I am excited to have everybody here today and to be able to provide Part Two of this “Dysphagia after a traumatic brain injury (TBI)” discussion. I am Erin Mattingly, and I do not have any financial disclosures; I have not received any compensation from test, treatment, or application developers or publishers. Any recommendations I give in this presentation are based on my own clinical experience. As for non-financial disclosures, I am a member of the American-Speech-Language-Hearing-Association's (ASHA) Special Interest Group 2 Coordinating Committee, which is the Neurogenic Communication Committee. I am a member of the Academy of Certified Brain Injury Specialists Marketing Committee and a member of the American Neurologic Communication Disorders and Sciences Communications Committee. Like I mentioned, all opinions that I give are my own.
TBI and Dysphagia - Review
We are going to go through this initial part quickly because I covered some of it in my previous Part One session on evaluation. There was a specific request to cover some information on speaking valves, so I did add that as a talking point to this session even though there is no slide on it.
Traumatic brain injury is a disruption in the normal function of the brain that can be caused by a bump, blow, or jolt to the head, or a penetrating injury” (Marr & Coronado, 2004). Alteration of consciousness is a result of the TBI, and is defined as “any period of loss of, or a decreased level of, consciousness; any loss of memory for events immediately before (retrograde amnesia) or after the injury (posttraumatic amnesia); neurologic deficits or any alteration in mental state at the time of injury (confusion, disorientation, slowed thinking, etc.)” (Menon, Schwab, Wright, & Maas, 2010).
An estimated 10 million people worldwide experience a TBI annually. Those are only the people that are documenting their experiences, so that is probably an underestimate. Within the US alone, an estimated 2.8 million people sustain a traumatic brain injury annually. TBI is a contributing factor to roughly a third (30%) of all injury-related deaths in the US. These are significant numbers. With the recent increase in awareness about concussion and mild traumatic brain injury, I am sure these numbers are higher and will continue to rise.
Children ages 0-4, adolescents ages 15-19, and adults 75 years old and older are among the most likely to have a TBI-related emergency department visit or to be hospitalized for TBI. If you think about it, children and the elderly are more likely to fall. Adolescents are more likely to engage in high-risk behaviors.
The annual average percentages of TBI by external cause are: falls, 47%; being struck by or against something, 15%; motor vehicle, 14%; and assault, 9%. Those statistics are from Taylor et al. (2017). Leading causes of non-fatal TBI in the US, per Faul and Coronado (2015), are: falls, 35%; motor vehicle-related injury, 17%; and strikes or blows to the head from or against an object (such as in sports injury), 17%. We hear a lot about football these days, but there are also significant numbers of soccer-related head injuries as well. Keep that in mind with your patients.
The majority of TBIs in the US are mild in nature; they are mild TBIs or concussions. Mild TBI rarely results in dysphagia, which is what we will be talking about today, so most of the patients that we are going to talk about have moderate to severe head injuries. We will mainly focus on the inpatient to intensive outpatient treatment areas, and discuss some aspects of acute and long-term care.
Dysphagia includes problems involving the oral cavity, pharynx, esophagus, or gastroesophageal junction, and can result in dehydration, malnutrition, aspiration, pneumonia, other lung disease processes, and possibly death. I am sure we have all seen patients without traumatic brain injury who come in for surgery and end up with aspiration pneumonia, perhaps as a result of sedating medication or something similar. Every once in a while I see a progression where somebody who did not come in with this issue starts having severe dysphagia and actually ends up passing away from it. It is very important to recognize that even folks who are not diagnosed with dysphagia right away can develop it, and it can progress rather quickly.
Dysphagia Following TBI
The incidence of dysphagia is as high as 93% in patients admitted to rehabilitation for TBI. Earlier, I mentioned that the majority of patients with brain injury have mild TBI, and they do not have dysphagia. But with the patients that you are seeing in acute care, inpatient rehab, or even outpatient rehab, there is a pretty high chance they are going to have some sort of dysphagia.
