Swallowing Trouble: Dysphagia

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My son Jesse, swallowing.

Dysphagia:  difficulty swallowing.

Stroke is the leading cause of dysphagia.

Approximately 62% of stroke survivors develop dysphagia at some point after stroke. Dysphagia is the most frequent cause of pneumonia poststroke. It can also delay other parts of recovery. (It's hard to recover when you can't swallow.)

 The treatment for dysphagia may follow the same neuroplastic rules as every other form of post stroke recovery. For example, repetitive practice of wrist extension will change the brain to make wrist extension easier as time goes on. But repetitive practice of wrist extension has no downside. The worst thing that can happen is that you get tired. But if you repeatedly practice swallowing there may be a risk. What happens if you can't swallow whatever it is you're trying to swallow? You choke! You may aspirate. Aspiration involves having whatever you attempt to "swallow" go "down the wrong pipe". Instead of going down the esophagus to the stomach, the material goes down the trachea to the lungs. Once lodged and lungs it can cause pneumonia. Why does it cause pneumonia? Because the lungs hate having foreign matter inside. So the lungs try to fight the foreign matter. The lungs attempt to fight the foreign matter is the very definition of infection. An infection in the lungs is called pneumonia.

There is a tendency for clinicians to undertreat patients with dysphagia. These clinicians feared that there is a risk of aspirating.

So, if repetitive practice works, but repetitive practice of swallowing is dangerous, what can you do? If a particular skill is not used (in this case swallowing), the portion of the brain that controls that skill will shrink. As that portion of the brain shrinks, the skill gets even worse. As the skill gets worse, that portion shrinks further... and a downward spiral is initiated. If the dysphagia patient is not swallowing, or not swallowing enough, the portion of the brain dedicated to swallowing will get smaller, and the skill will suffer. 

The movements involved in swallowing have been traditionally viewed as reflexive in nature. But swallowing also follows the same basic "repetitive practice equals more movement" rule.  But what if the person can't yet swallow safely in order to practice swallowing?

There is emerging literature that electrical stimulation may initiate the neuroplastic process. Again, this is not only true for the hand and foot emerging research indicates that the same is true for swallowing. Electrical stimulation may provide the "X” factor that provides small amount of movement on which to build more robust movement. This same continuum of care (e-stim to repetitive practice) is used by clinicians in rehabilitation hospitals around the country to reestablish nominal movement. Although not functional swallowing, electrical stimulation provides early steps towards regaining the ability to swallow.

In terms of the repetitive practice itself, the generally accepted way of safely repeating swallowing is called the "The Frazier Water Protocol". 

For a bit more science-y perspective, click here.

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"Why Can't They Use Stem Cells to Help Stroke Recovery?"

I am happy that this blog has been able to partner with SanBio, a company on the leading edge of stroke recovery research. They aim to answer the question, can stem cells help with stroke recovery? SanBio is a San Francisco based company that is looking for participants for their study.

You can get all the information you need by clicking on the SanBio link, to the right.

• A few pertinent points about the study:
• Participants (subjects) must be between 6 and 36 months post stroke
• All participants will have had an ischemic stroke (a block, not a bleed)
• All participants will have their movement, sensation and cognitive ability tested
• The safety of the treatment is the primary focus of the study
• The studies being conducted in two places: Palo Alto, CA and Pittsburgh, PA
• "All transportation and study-related costs will be covered"

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E=Recovery

Banking energy is essential to recovery. Muscle strengthening (even on the unaffected side) and cardio work, i.e. walking, recumbent steppers, upper-body ergometers) are essential to provide the underlying "banking" of energy. The banked energy is needed to provide the fuel needed to do the hard work of recovery. The average stroke survivor has half the amount of cardiovascular strength as age-matched "couch potatoes." But most ADLs (walking is what is usually measured) take twice as much energy. In other words, stroke survivors have half the energy to do twice the work.

The foundation of all recovery from stroke involves neuroplastic "rewiring" of the brain. And while the energy needed to drive neuroplastic change has not been measured, one thing is for sure-neuroplasticity takes a lot of energy. The buzz word in rehab research is intensity. But how can you do intensive without enough energy?

Up to 70 percent of stroke survivors suffer from severe fatigue. Many survivors consider fatigue the worst aspect of post- stroke life. Banking energy goes a long way toward fighting fatigue.

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Meaningful: Driving Stroke Recovery

When practicing to relearn movement effort should be task-specific. That is, tasks or component parts of a task should be practiced.  Choose tasks that are very meaningful. The more meaningful the task, the more motivation available. The more motivated, the more effort will be brought to bear. The more effort exerted, the more neuroplastic (brain rewiring) change will be driven. 

What motivates you? Fear? Friends not dropping by because you can't play cards anymore? Clients not trusting you because you've had a stroke? Recovery is not supposed to be comfortable. A dash of desperation is necessary.

Stretching After Stroke

Address soft tissue shortening.

Until soft tissue shortening is addressed (i.e. muscle tightness), the chronic (post 3 month) survivor has no chance of functional recovery. You can do a ton of hard work but if the muscle length is not there, that's as far as you'll go. It's that simple. This is particularly true of the tendency toward the shortening of soft tissue in the elbow, wrist, finger flexors in the arm and hand. In the leg and foot the main concern is the calf muscle. This muscle often shortens because the calf often has spasticity. Spasticity keeps the foot pointed down in that position, if held long enough will shorten the muscle.

There is a tendency for patients with chronic stroke to limit their stretching of at-risk joints to a few times a day. I would suggest that, given no pathological or orthopedic reasons not to, stretching should be done often. (Always: check with you friendly neighborhood PT or OT!)

Any therapist who works with any patient population with spasticity should know the implications of Botox and intrathecal baclofen, the range of oral medications as well as splinting. The anti-spasticity qualities of these medications are beyond the scope of this article, but they are important in the treatment of spasticity. And therapists are often the clinicians who can redirect patients back to physiatrists and neurologists. These docs then can suggest appropriate meds.

Upon discharge, therapists should "read the riot act" to stroke survivors. Therapists should inform them of the dangers of soft tissue shortening, including decreased function, less chance for future rehabilitation, pain and contracture.

(Note: There is considerable debate about the effectiveness of stretching out spastic muscles. This debate is not among clinicians as much as waged within the world of rehabilitation research. However, even though the scientists are not yet fully convinced, there's reasons to stretch outside of retention of tissue length. For example, the number one cause of poststroke shoulder pain is not subluxation (shoulder separation due to weakness of the shoulder muscles). The number one causes adhesions that build up in the capsule the shoulder. What keeps these adhesions at bay? Stretching. Or at least "ranging." "Ranging" is a term that therapists use to mean not necessary to be stretching, but taking the joint through its full range of motion. Ranging is done passively, as his stretching. That is, stroke survivors limb is moved through its available painless range of motion, but some outside force does it. It might be clinician, a caregiver, or the survivor themselves ranging the joint.)

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