**7. Treatment and rehabilitation of dysphagia patients**

Neurogenic dysphagia treatment is provided in complex with primary disease treatment. Stroke patients need follow-up and treatment and rehabilitation procedures by multidisciplinary team, including nutritional support, exercises and physiotherapy, logopedic correction, pain control treatment, and psychological correction [9, 15, 35].

Screening test shall always be conducted prior to patient feeding. Patient shall take oral medicines only in the presence or with assistance of medical staff. After taking medicines, a patient shall drink small portions of water. For this purpose, a patient shall be in a semi-sitting position or shall lie on a side with elevated chin; a risk of aspiration is lower in these positions. If even a mild swallowing disorder at pharyngeal phase is observed, it is required to act vice versa: to lower the chin. In this position, the tongue root is pushed backwards, and the epiglottis protective position is improved. This movement compensates for delayed initiation of pharyngeal swallow, as it narrows laryngeal inlet and prevents the bolus passing into the respiratory tract [36].

With nasogastric tube feeding, it is necessary to remember that long-period nasogastric feeding may cause such complications as nasopharyngitis, esophagitis, esophageal stricture, and nasopharynx edema. When dysphagia progression occurs or no swallowing function dynamics have been observed for a long period, a gastrostomy tube is used [37].

Dysphagia patient management, depending on the level of consciousness, reasoned contact, use of a tracheostomy tube, and other factors, shall include the following actions related to examination: [38].


Dysphagia rehabilitation procedures shall include: [39].


In order to facilitate the impaired process, various methods of swallowing training and retraining are developed. These methods include strengthening exercises, biofeedback stimulation, temperature and taste stimulation [29, 40].

The following rehabilitation methods are used for neurogenic dysphagia patient rehabilitation:

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tion period.

for eating.

function.

patient's relatives.

substantiated.

• Pulse time: 200 ms;

Physiotherapy tasks: [41, 42].

pedic articulation simulation;

parenteral feeding is used.

1.Preparatory. Preparation of the oral cavity for swallowing (cleaning and moisturizing with a sponge), removal and installation of removable dentures.

2. "Swallowing enhancement" method. After patient examination, food consistency, which is optimal as for the current moment, is selected. Subsequently, food of various consistency is given, and the volume of food for single administration is increased gradually. At the same time, the required swallow volume, amount of food for single administration, and feeding temperature range are determined. Taste sensation is recovered throughout the rehabilita-

3.Replacement therapy method. Nasogastric tube is installed (percutaneous endoscopic gastrostomy is further applied when required). In several cases,

4.Postural method, which involves the selection of a proper posture required

5.Training method, which consists of training exercises for strengthening the muscles involved in swallowing process, recovery of swallowing control

Complex approach and consistency of dysphagia patients rehabilitation of stroke patients is well-established. Rehabilitation shall be conducted by the members of the multidisciplinary team (MDT) trained on the methods of dysphagia-specific assistance rendering. It is quite important that speech-language pathologists carry out the main works on rehabilitation of neurogenic dysphagia patients. But other members of MDT shall assist speech-language pathologists: physician involved in therapeutic exercises, physiotherapy doctor, as well as

• Development of adequate afferentation flow by low-frequency electrophono-

• Speech and swallowing management program support;

• Recovery and support of CNS regulatory function.

• Pulse shape: triangular, with a very slow rise;

Approximate current parameters for electrical stimulation:

• Pause time: 1,000–7,000 ms (depending on patient's readiness);

• Support of non-functioning muscles tonus to prevent their atrophy;

• Prevention of degradation process in the cricoarytenoid joint capsule;

Physiotherapy aimed at electrical stimulation of the larynx and tongue root shall be performed during most of the acute stoke period, when it is medically

*Therapy Approaches in Neurological Disorders*

• Pharyngeal reflex assessment;

required);

(when required).

breath, speech;

• Acupuncture;

impaired;

rehabilitation:

ways for patient feeding;

• Psychological correction;

• Hygienic care of the oral cavity;

• Examination of patient's speech apparatus;

• Examination of the mouth and pharyngeal mucosa sensitivity;

• Testing of the reaction to the tracheostomy tube (when required);

Dysphagia rehabilitation procedures shall include: [39].