The tricky thing about dysphagia following TBI, as opposed to other diagnoses such as stroke, is that it is very complex and multifactorial in nature. You can have the neurological impairment itself - the site of injury - and then you may have a cognitive-communication impairment on top of that. We will talk more about that in a minute. Attention issues, memory issues, poor problem solving, and impaired executive functioning all play a role, in addition to communication problems. If you have a patient who ends up with aphasia and is not able to understand some of the compensatory strategies he is supposed to use, that can impact his dysphagia status.
There is also a behavioral side. For a variety of reasons, many of our patients with traumatic brain injury end up with behavior issues. This is usually tied to frontal lobe injury, but also, just because of the multifactorial nature of brain injury, you can see refusal, acting out, and/or aggression. It is important to note that with TBI, not only is there a focal injury, but there is also diffuse axonal injury, such that axons throughout the brain - not just at the focus of injury – are impacted. There can also be a hypoxic or anoxic component on top of that due to blood loss or surgery or whatever the case may be, so it is really complex.
The dysphagia caused by neurological impairment can impact any or all of the three phases of the swallow -- oral prep, oral, and pharyngeal phases. Medications can also impact swallowing after traumatic brain injury. Many of your patients, especially those with severe injuries, are on sedating medications. They may be in a medically induced coma or be on pain meds, antiseizure meds, etc. Antiseizure and blood pressure meds can be sedating in and of themselves. There is just a whole host of things that can impact swallowing after a TBI.
What else can affect swallowing post-traumatic brain injury? You can have patients who are on oral ventilation. You can have tracheostomy with or without a vent. We will talk a little bit more about that later. But that, of course, is going to impact swallowing in patients after a traumatic brain injury. I am sure that I am not the only one who has experienced writing an order for a swallow evaluation in somebody who is orally intubated. It is not an option, and it is important that we educate our MDs about why that is not an option, and that we appreciate that they are referring to us, but a swallow evaluation is not appropriate when the patient is orally intubated.
The other thing is the physical injury itself. Usually, if you are in an accident or have been assaulted or have fallen, and you have hit yourself hard enough to cause this moderate to severe injury, there is usually going to be injury somewhere else. There may be an injury in your head and neck area, or other areas of your body, that might impact your positioning. That is important to be aware of as well.
What else can impact swallowing after traumatic brain injury, other than what we have already talked about? Participants are saying safety awareness, motivation, issues with insight, depression or mood. All of those can definitely play a role.
Impact of Cognitive-Communication and Behavioral Deficits on Swallowing
Let’s talk about how these cognitive, communication and behavioral deficits impact the swallow. Attention and arousal are very important. As mentioned before, the patient needs to be able to really pay attention to what is in front of her, and pay attention to you, while giving her directions. As for arousal, if you are treating a patient who has just emerged from a minimally conscious state, she is only going to be able to handle so much throughout the day. The arousal level can impact the swallow and may make it unsafe to engage in regular oral feeding.
Memory affects patients’ swallowing, in that they may have difficulty remembering their strategies. They may not remember that they are on thickened liquids, or that they need to turn and attend to the left if they have right hemisphere attentional issues. Executive functioning impairments may result in lack of judgment and impulsivity. We have all seen that patient who is really impulsive and just throws food into his mouth and creates a real choking hazard.
I mentioned behavioral issues and agitation earlier. The patient may refuse to eat, or throw food, or shove food into his mouth. There may be attention-seeking behaviors.
Patients may be highly distractible, and there may be inattention to the food in front of them, or they may even be so distracted they forget to eat. We have all seen patients with trays in front of them when everyone else is eating but they are just too distracted by everything going on in the rehab gym or in the dining room. Low arousal can cause a swallow delay. Executive dysfunction may result in planning and organizing problems, such that they do not apply or carry over strategies to real life. You may have a patient who has been doing really well at focusing and following the swallowing strategies in the rehab gym or dining room, but if you take her out in the community, it is all gone, because she is so over-stimulated. It is important to watch for that. Behavioral outbursts may create a higher risk for aspiration.
