Dysphagia
Inhoud
Dysphagia...............................................................................................................................................1
General framework & introduction....................................................................................................2
Frames of reference: ICF & EBP......................................................................................................2
Goalsetting SMART & SMARTER.....................................................................................................3
Definition: what is dysphagia?........................................................................................................3
Classifications.................................................................................................................................3
Prevalence......................................................................................................................................4
Consequences of dysphagia............................................................................................................5
Team approach (swallowing-team)................................................................................................5
Setting.............................................................................................................................................6
Concepts & keywords.....................................................................................................................6
Anatomy.........................................................................................................................................7
Physiology & pathophysiology............................................................................................................8
Anatomy & physiology: introduction..............................................................................................8
Classification by stage/phase..........................................................................................................9
Physiology of deglutition: phases + cranial nerves.......................................................................10
Pathophysiology...........................................................................................................................17
Assessment: non-instrumental.........................................................................................................24
Assessment: introduction.............................................................................................................24
Frame of reference: ICF................................................................................................................24
Dysphagic symptoms/at risk (group of patients that come to an SLP).........................................24
Anamnesis & file study.................................................................................................................27
Clinical swallow evaluation (non-instrumental assessment of the swallowing act)......................31
Assessment: instrumental................................................................................................................38
Assessment: introduction.............................................................................................................38
Endoscopy: FEES – introduction...................................................................................................39
Radiography and DSS....................................................................................................................45
FEES vs DSS...................................................................................................................................49
Other techniques..........................................................................................................................50
Conclusion of diagnostic process..................................................................................................51
Treatment by SLP..............................................................................................................................51
Treatment plan: introduction.......................................................................................................51
1
, Behavioural therapy.....................................................................................................................53
Rehabilitation techniques.............................................................................................................54
Compensation techniques............................................................................................................57
Other tools....................................................................................................................................62
Medical treatment & team approach...............................................................................................64
Medical therapy............................................................................................................................65
Drugs and dysphagia.....................................................................................................................67
Surgical therapy............................................................................................................................67
Surgical therapy............................................................................................................................70
Treatment implementation and follow-up...................................................................................71
Team approach.............................................................................................................................71
General considerations.................................................................................................................71
General framework & introduction
Frames of reference: ICF & EBP
ICF
Important to get the whole picture (exam:
examples for each level: health condition,…)
Dysphagia has a small observable part (choking,
coughing, chewing time = objective), the big part
is the part we can’t see and have to ask for, this
is the hardest part for the client. The hardest
part is the embarrassment, eating
problems/pleasure and effort (not going to a
restaurant,…). Use questionnaires.
Health condition (= cause dysphagia): stroke
Body functions and structures: problems with structures of tongue, esophagus,
consciousness or attention, taste function, smell function, biting, chewing, manipulation of
food in the mouth,…
Activity: eating, drinking & meal preparing (adjustments needed in the recipe),…
Participation: eating in a bigger group (restaurant, birthdayparty, lunches with friends,…)
Environmental factors: availability of aids (tools/devices to make it easier to eat), food
adjustments by others,…
Personal factors: patients preferences in food and drinks (if patient doesn’t like vanilla
pudding), cultural or religious food choices (halal),…
EBP – evidence based practice:
Difference EBP and more traditional clinical management: looking at the
patient’s desires and more critical view of evidence = best management for
the patient (desires are always important!).
Steps of EBP:
1. Formulate a clinical question
2
, 2. Best evidence to answer the question
3. Value the evidence
4. Integrate the evidence, the preferences and our own clinical experience in the management
5. Evaluate again
Goalsetting SMART & SMARTER
Smart: goals formulated by the therapist (what and how we are going to do it and very
transparent)
Smarter: formulate the goals with your patient = shared decision making
o Shared = together with patient
o Monitored = evaluate with your patient the qualitative and
quantitively point of view
o Accessible = client friendly material
o Relevant = real life
o Transparent = clear for the patient which exercise is useful for
which problem
o Evolving = change your goals
o Relationship-centred = very important to have a connection
with the client
customized management
Definition: what is dysphagia?
= Difficulty/disorder to ingest foods
Children or infants = swallowing disorders = feeding disorders (don’t use in the group of adults)
>< adults = swallowing disorders
It’s always a symptom of underlying diseases (stroke, Parkinson, neurological diseases)
2 definitions:
Dysphagia: Rosenbek & Jones (2009): disordered movement of the bolus from mouth to stomach due
to abnormalities in the structures critical to swallowing or in their movements isn’t good enough;
physiological changes doesn’t mean there is a dysphagia (delay in transport, problem with tongue,…
doesn’t mean dysphagia)
Dysphagia: Groher & Crary (2016) by Tanner: impairment of emotional, cognitive, sensory, and/or
motor acts involved with transferring a substance from the mouth to stomach, resulting in failure to
maintain hydratation and nutrition, and posing a risk of choking and aspiration. good: said
something about structures, transport and safety (when getting older there are physical changes,
but this doesn’t mean that chewing will become more difficult, transport from mouth to stomach is
delayed doesn’t mean you have dysphagia (only when there is dehydration, risk of aspiration,
undernutrition). Also the cognitive part is mentioned (dementia: aren’t alert enough very high risk
to develop dysphagia).