• Correct selection of patient feeding pattern;

of mastication, expression, the tongue muscles;

• Testing of the reaction to sanitation of the area above the tracheal cuff (when

• Examination of saliva and sputum accumulated in the area above the cuff

• Calculation of the caloric value of products with modified consistency and

• Selection of food consistency, methods of oral cavity mucosa sensitivity stimulation, swallowing process stimulation and disinhibition, recovery of

• Logopedic exercises therapy aimed at correct positioning, stimulation of active swallowing, normal breathing, recovery and enhancement of functional activity of the muscles involved in the process of swallowing and eating: the muscles

• Physiotherapeutic treatment methods; in such case, the procedure of choice for neurogenic dysphagia is the larynx electrical stimulation of swallowing reflex;

• Surgical correction (if medically required) aimed at creation of alternative

• Lifestyle correction aimed at correction or creation of the conditions facilitating independent eating process for patients when the function is diminished or

In order to facilitate the impaired process, various methods of swallowing training and retraining are developed. These methods include strengthening exercises, biofeedback stimulation, temperature and taste stimulation [29, 40]. The following rehabilitation methods are used for neurogenic dysphagia patient

• Teaching relatives on feeding skills and complication prevention.

selection of nutritional formulas ensuring nutritional support;

**98**


Complex approach and consistency of dysphagia patients rehabilitation of stroke patients is well-established. Rehabilitation shall be conducted by the members of the multidisciplinary team (MDT) trained on the methods of dysphagia-specific assistance rendering. It is quite important that speech-language pathologists carry out the main works on rehabilitation of neurogenic dysphagia patients. But other members of MDT shall assist speech-language pathologists: physician involved in therapeutic exercises, physiotherapy doctor, as well as patient's relatives.

Physiotherapy tasks: [41, 42].


Physiotherapy aimed at electrical stimulation of the larynx and tongue root shall be performed during most of the acute stoke period, when it is medically substantiated.

Approximate current parameters for electrical stimulation:


The effectiveness of rehabilitation techniques in the treatment of patients after stroke has been shown in a number of studies [4, 10, 18, 29, 37–39]. Various methods of swallowing as part of complex therapy for dysphagia in stroke have shown high efficiency. The best results of swallowing recovery are shown when using integrated approach, include specialized nutritional mixtures with different densities. Recovery was better in patients with pseudobulbar disorders [16, 35]. Involvement of patient's relatives and patient motivation plays a significant role in recovery [4, 9].

## **8. Dysphagia patients feeding**

To perform oral feeding, it is necessary to awaken a patient and seat him/her up before feeding. Make sure a patient stays in a sitting position for 20–30 minutes after the end of oral feeding. First of all, it is necessary to ask patient if he/she wants to take breakfast, lunch and dinner among his/her family members or prefers to eat alone. Anyway, it is necessary to arrange the meal in a comfortable, quiet, and friendly atmosphere, and to put away all unwanted noise sources so that the patient can focus on eating. A patient with difficulty swallowing needs sufficient time for eating. Do not hurry a patient. It is important that a patient feels safe and enjoys the meal while eating.

It is necessary to provide proper positioning of a patient. Correct posture is important to prevent food aspiration while swallowing. When possible, a patient shall sit in an armchair while eating.

When a patient is fed sitting in the armchair, prepare pillows to keep the patient's position, comfortable table and non-slipping carpet before feeding.

Patient shall sit in so that the feet rest on flat surface or on the floor, the body is in vertical positions, and hands are free. If a patient is able to sit on a chair while eating, he/she can also incline forward and lean upon the table. Body inclined forward will prevent the head throwing back. Patient's head shall be on the middle line, not inclined rather than thrown back. The neck shall be slightly (not too much) bent forward to prevent aspiration.

When a patient is not able to keep his/her head position by own efforts, it is necessary to support his/her neck and shoulders from the back to prevent the head throwing back and to help a patient to control his/her tongue position. If, however, the patient's head is inclined too far forward, it is necessary to support his/her chin with the assistant's hand from below or to use special locking collar for the head support.

To prevent aspiration in the process of swallowing, the "chin-to-chest" posture will help; and for patients with unilateral weakness of the tongue muscles, slight turning of the head towards the impaired side while swallowing will be helpful.

