Vol. 21 • Issue 15 • Page 6

Cover Story

Dysphagia is common after stroke, specifically when the infarct is located in the brainstem. Many people with brainstem strokes cannot eat and drink safely due to the risk of aspiration. In the hospital setting it can be determined if it is safe for the individual to eat and drink based on overt signs and symptoms of aspiration or distress during a swallowing assessment. Symptoms may include coughing, throat clearing and wet/gurgly voice after eating or drinking. These patients may be deemed NPO.

As a result, the physician and speech-language pathologist may recommend that the patient receive alternative means of nutrition and hydration. Options are a nasogastric (NG) feeding tube and a percutaneous endoscopic gastrostomy (PEG) tube. An NG tube is a narrow tube passed through the patient's nose, down the esophagus, and into the stomach. A PEG is a tube that can be inserted directly into the stomach or small intestine. Because recovery of swallowing function after brainstem stroke sometimes can take up to several months, if not longer in certain cases, PEG tubes often are recommended to ensure the patient receives adequate nutrition and hydration as the rehabilitation process and stroke recovery begins.

The following case study demonstrates that intensive inpatient therapy and a longer-than-average length of stay may be necessary and beneficial for many patients to optimize their rehabilitation goals.

Jim, 61, presented to his local acute care hospital on July 20, 2008, with symptoms of right hand and toe numbness and tingling. He was admitted to the hospital, and a computed tomography (CT) scan of the head was performed. The results indicated Jim had suffered a stroke in the left internal capsule of his brain, a dense band of motor and sensory fibers that pass through the basal ganglia and thalamus. The nerve fibers passing through the internal capsule transmit most motor-related information from the brain to the muscles of the body and most sensory information from the muscles to the brain. Damage to the internal capsule frequently results in muscle paresis or paralysis, as well as disruptions in sensation.

Jim's side effects were not severe, and he was discharged to home from the acute care hospital after a few days. He was prescribed Plavix and Aggrenox to prevent blood clots. On Aug. 11 Jim was admitted to the hospital again complaining of body weakness on his left side and balance problems that he had experienced for two to three days. Magnetic resonance imaging (MRI) of the brain revealed a new stroke in the right medulla of the brainstem. The medulla is the lower third part of the brainstem connecting the pons and the spinal cord. It is also the place where nerve fiber tracts responsible for volitional movement cross from one side of the central nervous system to the other. Damage to the medulla often causes pharyngeal and laryngeal muscle weakness, sensory loss in the limbs, and vertigo. As Jim's stroke in the medulla evolved, he presented with quadriparesis, decreased sensation and dysphagia.

A videofluoroscopic swallowing study (VFSS) indicated that he had a delayed swallow response and impaired laryngeal elevation, resulting in premature spillage of puree and honey-thick liquids to the pyriform sinuses. Penetration of the airway was observed during the swallow, followed by deep penetration of pharyngeal residue afterwards. No aspiration was viewed during the swallow study in acute care, but neither was a sensory response to the deep penetration of the airway by the puree and honey-thick liquids. Recommendations at acute care were for NPO status, PEG tube placement, and neuromuscular electrical stimulation (NMES) in conjunction with dysphagia therapy.

The patient's two strokes were believed to be caused by protein S deficiency, a rare hereditary blood disorder that increases the risk of blood clots in the veins. Protein S is a natural substance in the body that acts as an anticoagulant to prevent blood clots. Most common complications resulting from protein S deficiency are deep venous thrombosis (DVT) and pulmonary embolism (PE).

Ten days after being admitted to the hospital, Jim was transferred to Kessler Institute for Rehabilitation, in West Orange, NJ, for a comprehensive, interdisciplinary inpatient stroke rehabilitation program.

A week later he participated in the first of three videofluoroscopic swallowing studies conducted during his acute rehab stay. Results revealed severe pharyngeal dysphagia characterized by impaired tongue base retraction, compromised hyolaryngeal elevation and excursion, and reduced pharyngeal sensitivity, as well as mistiming and discoordination of the swallowing mechanism.

Airway penetration and silent aspiration were observed with trials of thin liquids, nectar-thick liquids, honey-thick liquids and puree. The only consistency Jim consumed during the study that did not result in aspiration was a cracker. However, diffuse residue in the pharynx was noted after the swallow with all consistencies attempted. In order for Jim to clear the pharyngeal residue and pass into his esophagus, he was required to swallow four times. Recommendations were to remain NPO and begin trials of ice chips and hard/crunchy solids in conjunction with NMES using the VitalStim® Therapy System and a strategy of multiple effortful swallows.

