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Dysphagia 10:1-5 (1995)
Dysphagia
9 Springer-Verlag New York Inc. 1995
Swallowing Therapy of Neurologic Patients: Correlation of Outcome
with Pretreatment Variables and Therapeutic Methods
Stefanie Neumann, MA(phil), t Gudrun Bartolome, SLP, ~ David Buchholz, MD, 2 and Mario Prosiegel, MD 1
~Neurologisches Krankenhaus Miinchen, Munich, Germany; and 2The Johns Hopkins Swallowing Center and Department of
Neurology, The Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
Abstract. The results of swallowing therapy in 58 pa-
tients with neurologic disorders are presented. All pa-
tients received tube feeding, either partially or exclu-
sively, at admission, and successful outcomes, defined as
exclusively oral feeding, were achieved in 67% of pa-
tients over a median treatment interval of 15 weeks. A
subset of 11 patients who had experienced disease onset
25 weeks or more prior to admission nonetheless had a
similar success rate of 64%. No other pretreatment vari-
able, including age, localization of lesion, type or degree
of aspiration, or cognitive status, correlated with success-
ful outcome. Indirect therapy methods such as stimula-
tion techniques and exercises to enhance the swallowing
reflex, alter muscle tone, and improve voluntary function
of the orofacial, lingual, and laryngeal musculature were
utilized in all but 1 patient. Direct methods including
compensatory strategies such as head and neck position-
ing, and techniques such as supraglottic swallowing and
the Mendelsohn maneuver were additionally employed in
nearly one-half of patients. Swallowing therapy is associ-
ated with successful outcome, as defined by exclusively
oral feeding, among patients with neurogenic dysphagia,
regardless of pretreatment variables including time since
disease onset. Indirect treatment methods appear to be
effective when used either alone or in combination with
direct methods. Achievement of oral feeding is not asso-
ciated with undue risk of pneumonia. Further rigorous
scientific studies are needed.
Key words: Dysphagia -- Swallowing therapy --
Swallowing rehabilitation -- Deglutition -- Deglutition
disorders.
Swallowing therapy in patients with neurogenic dyspha-
gia takes two basic forms: direct and indirect. Direct
therapy emphasizes compensatory techniques to help
cope with sensorimotor impairment of the oral cavity,
pharynx, and/or larynx, resulting in swallowing dysfunc-
tion. Examples of these compensatory techniques include
postural adjustment, double swallowing, supraglottic
swallowing, and the Mendelsohn maneuver [1-4]. The
potential applications and benefits of these approaches
have been previously discussed [5-14].
Indirect swallowing therapy, on the other hand,
attempts to overcome sensorimotor impairment through
stimulation techniques and exercises to enhance the swal-
lowing reflex, alter muscle tone, and improve the func-
tion of voluntary orofacial, lingual, and laryngeal mus-
cles. It is based on the principle that, following
neurologic injury, recovery of lost functions can be facil-
itated by specific stimulation and re-education of the
neural pathways governing those functions [ 15,16]. This
principle underlies many established neurologic rehabili-
tation strategies [ 17-23].
The study reported herein retrospectively reviews
the outcomes of 58 patients with neurogenic dysphagia
who were treated with either indirect therapy alone or
indirect plus direct therapy. Additionally, patient out-
comes were correlated with important pretreatment vari-
ables. The results are consistent with the position that
swallowing therapy is safe and efficacious and should be
considered for all patients with neurogenic dysphagia.
Furthermore, indirect therapy alone appears to be an ef-
fective approach for selected patients.
Address offprint requests to:
David Buchholz, M.D., 601 N. Caroline
Street, Room 5072A, Baltimore, MD 21287-0876, USA
Patients and Methods
The
study group consisted of 32 males and 26 females aged 22-84 years
(median 57 years) who were hospitalized at a neurologic rehabilitation
2 S. Neumann et al.: Swallowing Therapy of Neurologic Patients
facility. They were seen consecutively over a period of 5 years and had
been referred for swallowing therapy because of overt difficulty swal-
lowing. Exclusion criteria were (1) nonneurologic underlying illness,
(2) exclusively oral feeding at time of admission, and (3) prior surgery,
such as cricopharyngeal myotomy or laryngeal suspension, to improve
swallowing.
Underlying illnesses included ischemic infarction, hemorrhage,
neoplasm, and traumatic brain injury. Additionally, 2 patients had
brainstem encephalitis. Lesions were categorized as either cortical,
basal ganglia, or brainstem and as either unilateral or bilateral. The
median time since onset of disease (time since lesion) was 10 weeks
with a range of 3-156 weeks.
