Combining treatment modalities to facilitate progress in a patient with difficulty swallowing following stroke.
As post-stroke dysphagia often affects both sensory and motor components of the swallow and both elements are necessary for safe and efficient swallowing, it makes good clinical sense to combine treatment modalities to rehabilitate both aspects of swallow function. Attacking dysphagia with all these weapons in our clinical arsenal, combined with a patient’s unwavering motivation to improve, can offer a powerful means to reach the all-important PO diet.
A.M., a 54-year-old male status post stroke with right-side paresis, was admitted to Kessler Institute for Rehabilitation in West Orange, N.J., on August 31, 2015 following a 13-day stay in an acute care hospital. The patient’s medical history included obesity, hypertension and hypercholesterolemia. The site of lesion was unclear as an initial CT scan taken in the hospital showed no acute intracranial pathology and the patient demonstrated poor tolerance of an MRI when that assessment was attempted.
The patient was admitted to Kessler NPO with a PEG for nutrition and hydration. The PEG placement occurred following a videofluoroscopic swallow study (VFSS) in the hospital on August 21 that indicated a moderate oral and severe pharyngeal dysphagia. At that time, A.M. was deemed to be at high risk for aspiration with all PO solid or liquid consistencies.
On Sept. 1, A.M. was seen for a clinical swallowing evaluation at Kessler Institute.
He continued to present with clinical symptoms consistent with a severe pharyngeal dysphagia, and a delayed pharyngeal swallow and decreased hyolaryngeal excursion were noted. A wet vocal quality and dysphonia were noted prior to the administration of PO trials and a wet vocal quality was inconsistently noted post limited trials of puree and water.
A repeat VFSS was conducted on Sept. 3 to establish a current baseline for pharyngeal swallow function and to direct the treatment plan. At that time, A.M. presented with a moderately severe oropharyngeal dysphagia. Oral stage deficits were noted in bolus propulsion time and bolus control (resulting in premature spillage).
Pharyngeal stage deficits were noted in the timing of the pharyngeal response, base of tongue retraction, pharyngeal constriction, hyolaryngeal elevation and excursion, pressure generation and sensory integrity. Due to the pharyngeal stage deficits, A.M. demonstrated mild to moderate residue in the vallecula and significant residue in the pyriform sinuses with all consistencies, and limited sensation of residue was also observed.
The patient was unable to fully clear residues with use of 5 to 10 additional effortful swallows per bolus. He was therefore deemed to be at continued high risk of aspiration with all PO consistencies, although no aspiration or penetration was visualized on the VFSS, and he was recommended to remain NPO.
An intensive dysphagia therapy program, consisting of at least five 30-minute sessions per week, was completed. Sessions were extended to 60 minutes and additional sessions were completed on Saturdays.
During his inpatient stay, he participated in a total of 15 therapy sessions and completed dysphagia exercises (in the absence of PO) independently.
Therapy included neuromuscular electrical stimulation (NMES) consisting of one electrode in a horizontal placement on the lower pharynx targeting the lower pharyngeal constrictors at up to 15mA. An additional electrode often could not be used due to the presence of hair on the superior part of the neck.
Therapy incorporated pharyngeal/laryngeal exercises and deep pharyngeal neuromuscular stimulation (DPNS) treatment techniques. The patient executed the effortful swallow, the super supraglottic swallow and the Mendelsohn in conjunction with limited 1cc to 3cc trials of water and/or ice chips. In addition, the Masako and exercises targeting base of tongue retraction were completed. DPNS techniques were used to facilitate sensory input to cranial nerves 5, 9 and 10.
Two follow-up video swallow studies were completed. The first, conducted on September 10, revealed a reduction in pharyngeal residue; however, the patient was not deemed ready to start on a PO diet until the final VFSS on Sept. 22.
During that study, the patient’s oropharyngeal dysphagia was characterized as mild in severity. Improved timing of the pharyngeal response and a significant reduction in vallecular/pyriform residue were noted when compared with the previous test.
Transient penetration was observed with residue from the pyriform sinuses. However, use of 4 to 5 additional swallows was effective at clearing pharyngeal residue. Sensory integrity was also noted to be improved from prior studies, as the patient spontaneously initiated second swallows. The patient was recommended to start on a PO diet of NDD3 (bite size soft) solids and all liquids if deemed clinically appropriate following a meal management session.
A.M. was subsequently seen for a trial meal session with the recommended solid and liquid consistencies and demonstrated clinical tolerance of this diet given minimal verbal cues to use compensatory strategies (controlled rate, controlled volume, multiple effortful swallows, alternation of consistencies). He was then started on a PO diet of NDD3 solids and all liquids shortly before discharge from Kessler Institute.
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