Dysphagia (a disruption to swallowing function) in adults can be a symptom associated with stroke, head and neck cancer treatment, or a chronic neurodegenerative disease such as ALS or Parkinson’s. But even in the general population, current evidence suggests that 15% of people over 65 years old experience dysphagia, and it’s estimated that 235 million older adults will suffer from a swallowing disorder worldwide in 2050. [i]
If you are drinking your favorite soda or water while reading this article, you are not likely giving much thought to swallowing, and that’s because most of swallowing is reflexive, under the control of swallowing centers in the brain. But, even though the act of swallowing food, liquid, and even saliva is a basic human function occurring hundreds of times a day and that most people take for granted, safe and efficient swallowing is actually an extremely complex neuromuscular process.
Because the upper aero-digestive tract is a shared system, at any given time, muscles and structures are involved in breathing, speech, and/or swallowing. If we begin to swallow, there must be a rapid re-organization from breathing to swallowing, with timely contraction and relaxation of muscles to allow food or liquid to pass safely from the mouth to the esophagus without entering the airway. If there is a failure in the timing, strength, or function in any part of the swallowing mechanism, there is a risk of aspiration (food or liquid entering the airway).
We Can’t Know What We Can’t See
When a patient is referred to my practice with a complaint of swallowing difficulty, the first thing I will do is obtain a thorough history, including any medications they are taking, a history of any surgeries and any recent illness or chronic disease diagnosis. Patients will be asked to complete several swallowing screening questionnaires, and an oral examination assessing cranial nerve function will be conducted. But, treating symptoms is not the goal of dysphagia intervention, so it’s important to visualize the physiology.
For over 30 years, the gold-standard method for assessing swallowing safety and efficiency has been through an instrumental exam known as a modified barium swallow study or videoflouroscopic swallowing study. This is an imaging exam conducted by a trained speech-language pathologist. Debra Tarakofsky, MS,CCC-SLP, Owner of Swallowing Diagnostic, a Mobile Swallowing Imaging Company, explains that the complex process of swallowing cannot be assessed by watching someone eat, therefore an x-ray in motion (called fluoroscopy) is used visualize the swallowing system (mouth, throat, airway, esophagus). While watching the patient swallow various foods and liquids, we can determine if anything is getting caught or going down the wrong way, and why. The analysis of the study is complex and requires a highly skilled clinician.
Applying Exercise Principles to Swallowing Rehabilitation
Although swallowing exercises have been prescribed by speech-language pathologists for many years, the benefit of most swallowing exercises to rehabilitate the swallowing muscles is still poorly understood and remains the subject of many investigations. Current research, however, shows that some dysphagia programs based on the principles of exercise physiology can result in safe/functional swallow pattern leading to a decrease in infection; increased oral intake; and increased efficiency.
Newer approaches to swallowing rehabilitation aim to use principles like exercise for skeletal muscles such as: frequency (sets/reps) and intensity which must increase over time. We also know that improved performance is heavily influenced by the presence of guidance and feedback. Unlike limb movement, swallowing produces no clear external movement patterns, and intrinsic or internal feedback systems are more likely impaired with neurological deficits, thus learning through just repetition alone is less likely to occur.
New Biofeedback Technologies Put Swallowing Exercise in the Patient’s Hands
Recently, at Voice Aerobics Private Practice, two new biofeedback swallowing treatment devices were added to our treatment arsenal. The Tongueometer https://e2scientific.com/the-tongueometer/ is a portable device designed to measure and increase tongue strength and endurance for individuals who may have reduced tongue strength secondary to disease, injury, or even aging. The developers of the device, Ed Steger, a head and neck cancer survivor, and Elizabeth Lipton Daly, a speech-language pathologist, have used their combined knowledge, personal experiences, and feedback from numerous patients, clinicians, and researchers, to create a novel rehabilitation device. Patients can use the Tongueometer first under the guidance of their therapist during direct one:one dysphagia treatment, and then be used independently at home as part of their dysphagia rehabilitation program.
Mobili-T https://www.trueanglemedical.com/ is a swallowing exercise system developed by Speech-language pathologist and researcher Gabi Constantinescu with a goal of improving the well-being of individuals affected by swallowing disorders (dysphagia). Mobili-T is composed of a wireless device that is placed under the chin and provides sEMG biofeedback. When given a cue, for example to “swallow hard,” the patient is able to see on a display if they are attaining their target. Reps and sets are recorded daily and tracking information is available to the patient and their therapist. While treatment may begin in the clinic, the device was developed for patients to use at home under the guidance of their swallowing therapist.
Both portable swallowing rehabilitation devices interface with an app that can be downloaded to a phone or tablet. The visual display on the tablet screen provides feedback to patients while they are performing an exercise and stores data which can be downloaded by their therapist, or sent to their therapist, if the device is being used at home. Thus, performance over time can be monitored and new training targets established.
Professional Collaboration + Patient centered Care
For over 10 years, the team of Swallowing Diagnostics, and Voice Aerobics have provided dysphagia services to the SW Florida community. This collaborative approach allows us to effectively assess and analyze the swallowing system and develop an individualized treatment program which may include strength training, endurance training, coordination of breathing and swallowing, improving the respiratory muscle system, utilizing specific compensations, discussing your medication routine with your doctors, and many other variables. Referral to other specialists such as ENT (Ear Nose and Throat), Gastroenterology, Neurology may be recommended, and the MBS video can be reviewed with the patient and their carepartners, helping them understand what physiological impairments are impacting swallowing and the goals for swallowing rehabilitation.
In-person and Telepractice/Telehealth Dysphagia Treatment is currently re-imburseable under Medicare. Patients who are unable to drive or who live a long distance from a preferred provider, and who are comfortable using their computer for distance treatment may find the combination of a device intervention and teletherapy to be a satisfactory way of receiving dysphagia treatment. Contact Voice Aerobics to schedule an appointment: firstname.lastname@example.org or visit the website: https://voiceaerobicsdvd.com/voice-aerobics-private-practice/
Has Your Doctor Recommended a Swallowing Study? Do You Live in South Florida?
Swallowing Diagnostics, Inc. is a provider of portable and office-based diagnostic services performing Modified Barium Swallow Studies, FEES, Ultrasound studies and X-Ray in the South Florida area since 2000. Visit: https://www.swallowingdiagnostics.com/
Additional Resources: Inspired by the limitations of available treatments and the struggles, challenges and sheer bravery of patients suffering from dysphagia the National Foundation of Swallowing Disorders (NFOSD) was founded in 2006 and is the only organization of its kind, bringing together patients and medical professionals impacted by dysphagia. NFOSD provides education, resources, and patient/caregiver support groups for individuals with dysphagia. Learn more, visit: http://swallowingdisorderfoundation.com/
[i] Clinical Interventions in Aging 2019:14 283–288. An intensive swallowing exercise protocol for improving swallowing physiology in older adults with radiographically confirmed dysphagia
My Mission: To enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate and empower. Mary Spremulli, MA, CCC-SLP * FiTOUR® Group Exercise Instructor * Voice Aerobics® A Whole Body Approach to Voice Practice