Patients were studied by means of interview, clinical ("bed-
side") swallowing examination, cognitive testing, and cineradiographic
evaluation of swallowing based on the method of Donner modified by
Hannig [24]. Swallowing studies were performed before and after (and
in some cases also during) swallowing therapy.
Pretreatment patient variables included (1) age, (2) localization
of lesion, (3) time since lesion, (4) type of feeding (partially or exclu-
sively tube feeding), (5) swallowing phase impairment (oral prepara-
tory, oral, pharyngeal, and/or esophageal), (6) type of aspiration (none,
pre-, intra-, or postdegluttitive), (7) degree of aspiration (none, penetra-
tion of laryngeal vestibule without subglottic contrast, < 10% subglottic
contrast with cough present, or > 10% subglottic contrast and/or cough
absent), and (8) cognitive status (presence or absence of attention,
memory, or planning/problem solving deficits).
Swallowing therapy was of two types: direct and indirect. Direct
methods involve compensatory strategies based on manipulation of the
act of swallowing during food intake. These techniques have been
previously described in detail [1-14] and include head and neck posi-
tioning, supraglottic swallowing, and the Mendelsohn maneuver.
Indirect therapy methods attempt to stimulate the swallowing
reflex and to restore voluntary orofacial, lingual, and laryngeal motor
activity; they can be divided into three categories: (1) stimulation, (2)
assisted exercises, and (3) independent exercises.
Stimulation is conducted prior to exercising and utilizes sensory
stimuli not only to promote reflex activity but also to encourage volun-
tary motor function or alter muscle tone. For example, as described by
Logemann [5], an iced mirror applied to the faucial arches is intended to
trigger the swallowing reflex. Passively stretching a patient's cheek
laterally with a tongue blade placed into the corner of the mouth is
utilized to increase facial muscle tone and enhance subsequent volun-
tary closure of the mouth. Stimulation of the tongue via stretching,
brushing, or icing is performed to activate movements and, depending
on the stimulus, increase or decrease muscle tone.
Assisted exercises can be isotonic (movement against resis-
tance) or isometric (maintenance of position against resistance). For
instance, an isotonic exercise would be pushing a tongue blade away
from the mouth with the tip of the tongue, whereas an isometric exercise
would be holding the tongue steady in the midline while the therapist
applies lateral pressure.
Independent exercises include more complex, voluntary actions
that are described and/or demonstrated by the therapist and then copied
by the patient. For example, the patient may be taught to voluntarily
prolong laryngeal elevation. By building on these learned skills, the
patient may then be able to accomplish compensatory techniques such
as supraglotfic swallowing and the Mendelsohn maneuver, which are
among the methods of direct therapy. Indirect therapy can thereby serve
as a bridge to successful direct therapy.
The patients in this study received individualized therapy 5 days
per week for approximately 45 rain per session. Twenty-nine patients
(50%) received indirect therapy alone, 28 were treated with both direct
and indirect methods, and 1 patient had only direct therapy. The deci-
sion as to how each patient was treated was made at the discretion of the
Table 1. Swallowing phases showing impairment (>10% prevalence)
Pharyngeal 31%
Oral preparatory + oral + pharyngeal 26%
Oral preparatory + oral 17%
Oral + pharyngeal 12%
Table 2. Type of aspiration
21%
14%
7%
24%
None
Predegluttitive aspiration ~. __
- - Intradeglutt~tlve .... asp~ratlon ~ 13%. ^_
9% Postdegluttitive aspiration / 1o%
The converging lines indicate percentages of coexisting types of aspira-
tion.
Table 3. Degree of aspiration
None 21%
Penetration of laryngeal vestibule 21%
< 10% with cough present 23%
> 10% and/or cough absent 35%
swallowing therapist, based on clinical and radiographic assessment.
Regardless of the type of therapy chosen, all patients received appropri-
ate modification of dietary consistencies. Treatment lasted a median of
15 weeks with a range of 2-52 weeks.
Outcome of therapy was judged on the following scale: (1)
exclusively oral feeding without compensatory techniques, (2) exclu-
sively oral feeding with compensatory techniques, (3) partially oral
feeding without compensatory techniques, (4) partially oral feeding
with compensatory techniques, and (5) exclusively tube feeding. For
statistical analysis, a successful outcome was defined strictly as catego-
ries 1 and 2 (exclusively oral feeding without or with compensatory
techniques). Successful outcomes were correlated with pretreatment
patient variables and with the type of therapy (indirect alone vs. indirect
plus direct). In addition, the type and duration of therapy were corre-
lated with each other and with certain pretreatment variables.
Results
Prior to treatment, 50 patients (86%) had exclusively
tube feeding and 8 (14%) had combined oral and tube
feeding. The frequencies of swallowing phase impair-
ments with prevalence greater than 10%, alone or in
combination, are presented in Table 1. The frequencies
of the types and degrees of aspiration are shown in Tables
2 and 3, respectively. Table 4 lists the prevalence of
cognitive deficits.