Classifications
Classification by age
Pediatric
Adults
Presbyphagia: dysphagia caused by the normal process of getting older
3
, Classification by stage/phase (adults)
Need to know the normal process of swallowing (4 stages)
1. Oral preparatory
2. Oral pharyngeal and oesophageal
Oropharyngeal dysphagia: caused in the mouth or throat (Focus of SLP)
Oesophageal dysphagia: esophagus/slokdarm (can cause problems in the oropharynx:
obstructions, movability, tumor,... will affect the oropharynx) refer to others to make sure
there is no other problem left
Classification by etiology (cause)
Different approach/management
1. Neurological
a. Acute: happened now (stroke, TBI,…)
b. Chronic: afterwards (not acute anymore)
c. Degenerative: progressive diseases (Parkinson,…)
2. Structural
a. Pathology
i. Congenital: born with it
ii. Acquired: Classification by
etiology
after birth
(tumor,…) neurologic structural iatrogenic presbyphagia psychogenic
b. Therapy: chemo-,
radiotherapy can acute pathology therapy primary
cause problems
with the chronic congenital secondary
production of
saliva or degenerative acquired
movement of
structures. Caused by therapy which was needed to make tissue healthy again.
3. Iatrogenic: caused by a medicine (intubated problems with vocal folds, general weakness
after surgery)
4. Presbyphagia: elder people (primary = normal process of getting older & secondary = those
who have a stroke or second problem on top of the fact that they’re old)
5. Psychogenic: when there aren’t any medical causes (phagophobia = fear of swallowing as a
result of trauma,....)
Prevalence
Frequent phenomenon (3% to 4% of the population will have problems with swallowing &
dysphagia) specific pathology groups >50%
Various figures: caused by different populations (older people will have higher prevalence) &
used criteria
4
Inhoud
Dysphagia...............................................................................................................................................1
General framework & introduction....................................................................................................2
Frames of reference: ICF & EBP......................................................................................................2
Goalsetting SMART & SMARTER.....................................................................................................3
Definition: what is dysphagia?........................................................................................................3
Classifications.................................................................................................................................3
Prevalence......................................................................................................................................4
Consequences of dysphagia............................................................................................................5
Team approach (swallowing-team)................................................................................................5
Setting.............................................................................................................................................6
Concepts & keywords.....................................................................................................................6
Anatomy.........................................................................................................................................7
Physiology & pathophysiology............................................................................................................8
Anatomy & physiology: introduction..............................................................................................8
Classification by stage/phase..........................................................................................................9
Physiology of deglutition: phases + cranial nerves.......................................................................10
Pathophysiology...........................................................................................................................17
Assessment: non-instrumental.........................................................................................................24
Assessment: introduction.............................................................................................................24
Frame of reference: ICF................................................................................................................24
Dysphagic symptoms/at risk (group of patients that come to an SLP).........................................24
Anamnesis & file study.................................................................................................................27
Clinical swallow evaluation (non-instrumental assessment of the swallowing act)......................31
Assessment: instrumental................................................................................................................38
Assessment: introduction.............................................................................................................38
Endoscopy: FEES – introduction...................................................................................................39
Radiography and DSS....................................................................................................................45
FEES vs DSS...................................................................................................................................49
Other techniques..........................................................................................................................50
Conclusion of diagnostic process..................................................................................................51
Treatment by SLP..............................................................................................................................51
Treatment plan: introduction.......................................................................................................51
1
, Behavioural therapy.....................................................................................................................53
Rehabilitation techniques.............................................................................................................54
Compensation techniques............................................................................................................57
Other tools....................................................................................................................................62
Medical treatment & team approach...............................................................................................64
Medical therapy............................................................................................................................65
Drugs and dysphagia.....................................................................................................................67
Surgical therapy............................................................................................................................67
Surgical therapy............................................................................................................................70
Treatment implementation and follow-up...................................................................................71
Team approach.............................................................................................................................71
General considerations.................................................................................................................71
General framework & introduction
Frames of reference: ICF & EBP
ICF
Important to get the whole picture (exam:
examples for each level: health condition,…)
Dysphagia has a small observable part (choking,
coughing, chewing time = objective), the big part
is the part we can’t see and have to ask for, this
is the hardest part for the client. The hardest
part is the embarrassment, eating
problems/pleasure and effort (not going to a
restaurant,…). Use questionnaires.
