Therapy for Swallowing Problems
Problems with swallowing (dysphagia) in people with MS result from lesions in the brainstem that cause loss of control over the muscles involved in swallowing which can slow swallowing and increase the risk of aspirating food or liquid into the lungs. There are a total of 30 different muscles involved in swallowing which is done in four stages: (1) oral preparation, (2) oral stage, (3) pharyngeal stage, and (4) esophageal stage. When you have a swallowing problem, the speech/language pathologist will look at each of these stages to see where the problem may occur and what interventions will help.
Stages of Swallowing
- Food is chewed, requiring a coordinated action of lips, tongue, jaw muscles to move food onto teeth and mix with saliva
- Bolus of food (ball of chewed food) is pushed using tongue to back of mouth, where bolus stimulates sensory nerves, triggering the swallow (a contraction in pharynx or throat)
- Pharyngeal swallow results in series of neuromuscular actions, including lifting of soft palate to close entrance to nose and airways
- Base of tongue and throat walls move together (called peristalsis) to force bolus of food down throat into the esophagus
- Contraction of walls of esophagus forces food bolus down esophagus and into stomach
- Normally, it takes 2 seconds after swallowing for food to pass from mouth and throat to esophagus and another 8 to 20 seconds for food to travel down the esophagus into the stomach
The most common swallowing problems that occur in people with MS are shown below.
- Delayed swallowing response: After food has been prepared by chewing and moved backward by the tongue, the swallowing response, involving a series of reflex actions to send food down the esophagus, is triggered
- Reduced pharyngeal peristalsis: During pharyngeal peristalsis, the chewed ball of food (called a bolus) is squeezed through the pharynx (the cavity behind mouth and nose connecting them to esophagus)
- Reduced laryngeal function: During swallowing the larynx elevates and closes, allowing the bolus of food to pass into the esophagus
- Reduced lingual function: The tongue (the word lingual refers to the tongue) plays an important role in swallowing, by helping to manipulate food during chewing and then propelling food back, triggering the swallowing reflex
If you, a friend or family member, or a member of your healthcare team notices signs of a swallowing problem, including pocketing of food in the mouth, repeated attempts to swallow food, unexplained weight loss, weak or hoarse voice quality, increased body temperature during the hour after eating, drooling or regurgitation, food sticking in throat, or signs of food aspiration (such as wheezing, fever, pneumonia), your doctor should refer you to a speech/language pathologist for assessment and treatment.
Assessment of swallowing problem
The first step in rehabilitation for a swallowing problem is a thorough evaluation. The speech/language pathologist will conduct this evaluation during your first visit. It will involve a detailed interview to explore the nature of your swallowing difficulty and identify factors that might be contributing to the problem, a clinical evaluation involving an examination of various structures (oral and pharyngeal) involved in swallowing, a mealtime evaluation, and a videofluoroscope evaluation. For the videofluoroscope exam, you will swallow a bit of food which contains a contrasting dye, typically barium, while an x-ray video follows the passage of food during the swallowing process.
Treatment of swallowing problems
The goal of treatment for swallowing problems is to help you maintain the ability to swallow food safely and get the nutrition you need. Depending on the nature of your swallowing problem, the speech/language pathologist will work with you to help you strengthen and/or maintain coordination of muscles and structures involved in swallowing. Shown below are some common swallowing problems in people with MS and interventions used to address each problem.
Interventions for Common Swallowing Problems in MS
- Position changes to compensate, for example holding the head forward when preparing to swallow and then throwing it back to move bolus back to pharynx
- Exercises to increase strength and range of motion of tongue
- Using head flexion (stretching and rotation) to position food in preparation for swallowing (decreases risk of aspiration)
- Change diet to thicker foods and liquids to enhance swallowing reflex
- Thermal stimulation of soft palate or back of tongue
- Use supraglottic-swallowing procedure (hold breath while swallowing, then cough afterwards)
- Can result from reduced pharyngeal peristalsis, insufficient elevation of larynx, or other dysfunction
- Cough following each swallow to clear pharynx of residue
- Smaller more frequent meals
- Non-oral feeding alternatives