, and new learning; manage language confusion and confabulations; and increase functional participation. AAC will be implemented for those who remain nonspeaking.
Late Stage of Recovery (Rancho Levels VI–VIII) : The intervention focuses on increasing orientation, memory, carryover of new learning, and eventually higher-level executive functions.
Mild brain injury
High level cognitive communication disorders can affect social reintegration. Impairments of executive function are common. Intervention focuses on increasing awareness and education.
Alzheimer Disease and Other Dementias
Definitive diagnosis hinges on evidence of short-term and long-term memory impairment in addition to the presence of at least aphasia, apraxia, agnosia, or impaired executive functioning. Treatment often occurs in bouts, occurring at crucial times during the patient’s disease progression.
Motor Speech Disorders
Dysarthria (eSlide 3.6)
Dysarthria is a major source of disability and involves impairments of respiration, phonation (larynx), resonance (velopharynx), and articulation (tongue and lips). It can be categorized into several types: flaccid, spastic, ataxic, hypokinetic, hyperkinetic, and mixed. Management of dysarthria depends on subsystem involvement and severity, and extensive practice is necessary for optimal recovery.
Apraxia
Apraxia of speech is characterized by a slow speaking rate, lengthened sounds and durations between sounds, sound distortions, consistent errors, abnormal prosody, difficulty in initiating speech, and a preference for automatic speech. The assessment includes an oral mechanism and a motor speech examination. Therapy typically involves behavioral therapy that focuses on the position or movement of the articulators and is based on principles of motor learning.
Rehabilitation of Patients with Swallowing Disorders
Swallowing disorders, or dysphagia, can lead to malnutrition, dehydration, respiratory compromise, and a decrease in quality of life. This section provides an overview of the neurophysiology, common assessment tools, disorders, and treatments related to dysphagia.
Physiology and Pathophysiology (eSlides 3.7, 3.8 and 3.9)
A normal swallow is divided into oral preparatory, oral transit, pharyngeal transit, and esophageal stages. It depends on a coordinated sucking, swallowing, and breathing pattern regulated by a swallow central pattern generator. Both food transport and airway protection should be considered when assessing dysphagia.
- 1.
Oral preparatory and transit stages: the food is prepared for transport to the pharyngeal cavity. Natural mastication includes the following stages: (1) the preparatory series, when the food is transported between the molar teeth; (2) the reduction series, when the food is broken down; and (3) the preswallowing series, when the food is transported into a “swallow-ready” position. Disorders of this stage include retention of the bolus, anterior spillage (due to an inadequate labial seal), pocketing in the lateral sulcus (weak cheeks or buccal walls), and premature leakage (impaired tongue–palate contact).
- 2.
Pharyngeal stage: the soft palate and pharyngeal wall achieve a velopharyngeal seal. The base of the tongue retracts, the pharyngeal walls contract, and the upper esophageal sphincter (UES) opens to allow the bolus to pass through. Disorders at this stage may include impaired swallow initiation, ineffective bolus propulsion, bolus retention in the pharyngeal recesses or vallecula, nasal regurgitation (due to an inadequate velopharyngeal seal), and aspiration. To protect the airway, the true vocal folds adduct, the arytenoids tilt to the base of the epiglottis, and the hyolaryngeal mechanism moves upward and forward. Laryngeal penetration is defined as passage of material into the larynx but not through the vocal folds. Aspiration is defined as passage of material through the vocal folds. Impaired opening of the UES can be caused by increased stiffness of the UES, failure of relaxation of the cricopharyngeus muscle, weakness of the muscles of sphincter opening (related to hyolaryngeal elevation), discoordination, and inadequate pressure of the bolus.
- 3.
Esophageal stage: the esophagus is composed of striated muscle proximally and smooth muscle distally, both of which propel the bolus by peristalsis. The lower esophageal sphincter (LES) relaxes during a swallow. Esophageal dysfunction can lead to retention of material, regurgitation, and aspiration. Structural disorders should be ruled out.
Dysphagia is found in half of individuals with a recent stroke (most recover in less than 2 weeks). It is characterized by discoordination, reduced laryngeal elevation, insufficient UES opening, and weakness of the vocal fold and oropharyngeal muscles. Dysphagia is typically more severe in bilateral cerebral and brainstem lesions.
Evaluation (eSlide 3.10)
The purpose of a swallowing evaluation is to assess dysphagia and make recommendations for diet, swallowing strategies, and interventions. Silent aspiration occurs in 25% to 30% of patients with dysphagia, and pharyngeal disorders should be evaluated with instrumentation; however, note that the instrumentation results will represent only a snapshot of the patient’s swallowing function. It is imperative to interpret the results in conjunction with the overall clinical picture of the patient.
Bedside/Clinical Swallow Assessments
Swallow screening
The purpose of swallow screening is to identify individuals at risk of dysphagia and to refer them for further evaluation. The screening protocol should be quick and minimally invasive. In the Yale Swallow Protocol, the individual must consume 3 ounces of water uninterrupted without overt signs of aspiration.
Clinical swallow examination
The clinical swallow examination (CSE) has five basic components: (1) medical history and medical status; (2) cognitive/mental status; (3) oral motor function: strength, tone, symmetry, movement of the lips, tongue, and palate, and dentition and oral mucosa; (4) laryngeal and pulmonary function: strength of the cough and vocal quality and respiratory rate; and (5) trial swallows: saliva, followed by ice chip, and then other bolus sizes and consistencies. Submandibular, hyoid bone, and laryngeal movements are assessed. Any clinical signs of aspiration usually trigger a referral for instrumental assessment.
