Welcome to the TBI-HELP Live Chat

  Today's topic is: "Swallowing Disorders Relating to TBI"

 Our Guest is: Ms. Suzanne Marinos, M.S.CCC-SIP, Chief of Speech and Audiology, Jamaica Hospital Medical Center

[19:02:12] mod: Welcome Susanne. Susanne comes to us tonight from Jamaica Hospital Medical Center and is the Chief of Speech and Audiology.
[19:02:36] mod: Her topic this evening pertains to Swallowing Disorders related to Traumatic Brain Injury.
[19:03:06] Suzanne: It's my pleasure to be here.
[19:03:20] Suzanne: Hello everyone!
[19:05:37] mod: Susanne can you please explain a little about swallowing disorders?
[19:06:13] Suzanne: Swallowing disorders can occur post traumatic brain injury. This is caused from trauma to the brain, brainstem, or cranial nerves. The swallowing disorder is usually oral and pharyngeal in nature. This means that the patient may have loss of bolus control and reduced tongue control. The patient may also have a delay in triggering the swallow. We notice that the bolus slips into the pharynx before triggering a swallow reflex.
[19:09:13] mod: What does a trauma to the brain have to do with swallowing?
[19:10:40] Suzanne: Trauma to the brain, brainstem, or cranial nerves responsible for swallowing function may be impaired. The patient may have oral and/or pharyngeal dysphagia. This means that the patient may have loss of bolus control and reduced tongue movement. Impaired cognition due to brain injury also interferes with oral intake. Decreased attention, increased agitation, and short-term memory deficits are all factors that can affect oral intake.
[19:14:21] mod: What is the frequency and type of swallowing disorders in patients with severe brain disorders?
[19:14:46] Suzanne: In a recent study of 54 patients, 61% of the patient population had swallowing impairments. The study focused on patients with severe brain injury.
[19:17:52] mod: PattiSue: Hi. How can you help a person with a swallowing disorder control drooling?
[19:18:08] Suzanne: The patient would receive dysphagia therapy which would focus on improving oral motor skills for swallowing. In addition, therapy would focus on remediating the cognitive deficits which interfere with oral control.
[19:19:55] mod: Rail: Suzanne - are there other, correlated problems where swallowing control is an early indicator-that may be more serious?
[19:20:33] Suzanne: Rail, would you please be more specific.
[19:20:36] mod: PattySue: what's the correct head positioning for the best swallow?
[19:21:25] Suzanne: PattiSue, in answer to your question, the best head position is usually determined during a swallowing study. That is the study we do in Radiology. We give the patient different consistencies to swallow. If we see that the patient has delayed oral/pharyngeal stage of swallow, we may introduce some provocative maneuvers to facilitate the swallow and avoid aspiration.
[19:22:42] mod: PattiSue: that blue dye stuff?
[19:23:24] Suzanne: Oh yeah! the famous blue food coloring. We use that with trach patients. Signs of blue dye following suctioning from the trach site is indicative of an inability to tolerate their secretions. However, if the patient can tolerate a swallowing study, we would use that procedure instea or in conjunction with the blue dye.
[19:25:12] mod: Is there a special diet for people with swallowing problems?
[19:25:59] Suzanne: Usually we chose what is considered the safets diet. The safest is the one that reduces the risk of aspiration. Patients with poor bolus control or reduced tongue strength may benefit from a pureed diet with thickened liquids. Following dysphagia therapy, we strive to upgrade their diet to atleast a chopped consistency.
[19:27:20] mod: PattiSue: So actually its possible that a person with the cognitive ability to learn can relearn how to swallow without aspirating?
[19:28:40] Suzanne: They could learn to swallow without aspirating if they are able to follow specific instructions, or demonstrate compensatory strategies that will prevent from aspirating. Usually these strategies are evaluated in terms of effectiveness during the swallowing study.
[19:29:12] mod: henry: How do you evaluate what someone can eat?
[19:29:58] Suzanne: Hi Henry! Good question. We use a specific radiological procedure called the modified barium swallow. The patient is given various consistencies and we use special x-ray to watch the consistencies from the time it enters the mouth till it enters the stomach.
[19:30:44] mod: henry: Interested to know what are some of the dysphagia therapies that one can use and how effective are they?
[19:32:06] Suzanne: Dysphagia therapy can be direct or indirect. We may work on improving oral motor control (tongue exercises), stimulating the swallowing reflex, or may give the patient therapeutic trials of purre/thickened liquids. This is all done under the direction of a speech-language pathologist.
[19:33:04] mod: Welcome Amanda: Amanda has an interesting question: How often is retesting done after a not so good result? Can swallowing improve as healing takes place?
[19:33:55] Suzanne: It depends on the severity of the brain injury. Sometimes we will re-evaluate within 2 weeks, especially if we notice that the patient is responding to dysphagia therapy.: I must say that I had to retest sooner, especially when the patient not only voiced his desire for a hamburger, but also tried to take another person's food tray.
[19:34:38] mod: Rail: In addition to Radiology Studies, are there other diagnostic tools that are used such as monitoring muscular activity within the throat to observe correct swallow sequences?
[19:36:40] Suzanne: Rail, there are other method for measuring muscular activity however, those diagnostic tools may tell you that the patient will aspirate. However, we want to know how to prevent aspiration.