A successful outcome (exclusively oral feeding)
was achieved in 39 patients (67%). Statistical correlation
of each pretreatment variable with regard to successful
S. Neumann et al.: Swallowing Therapy of Neurologic Patients 3
Table 4. Cognitive deficits
Attention deficits 52%
Memory deficits 36%
Planning/problem solving deficits 36%
Table 5. Attention deficits correlated with median duration of therapy
Attention deficits present (n = 30; 52%) 20 weeks
Attention deficits absent (n = 28; 48%) 10 weeks
p = 0.00136; Mann-Whitney U-test, two-tailed probability.
Table 6. Time since lesion and successful outcome
Time since lesion Successful outcome (%)
<25 weeks (n = 47; 81%) 68
/>25 weeks (n = 11; 19%) 64
Not significant; Chi-square test, two-tailed probability.
Table 7. Swallowing phase impairment correlated with type of therapy
chosen
Swallowing phase Indirect Indirect + direct
impairment therapy (%) therapy (%)
Pharyngeal a 23 72
Oral preparatory + oral 60 40
+ pharyngeal
Oral preparatory + oral 80 20
Oral + pharyngeal 42 58
aOne patient with pharyngeal phase impairment received direct therapy
alone.
outcome revealed no significant relationship of any of the
variables, although patients with attention deficits re-
quired longer duration of therapy (Table 5). This study
failed to confirm the results of a previous study indicating
that attention deficits were associated with poorer out-
come of swallowing therapy [26], perhaps because of the
relatively small number of patients studied. Of special
note is the fact that "time since lesion" did
not
correlate
with outcome when patients were segregated into two
categories; less than 25 weeks and 25 weeks or more
(Table 6). Those in the latter category tended to require
longer duration of therapy (20 weeks vs. 12 weeks),
although the difference was not statistically significant.
Correlation of swallowing phase impairment with
the type of therapy chosen (indirect vs. indirect plus
direct) revealed that indirect therapy alone was the pre-
ferred method in 80% of patients with oral preparatory
and oral phase impairment, as compared with 50% of
patients overall and only 23% of patients with pharyngeal
phase impairment alone (Table 7). With regard to time
since lesion, indirect therapy alone was somewhat more
likely to be chosen in the group of patients who were less
than 25 weeks (Table 8).
Indirect plus direct therapy tended to last longer
than indirect therapy alone (18 weeks vs. 12 weeks), but
the difference was not statistically significant. Successful
outcomes tended to be associated with indirect therapy
alone, but not to a significant degree (Table 9).
The overall outcome of swallowing therapy, ac-
cording to type of feeding before and after treatment, is
indicated in Table 10. Table 11 indicates that achieve-
ment of oral feeding was not associated with increased
risk of pneumonia during or after therapy; to the contrary,
Table 8. Time since lesion correlated with type of therapy chosen
Indirect Indirect +
Time since lesion therapy (%) direct therapy (%)
<25 weeks 55 45
1>25 weeks 27 73
Not significant; Chi-square test, two-tailed probability.
Table 9. Type of therapy correlated with successful outcome
Type of therapy Successful outcome (%)
Indirect 76
Indirect + direct 57
Not significant; Chi-square test, two-tailed probability.
Table 10. Type of feeding before and after swallowing therapy
Before (%) After (%)
Exclusively tube feeding 86 14
Oral and tube feeding combined 14 19
Exclusively oral feeding 0 67
patients who remained tube-feeders were much more
likely to incur pneumonia.
Discussion
The results of this study are consistent with previous
reports indicating that swallowing therapy is associated
with successful outcome, in this study defined by
achievement of oral feeding, in patients with neurogenic
dysphagia [8,11,25,26]. It is acknowledged that, follow-
ing neurologic injury such as stroke or trauma, spontane-
ous recovery of impaired neurologic functions may con-
tribute to improved outcome in the setting of
rehabilitative management. In this study, however , the
beneficial role of swallowing therapy, independent of
natural neurotogic recovery, is substantiated by the simi-
4 S. Neumann et al.: Swallowing Therapy of Neurotogic Patients
Table 11. Occurrence of pneumonia during and after therapy accord-
ing to feeding status at discharge
Pneumonia
Pneumonia within 4-6 weeks
during therapy (%) after therapy (%)
Exclusively tube feeding 89 22
Oral and tube feeding 17 9
combined
Exclusively oral feeding 9 2
larly high rates of successful outcomes (68% vs. 64%,
respectively) in not only those patients with recent le-
sions (<25 weeks) but also those with remote lesions
(~>25 weeks). The vast majority of spontaneous recovery
takes place within the first 25 weeks after neurologic
injury, and subsequent improvement, as in this study,
implies the effect of some other factor, in this case swal-
lowing therapy.