Assessment of Dysphagia
All of you know that assessment should begin with a very thorough patient history. You need to do an oral-motor exam to look at cranial nerve involvement, dentition, oral hygiene, and so on. A cognitive-communication screen allows you to see how aware patients are of swallowing issues as well as everything else. You also want to do an overall observation of function. Is the patient aware of what a fork and a spoon are? Does he know how to use a cup and a straw? It
There are instrumental and non-instrumental assessments. By instrumental, I mean fiberoptic endoscopic evaluation of the swallow (FEES), or the videofluoroscopic swallow study (VFSS) or the modified barium swallow study (MBS). Usually, those last two terms are used interchangeably. There was a bit of debate in the last presentation about the modified blue dye test; that is considered an instrumental evaluation despite a lack of evidence for its efficacy. Non-instrumental assessments would include the bedside swallow evaluation (BSE), bedside water screening protocol, and so on.
Treatment of Dysphagia following TBI
Primary Goals of Dysphagia Intervention
This information comes from the ASHA Adult Dysphagia Practice Portal, which I highly recommend if you have not checked it out yet. I don’t work for ASHA, and this is just my opinion, but I think it is a great resource.
The first primary goal of dysphagia intervention, as stated by ASHA, is to safely support adequate nutrition and hydration, and return to safe and efficient oral intake. I really like that goal because it is very functional. We want our patients to get back to being able to consume things orally. We do not want them stuck on percutaneous endoscopic gastrostomy (PEG) tubes for years, or on nasogastric (NG) tubes for longer than they should be.
Other goals are to determine the optimum feeding methods and/or techniques to maximize swallowing safety and feeding efficiency and minimize the risk of pulmonary complications such as aspiration pneumonia. We also want to reduce patient and caregiver burden while maximizing the patient's quality of life. I am sure most of you have interacted with caregivers who are completely overwhelmed by the thought of having to thicken liquids every single day of their loved ones’ lives, or for the rest of their lives. So think about trying to lessen that impact when you can, while still keeping patient safety in mind. Lastly, it should be our goal to develop treatment plans that improve safety and efficiency of the swallow. All of those are, per ASHA, the primary goals of dysphagia intervention.
Categories of Dysphagia Treatment
We talked about how the clinical or non-instrumental assessment at the bedside, and/or the instrumental assessment, should always occur prior to initiating treatment. Even if a patient is coming in with a complete medical history, or just had an MBS and does not need another right away, you want to do a bedside screen to see how she performs. Always start out treatment with an evaluation.
There are different types or categories of treatment. The goal of rehabilitative and restorative treatment is to restore function. Compensatory strategies may include the tongue hold, chin tuck, and diet modifications such as thickening liquids; the goal of these is not to restore function, but to prevent aspiration or signs/symptoms of dysphagia. There are also approaches that incorporate both these types of treatment, by trying to prevent aspiration while also restoring function at the same time.
Let’s start with the rehabilitative and restorative exercise piece. These are exercises that impact swallowing physiology and bolus flow.
Tongue hold. One example of this is the tongue hold, which is used with patients who are demonstrating decreased contact between the tongue base and pharyngeal wall. To do this exercise, you bite your anterior tongue and swallow. If you do that, you will feel how it creates this “bulkiness” in the anterior pharyngeal swallowing space and allows increased contact between the two areas. It is a little bit awkward and probably not great for severely brain-injured folks, but it is a good exercise to try and a little less complicated than some of the others.
Shaker exercise. There is also the Shaker exercise, which is quite complex. It helps with decreased upper esophageal sphincter opening and weakness of the suprahyoid muscles. To do it, you lie supine (i.e., on your back). You complete three head lifts sustained for one minute each, followed by a rest period. Then you do 30 consecutive head lifts for two seconds each. The goal is to increase hyolaryngeal excursion by increasing the strength of the suprahyoid muscles and shortening that thyroid-hyoid (thyrohyoid) space. It is very, very complex. I think this would be better for someone with a very mild brain injury or someone who is an outpatient.
The tongue hold can be considered both compensatory and restorative because it is strengthening that musculature (restorative) while also shortening the tongue base/pharyngeal wall gap (compensatory).