Lynn Reed, MA, CCC-SLP, a clinical specialist at Kessler Institute for Rehabilitation, discusses NMES with patient Michel Slim, MD, a former chief of pediatric surgery, accompanied by his daughter, Lina Slim-Topdjian, MA, CCC-SLP, BCBA, a speech-language pathologist in private practice.

Considering the patient's reduced pharyngeal sensation, trials of ice chips were recommended for the cold temperature and because water has a neutral pH level. Water generally is well tolerated by the lungs and absorbed into the bloodstream if aspirated. Oral care was essential in order for Jim to keep his mouth clean and reduce colonization of bacteria, which could result in aspiration pneumonia if it entered the lungs. He was encouraged to direct his caregivers to brush his teeth and tongue during the day, in addition to the oral care provided by the nursing staff and his speech-language pathologist.

Jim received 19 sessions of swallowing therapy lasting 30 to 60 minutes in conjunction with NMES. Electrode placement 3b was used to target muscles for hyolaryngeal elevation and pharyngeal contraction. The first set of VitalStim electrodes was placed horizontally above the hyoid bone, and the second set was positioned horizontally on either side of the thyroid notch of the larynx.

Due to decreased sensation resulting from the two strokes, in addition to his stated history of radiation for neck cancer approximately 15 years prior, Jim was able to tolerate high levels of NMES, a maximal amplitude of 20 to 25 milliamps (mA). Because he was cognitively intact, he was able to employ swallowing strategies, using multiple effortful swallows with each trial of ice chips and hard/crunchy solids during therapy.

Results of a second VFSS indicated a functional oral stage of the swallow and moderate pharyngeal dysphagia. He continued to demonstrate a delayed swallow response and reduced pharyngeal contraction but was able to safely manage regular-consistency solids and nectar-thick liquids by teaspoon.

He deeply penetrated trials of nectar-thick liquids by straw, and he silently aspirated all trials of thin liquids presented during the study. Recommendations were to begin a PO diet of regular-consistency solids and nectar-thick liquids by teaspoon. However, Jim required total assistance for feeding due to quadriparesis, making training of his caregivers essential.

He received another 20 sessions of swallowing therapy in conjunction with NMES, continuing to tolerate 20 to 25 mA of stimulation while completing pharyngeal strengthening exercises. An oral hold strategy was introduced so he could gain better control of thin liquid trials in his oral cavity and thus improve the timing of his pharyngeal swallow response.

Lynn Reed works with patient Michel Slim, 81, who was diagnosed with dysphagia following a stroke. He is now on a chopped diet and able to drink all liquids.

On Oct. 21 Jim participated in his final VFSS at Kessler Institute. His diagnosis was a functional oral stage of the swallow and minimal-mild pharyngeal dysphagia characterized by a mildly delayed swallow response, reduced pharyngeal constriction and reduced pharyngeal sensitivity. He was observed to penetrate his airway deeply to the level of the vocal folds with consecutive straw sips of thin liquids. Trace silent aspiration was observed during the swallow on only one trial of consecutive sips of thin liquids via straw. No penetration or aspiration was viewed when Jim consumed thin liquids by small single straw sips.

Recommendations were to remain on regular-consistency solids but to upgrade to thin liquids by small, single straw sips. He was able to monitor the size of his sips and direct his caregivers on how to feed him safely.

Jim was discharged from Kessler Institute for Rehabilitation on Oct. 28 to a subacute facility for additional physical and occupational therapies. At the time of discharge, he had participated in 40 sessions of swallowing therapy in conjunction with NMES, was tolerating a regular-consistency diet with thin liquids by small straw sip, and achieved all of his speech and swallowing goals.

During the course of his therapy, Jim was compliant with all recommendations made, participated to the best of his ability in all therapy sessions, and demonstrated excellent carryover of swallowing strategies. He tolerated NMES well and never developed aspiration pneumonia while at Kessler. After his subacute stay and home modifications were completed for wheelchair accessibility, Jim returned home with his wife.

Resources

• Brookshire, R.H. (1997). Introduction to Neurogenic Communication Disorders (5th ed.). Mosby.
• Feinberg, M.J., Knebl, J., Tully, J., et al. (1990). Aspiration and the elderly. Dysphagia, 5: 61-71.
• Feinberg, M.J., Knebl, J., Tully, J. (1996). Prandial aspiration and pneumonia in an elderly population followed over three years. Dysphagia, 11: 104-09.