Moreover, the benefit of swallowing therapy
demonstrated by this study cannot be attributed solely to
improved compensation in the face of stable oropharyn-
geal dysfunction, as one-half of the patients received
indirect therapy
alone
and therefore were not trained in
compensatory techniques. The implication is that, as in
other areas of rehabilitation, specific stimulation meth-
ods and exercises can facilitate the return of impaired
voluntary motor functions.
The relative efficacy of indirect therapy vs. indi-
rect plus direct therapy cannot be inferred from this
study, because the patients selected for each type of ther-
apy were not strictly comparable. Patients who received
indirect therapy alone were more likely to have had re-
cent neurologic injury (<25 weeks) and to have had oral
preparatory and oral phase impairment. The tendency to
choose indirect therapy alone for those patients with re-
cent lesions may reflect greater optimism about the po-
tential for functional recovery in those patients. The cor-
relation between choice of indirect therapy alone and oral
preparatory or oral phase impairment is understandable,
corresponding to the focus of indirect therapy on volun-
tary motor functions such as those involved in these
phases, as opposed to the involuntary nature of the pha-
ryngeal phase.
It should be emphasized that indirect and direct
therapy are compatible, as in nearly one-half of the study
patients, and they can be productively integrated. For
some dysphagic patients it may be mandatory to first
attempt to reestablish orofacial, lingual, and laryngeal
muscle performance using indirect therapy prior to insti-
tuting compensatory methods (direct therapy), because
these patients may be unable to carry out compensatory
techniques such as supraglottic swallowing or the Men-
delsohn maneuver if the requisite voluntary musculature
functions inadequately.
It is possible that the apparent benefit of swallow-
ing therapy as demonstrated by this study is related not to
specific therapeutic interventions but rather to nonspe-
cific factors inherent in the therapeutic interaction, such
as frequent human contact, mobilization, or increased
attention to swallowing impairment and its potential
complications. A randomized, prospective trial with
three arms (specific treatment, nonspecific interaction,
and no treatment) would be needed in order to investigate
this possibility.
As no pretreatment variable correlated with suc-
cessful outcome, this study provides no evidence to help
predict which patients with neurogenic dysphagia are
more or less likely to respond favorably to swallowing
therapy. Even patients with cognitive deficits had no
statistically significant tendency toward treatment fail-
ure. Accordingly, all patients with neurogenic dyspha-
gia, regardless of factors such as age, localization of
lesion, time since lesion, type and degree of aspiration,
and cognitive status, should be considered for swallow-
ing therapy.
Swallowing therapy appears to be relatively safe
in that there was a low incidence of pneumonia during or
within 4-6 weeks following therapy among those patients
who achieved oral feeding. On the other hand, patients
who had to continue tube feeding were much more likely
to suffer pneumonia, presumably because their severely
compromised swallowing function not only precluded
oral feeding but also predisposed to aspiration of oropha-
ryngeal secretions and/or refluxed tube feedings. The
approximately fourfold higher occurrence of pneumonia
during therapy as compared with the interval within 4-6
weeks after therapy probably reflects the several-fold
longer duration of the therapy interval (i.e., the incidence
was stable, but the periods of ascertainment varied in
length). Alternative explanations include (1) pulmonary
protective mechanisms may have been more impaired
during the therapy interval because of the relative re-
cency of the patients' acute illnesses during that time as
compared with the post-therapy interval; (2) the therapy
itself may have contributed to the occurrence of pneumo-
nia during treatment, although this is unlikely given the
very small amounts of material ingested under careful
supervision; and (3) the lower occurrence of pneumonia
after therapy may indicate a beneficial effect of therapy
on airway protection, even among those patients who did
not achieve oral feeding.
Despite the apparent benefit of swallowing ther-
apy as evidenced by the two-thirds of patients in this
study who achieved fully oral feeding, further and better
studies are needed. Only prospective, randomized, con-
trolled studies employing treatment and nontreatment
S. Neumann et al.: Swallowing Therapy of Neurologic Patients 5
arms will finally resolve the issue of whether or not
swallowing therapy is efficacious and cost effective, as
well as the relative contributions of indirect and direct
methods.
Conclusions
Swallowing therapy is safe and is associated with suc-
cessful outcome, in this study defined by achievement of
oral feeding, in patients with neurogenic dysphagia, re-
gardless of pretreatment variables including time since
disease onset. Indirect treatment methods such as stimu-
lation techniques and exercises appear to be effective
when used either alone or in combination with direct
methods such as compensatory maneuvers. Truly rigor-
ous, controlled, scientific studies are needed.
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