Blue dye clinical swallow examination
The blue dye clinical swallow examination (BDCSE) is performed by adding food coloring to the ingested substance to allow detection of aspiration through the tracheostomy. It has a low sensitivity in detecting aspiration.
Cervical auscultation
Cervical auscultation enables evaluation of swallowing and airway sounds. It has limited interrater reliability and correlation with physiologic events (e.g., aspiration).
Instrumental Swallow Assessment
Videofluoroscopic swallow study
The videofluoroscopic swallow study (VFSS), which uses various consistencies of barium sulfate to evaluate swallowing function, is considered the gold standard for diagnosing dysphagia. It allows evaluation of the integrity of airway protection in all swallowing phases, as well as assessment of the effectiveness of bolus modifications, postural changes, and swallowing maneuvers.
Fiberoptic endoscopic examination of the swallow procedure
The fiberoptic endoscopic examination of the swallow (FEES) is the second most common instrumental assessment and allows for an evaluation of the related anatomic structures, secretion levels, swallowing ability, sensory input and airway protection, and effect of compensatory strategies. Endolaryngeal secretions and reduced vocal fold mobility are predictive of aspiration.
Comparison of VFSS and FEES
Both VFSS and FEES procedures are valuable methods to evaluate swallowing function. The selection is usually driven by specific patient characteristics or instrument availability.
High resolution manometry
High resolution manometry measures pressure events along the entire length of the pharynx and esophagus, providing a more comprehensive picture of how bolus volumes affect swallowing function.
Ultrasonography
The advantages of ultrasonography include no exposure to radiation, noninvasiveness, and portability. Submental placement assesses bolus transport during the oral phase and hyoid bone displacement in the pharyngeal phase. It has inadequate reliability in detecting aspiration.
Electromyography
Electromyography (EMG) of the muscles of the pharynx and larynx is a reliable method for detecting lower motor neuron dysfunction and aberrant central motor patterning. It can be used with biofeedback. EMG should be used only as an adjunct to other instrumental assessments.
Treatment of Dysphagia
Early treatment of dysphagia reduces the risk of aspiration pneumonia, the likelihood of medical complications related to malnutrition and dehydration, and the length of hospital stay. Equally important is to increase an individual’s ability to participate in and enjoy the pleasures of eating orally.
Restorative: Exercise Training and Plasticity Considerations (eSlide 3.11)
The oropharyngeal system exhibits considerable plasticity. Strength training follows the principles of specificity and overloading. Examples include the Mendelsohn and Masako exercises, isometric lingual exercises, expiratory muscle strength training (EMST), effortful swallowing, and Shaker exercises.
Compensatory Strategies in Swallowing Rehabilitation (eSlides 3.12 and 3.13)
Compensatory strategies can be divided into postural strategies, maneuvers, and diet modification. Postural strategies successfully address 80% of all swallowing disorders. Modification of food should be viewed as a treatment of last resort. Thermal tactile stimulation is recommended in cases of delayed pharyngeal swallow, but it should be viewed as a short-term compensatory strategy.
Surgery for Dysphagia
Surgery is rarely indicated, but it may be needed for large Zenker diverticulum. Cricopharyngeal myotomy can reduce UES pressure. Botulinum injections can help patients with dystonia, trismus, or cricopharyngeal dysfunction. In severe and chronic aspiration, a permanent tracheostomy with a laryngectomy can be necessary.
Pharyngeal Bypass (eSlide 3.14)
Pharyngeal bypass procedures provide alternative means for achieving nutrition and hydration.
Prevention of Aspiration Pneumonia (eSlide 3.15)
Measures to minimize aspiration include upright positioning, head elevation, oral hygiene, proper meal duration, and use of slow and continuous tube feedings. Education of family and caregivers is important. Neither tube feedings nor tracheostomies prevent aspiration pneumonia. Tracheostomy alters normal aerodynamics, eliminating positive subglottic pressure and hampering laryngeal protective reflexes. An inflated cuff, likewise, does not fully eliminate the risk of aspiration.
Psychological Considerations
Treatment focuses on providing education regarding the risk and management (e.g., Heimlich maneuver) of airway obstruction in the short term and on social and community reintegration in the chronic stages. Psychological consultation should be requested when appropriate.
Given the variety of disorders that can cause communication and swallowing disorders, as well as the serious impacts and complications that can result, a comprehensive understanding of normal and abnormal physiology and prognosis is essential. A team approach to addressing the medical, cognitive, physical, and psychosocial aspects of these disorders facilitates as near a return to independence as possible.
Communication disorders (including aphasia, cognitive communication disorders, dysarthria, and apraxia) and dysphagia are major sources of disability. Rehabilitation focuses on restorative and compensatory strategies and techniques.
Early implementation of AAC strategies and incorporation of family and caregivers in the treatment plan to ensure participation of individuals with communication disorders are essential.
Interventions for patients with brain injury focus on optimizing the progressions through different stages; these stages are often described using the Rancho Los Amigos Levels of Cognitive Functioning Scale.
Normal swallowing is divided into oral preparatory, oral transit, pharyngeal transit, and esophageal stages. Swallowing disorders result in retention of the bolus, anterior spillage, lateral pocketing, premature leakage, impaired initiation, nasal regurgitation, and aspiration.
The purpose of CSE is to identify individuals at risk so that they can be referred for instrumental assessment (e.g., VFSS and FEES). Silent aspiration occurs in 25% to 30% of patients with dysphagia.
The results of instrumental assessments represent only a snapshot of swallowing function. It is imperative to interpret the results in conjunction with the overall clinical picture.
Neither tube feedings nor tracheostomy tubes prevent aspiration pneumonia. Measures to minimize aspiration include upright positioning, head elevation, oral hygiene, proper meal duration, and use of slow and continuous tube feedings.
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