[19:37:15] Suzanne: Let me clarify a big misconception about swallowing studies.
[19:37:41] Suzanne: If the patient is given a barium swallow and he aspirates, the radiologist terminates the study. However, if a modifies barium swallow is ordered, the speech therapist performs the study with the radiologist. We know the patient will aspirate. We want to chose the best type of consistency that will prevent aspiration and avoid the use of a feeding tube.
[19:38:59] mod: Carol: Can someone with a TBI and swallowing problems ever be retained to swallow or eventually eat again?
[19:40:51] Suzanne: Carol, I answered this question earlier but will provide you with some of my answer because it is a good question which is asked frequently. The goal of dysphagia therapy is to provide the patient with the safest diet consistency to avoid aspiration. Initially, the patient will receive intense therapy to facilitate oral motor control and to improve the swallow reflex. True, there is improvement in swallow function as there in improvement in brain functioning. We chose the safest diet to be taken while the patient is recovering.
[19:43:38] mod: Rail: Given the details we know about the muscular sequence for the heart, don't we have similar knowledge about the muscles and neuro-muscular sequencing in the swallow? And, if we have that, can't we intervene with something like a pacemaker to correct the sequence once a swallow begins?
[19:45:27] Suzanne: Rail, that's a good question. However, there are 3 stages to swallowing which are controlled by the brain. Dysphagia therapy works towards improving the brain function for the swallowing mechanism.
[19:45:39] mod: Carol:  What are some of the emotional concerns that both patients and families have regarding swallowing, choking and not being able to eat...Do the patients get depressed?
[19:46:10] Suzanne: Carol, patients and family members get depressed. The dysphagia may also contribute to the patient's agitation. Family memebers also become depressed because the may feel that eating normally means your on your way to being like you used to be.
[19:47:44] mod: Amanda: which part of the brain controls speech and swallowing? Which part needs to be retrained to help this disorder?
[19:48:30] Suzanne: Speech output is controlled in the left hemisphere in the frontal lobe area. Swallowing function is controlled by the cranila nerves (brainstem). However, in TBI unlike with a stroke which is a focal lesion, the diffuse trauma affects the entire brain circuitry
[19:50:26] mod: Jeff: Do people that have problems with swallowing also have problems with speech and visa versa?
[19:50:59] Suzanne: Yes, Jeff they do. Patients with swallowing disorders may also have dysarthria. Dysarthria is impairment of the neuromuscular control of how the patient articulates, breathes, phonates, moves his tongue, etc.
[19:51:41] mod: Amanda: I think part of an answer to patient depression about dysphagia is that eating is a social activity and we all participate in.
[19:53:16] Suzanne: Amanda, I totally agree. Especially in some cultures where eating is the thing we all do at dinner, family events, holidays, etc. I feel bad when a patient is unable to go home for the holidays and to top it off can't have a chopped diet (like chopped turkey or something).
[19:54:15] mod: What does the future hold for new therapies for these conditions?
[19:55:54] Suzanne: Jeff, recently my staff went to a workshop on Deep Pharyngeal Neuromuscular therapy that is more intense than just tongue exercises or thermal stimulation. We have used this therapy on a few patients and have seen some nice results.
[19:56:18] mod: Jeff: How do we compensate for the issues Amanda raises during the holidays?
[19:57:38] Suzanne: Jeff, it depends on the stage of dysphagia, and really it depends on working close with the therapist.
[19:59:04] mod: Jeff: Can you explain DPN therapy...I'm really not familiar with it of much else on this topic?
[19:59:43] Suzanne: Basically, we use ice cold lemon glycerine swabs. We place the swab on areas of the pharyngeal cavity (by the tonsils, the pharyngeal wall) to stimulate a reflex. Overtime, the swallowing reflex improves.: We ask the patient to swallow his saliva post stimulation of the reflex.
[20:00:26] mod: Amanda: Can different temp. foods be swallowed easier than others?
[20:01:20] Suzanne: Yes. For example, cold food /liquids heighten the oral awareness of the presence of something in your mouth. Also, different tastes, like sweet or sour are easier for patient to swallow. It's not because it goes down easier, but because they are more aware of the food.
[20:02:16] mod: Are you looking for a gag reflex?
[20:03:05] Suzanne: No, not a gag reflex, a swallowing reflex.
[20:03:48] mod: I am sorry to say that we have come to the end of our chat. I want to thank Suzanne for her participation tonight on this very interesting topic and we look forward to having her as a guest in the future.
[20:03:58] mod: Good night to all and see you next week.
[20:04:36] Suzanne: Thanks everyone for such interesting questions. I hope it was informative.