Health condition (= cause dysphagia): stroke
Body functions and structures: problems with structures of tongue, esophagus,
consciousness or attention, taste function, smell function, biting, chewing, manipulation of
food in the mouth,…
Activity: eating, drinking & meal preparing (adjustments needed in the recipe),…
Participation: eating in a bigger group (restaurant, birthdayparty, lunches with friends,…)
Environmental factors: availability of aids (tools/devices to make it easier to eat), food
adjustments by others,…
Personal factors: patients preferences in food and drinks (if patient doesn’t like vanilla
pudding), cultural or religious food choices (halal),…
EBP – evidence based practice:
Difference EBP and more traditional clinical management: looking at the
patient’s desires and more critical view of evidence = best management for
the patient (desires are always important!).
Steps of EBP:
1. Formulate a clinical question
2
, 2. Best evidence to answer the question
3. Value the evidence
4. Integrate the evidence, the preferences and our own clinical experience in the management
5. Evaluate again
Goalsetting SMART & SMARTER
Smart: goals formulated by the therapist (what and how we are going to do it and very
transparent)
Smarter: formulate the goals with your patient = shared decision making
o Shared = together with patient
o Monitored = evaluate with your patient the qualitative and
quantitively point of view
o Accessible = client friendly material
o Relevant = real life
o Transparent = clear for the patient which exercise is useful for
which problem
o Evolving = change your goals
o Relationship-centred = very important to have a connection
with the client
customized management
Definition: what is dysphagia?
= Difficulty/disorder to ingest foods
Children or infants = swallowing disorders = feeding disorders (don’t use in the group of adults)
>< adults = swallowing disorders
It’s always a symptom of underlying diseases (stroke, Parkinson, neurological diseases)
2 definitions:
Dysphagia: Rosenbek & Jones (2009): disordered movement of the bolus from mouth to stomach due
to abnormalities in the structures critical to swallowing or in their movements isn’t good enough;
physiological changes doesn’t mean there is a dysphagia (delay in transport, problem with tongue,…
doesn’t mean dysphagia)
Dysphagia: Groher & Crary (2016) by Tanner: impairment of emotional, cognitive, sensory, and/or
motor acts involved with transferring a substance from the mouth to stomach, resulting in failure to
maintain hydratation and nutrition, and posing a risk of choking and aspiration. good: said
something about structures, transport and safety (when getting older there are physical changes,
but this doesn’t mean that chewing will become more difficult, transport from mouth to stomach is
delayed doesn’t mean you have dysphagia (only when there is dehydration, risk of aspiration,
undernutrition). Also the cognitive part is mentioned (dementia: aren’t alert enough very high risk
to develop dysphagia).
Classifications
Classification by age
Pediatric
Adults
Presbyphagia: dysphagia caused by the normal process of getting older
3
, Classification by stage/phase (adults)
Need to know the normal process of swallowing (4 stages)
1. Oral preparatory
2. Oral pharyngeal and oesophageal
Oropharyngeal dysphagia: caused in the mouth or throat (Focus of SLP)
Oesophageal dysphagia: esophagus/slokdarm (can cause problems in the oropharynx:
obstructions, movability, tumor,... will affect the oropharynx) refer to others to make sure
there is no other problem left
Classification by etiology (cause)
Different approach/management
1. Neurological
a. Acute: happened now (stroke, TBI,…)
b. Chronic: afterwards (not acute anymore)
c. Degenerative: progressive diseases (Parkinson,…)
2. Structural
a. Pathology
i. Congenital: born with it
ii. Acquired: Classification by
etiology
after birth
(tumor,…) neurologic structural iatrogenic presbyphagia psychogenic
b. Therapy: chemo-,
radiotherapy can acute pathology therapy primary
cause problems
with the chronic congenital secondary
production of
saliva or degenerative acquired
movement of
structures. Caused by therapy which was needed to make tissue healthy again.
3. Iatrogenic: caused by a medicine (intubated problems with vocal folds, general weakness
after surgery)
4. Presbyphagia: elder people (primary = normal process of getting older & secondary = those
who have a stroke or second problem on top of the fact that they’re old)
5. Psychogenic: when there aren’t any medical causes (phagophobia = fear of swallowing as a
result of trauma,....)
Prevalence
Frequent phenomenon (3% to 4% of the population will have problems with swallowing &
dysphagia) specific pathology groups >50%
Various figures: caused by different populations (older people will have higher prevalence) &
used criteria
4
