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Swallowing Problems (Dysphagia) in Multiple Sclerosis: A Provider’s Approach

Katherine Walker, M.A., CCC-SLP
Marilyn Selinger, Ph.D., CCC-SLP, Section Chief Audiology/Speech Pathology
Denver VA Medical Center
 

Definition 
Swallowing Problems 
Diagnosing Swallowing Problems 
Treating Swallowing Problems 
Conclusion 
References

Definition

Swallowing problems (dysphagia) are often seen in people with multiple sclerosis. Swallowing problems can occur in the mouth, back of the throat or esophagus. Available research has varying estimates of how often swallowing problems happen in people with multiple sclerosis. The range is from 3% to 51%. Common symptoms include the following:

  • coughing,
  • choking,
  • a sticking sensation,
  • difficulty starting to swallow and
  • difficulty chewing.

People with multiple sclerosis are more likely to develop problems swallowing (dysphagia) as their multiple sclerosis progresses.
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Swallowing Problems

Swallowing problems can lead to complications including poor nutrition, dehydration and lung infections caused by swallowing “down the wrong pipe” (aspiration pneumonia). In addition, it can interfere with enjoyment of meals, a major source of social interaction and pleasure for many individuals.

Aspiration pneumonia is a potentially life-threatening lung infection caused by breathing in a foreign material like food, liquid, or bacteria-infused saliva. In the past scientists thought that aspiration pneumonia occurred after breathing in food or liquid alone. Current thought suggests, however, that three steps must occur.

  • First, bacteria must breed in the mouth or the back of the throat.
  • Second, the material must be breathed in.
  • Finally, the patient must not be able to cough out the material either immediately or after breathing it in.

There is a common belief that patients with multiples sclerosis who experience swallowing problems alone are at a high risk of aspiration pneumonia. The research from Susan Langmore and colleagues in 1998 suggests that we should question this belief. They demonstrated that there are many risk factors for aspiration pneumonia that must be considered. These factors include:

  • being fed by another person,
  • having another person help with cleaning the mouth,
  • the number of decayed teeth, tube feeding,
  • having more than one medical problem,
  • taking multiple medicines and
  • smoking.

The authors concluded that while dysphagia was an important risk factor, it was not generally "sufficient to cause pneumonia unless other risk factors are present as well."
A later study in 2002 (Langmore, et. al. 2002) evaluated risk factors in nursing homes. This study identified some novel risk factors including:

  • suctioning use,
  • chronic obstructive pulmonary disease (emphysema),
  • chronic heart failure,
  • being in bed all the time and
  • having a feeding tube.

Interestingly, swallowing problems is listed as the eighth risk factor (in order of importance). The authors wrote that though aspiration (swallowing down the wrong pipe) may occur, aspiration pneumonia will develop only if the material aspirated is pathogenic to the lungs and the patient's natural resistance to the material is compromised. It is important to note that placing a feeding tube is not likely to reduce that risk. Health care providers must review all of the risk factors of our patients and modify them, if possible. Providers must avoid looking only at swallowing status, but must consider this issue in the global view of patient function. Finally, there is little information on outcomes related to feeding tube placement in multiple sclerosis. This is a question scientists should investigate further.
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Diagnosing Swallowing Problems

The goal of treating swallowing problems is to maximize the safety and efficiency of eating. In order to meet that goal it is important to thoroughly review the patient's history and to evaluate the swallowing mechanism. This might include a clinical or bedside evaluation, using a tube called a fiberoptic scope to watch a person swallow from the inside and/or an x-ray test called a modified barium swallow. The completion and interpretation of these studies provide information about how to manage swallowing problems. It is important to note, however, that silent aspiration (aspiration with no overt signs of swallowing problems) can be an issue in multiple sclerosis, sometimes limiting the value of a clinical exam.

During the examinations, compensatory techniques may be attempted to reduce the symptoms of swallowing problems. Postural adjustments, therapeutic techniques and/or diet changes can be assessed during the actual exam to determine if they are, indeed, effective. Specific treatment recommendations can be made once the evaluation process is complete.
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Treating Swallowing Problems

Treatment techniques for swallowing problems may include direct treatment (aimed at increasing the strength or movement of the swallowing structures) or compensations (designed to improve the swallow without directly treating a deficit). There are many treatment techniques available for persons who have swallowing problems secondary to multiple sclerosis. The research supporting these treatments is, however, quite limited. Clinicians and other consumers of swallowing problems management techniques should carefully consider treatment options. Some claims made by developers of specific treatments seem to be too good to be true and sometimes, they are.

Texture adjustments of the diet, most often thickened liquids, are often recommended to manage swallowing problems. Current scientific studies suggest that when geriatric stroke patients are put on thickened liquids (a common strategy for managing swallowing problems) they are at higher risk of becoming dehydrated (Firestone, et. al, 2001, Whelan, 2001). It is important to consider this risk in patients with other neurological problems like multiple sclerosis. For that reason, this option should be considered as a last resort.
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Conclusion

It is important to remember that swallowing problems management must be carefully designed for each individual patient. There are no specific techniques that consistently improve every patient's swallowing. Therefore, recommendations should be made only after the person with multiple sclerosis is thoroughly evaluated by a trained speech-language pathologist.
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References

  • Finestone HM, Foley NC, Woodbury MG, Greene-Finestone L. Quantifying fluid intake in dysphagic stroke patients: a preliminary comparison of oral and non-oral strategies. Arch Phys Med Rehabilitation. 85(12): 1744-1746, 2001.
  • Langmore, SE, Skarupski, KA, Park Ps, Fries BE: Predictors of aspiration pneumonia in nursing home residents. Dysphagia 17(4): 298-307, 2002.
  • Langmore, SE, Terpenning, MS, Schork, A, Chen Y, Murray JT, Lopatin, D, Loesche, WJ: Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 13(2): 69-81, 2004.
  • Whelan K. Inadequate fluid intakes in dysphagic acute stroke. Clinical Nutrition. 20(5): 423-428, 2001.

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Updated: September 2009