When a patient is fed in the bed (if it is impossible to sit him/her in a bedside chair), the patient shall be kept in a comfortable semi-vertical position. For this purpose, raise a patient slightly to the bedhead, supporting him/her with pillows so that the body rests along the middle line. The head and neck shall be inclined forward slightly. The patient's knees shall be bent slightly with a cushion/pillow put underneath.

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*Dysphagia Associated with Neurological Disorders DOI: http://dx.doi.org/10.5772/intechopen.96165*

and to take food in the mouth using lips, not teeth.

day to maintain the oral cavity hygiene.

for 30–40 minutes after the meal.

**9. Conclusion**

**Conflict of interest**

No conflict of interest.

low. In such cases, tube feeding is required.

work ahead of us and, I hope, important discoveries.

shall remove food residuals with a finger after each swallow.

drink from a spoon.

It is necessary to teach a patient to take food and to lift it to his/her mouth with a hand or both hands. When a patient is not able to suck in liquids, teach him/her to

Patient shall be advised to take just a small amount of food or liquid at a time. Teach a patient to lift food or liquid to the middle of his/her mouth, not to a side,

It is quite important to attract patient's attention to the fact that his/her oral cavity shall be absolutely empty after each spoon or piece of food, in order to prevent food accumulation at the side with weak tongue or cheek muscles. Patient

When required, help a patient to clean his/her oral cavity: mucus and saliva accumulated in the mouth shall be removed with wet towel on a regular basis. Remember that the patient's teeth and dentures shall be cleaned minimum twice per

Do not give a patient drinks together with solid food. In order to reduce the risk

When a patient meets problems with food swallowing, ask him/her to cough up. Examine the patient's oral cavity after eating. As far as a risk of aspiration still exists for a certain period of time after eating, a patient shall stay in vertical position

Do not feed a patient if there are any doubts concerning his/her ability to swal-

We now know much more about neurogenic dysphagia than we did before. The questions of pathogenesis, clinical picture, diagnostics are well studied. The described approaches in the diagnosis and treatment of neurogenic dysphagia play an important role in clinical practice and are necessary for quality medical care for these patients. Although to date, the level of their evidence remains in the category of cohort studies and expert opinion. This means that we have a lot of interesting

of aspiration, drinks shall be given prior to or immediately after eating.

*Therapy Approaches in Neurological Disorders*

• Time of procedure execution: 30 min;

• Frequency of execution: every day No. 10–15.

The effectiveness of rehabilitation techniques in the treatment of patients after stroke has been shown in a number of studies [4, 10, 18, 29, 37–39]. Various methods of swallowing as part of complex therapy for dysphagia in stroke have shown high efficiency. The best results of swallowing recovery are shown when using integrated approach, include specialized nutritional mixtures with different densities. Recovery was better in patients with pseudobulbar disorders [16, 35]. Involvement of patient's relatives and patient motivation plays a significant role in

To perform oral feeding, it is necessary to awaken a patient and seat him/her up before feeding. Make sure a patient stays in a sitting position for 20–30 minutes after the end of oral feeding. First of all, it is necessary to ask patient if he/she wants to take breakfast, lunch and dinner among his/her family members or prefers to eat alone. Anyway, it is necessary to arrange the meal in a comfortable, quiet, and friendly atmosphere, and to put away all unwanted noise sources so that the patient can focus on eating. A patient with difficulty swallowing needs sufficient time for eating. Do not hurry a patient. It is important that a patient feels safe and enjoys the

It is necessary to provide proper positioning of a patient. Correct posture is important to prevent food aspiration while swallowing. When possible, a patient

position, comfortable table and non-slipping carpet before feeding.

When a patient is fed sitting in the armchair, prepare pillows to keep the patient's

Patient shall sit in so that the feet rest on flat surface or on the floor, the body is in vertical positions, and hands are free. If a patient is able to sit on a chair while eating, he/she can also incline forward and lean upon the table. Body inclined forward will prevent the head throwing back. Patient's head shall be on the middle line, not inclined rather than thrown back. The neck shall be slightly (not too much)

When a patient is not able to keep his/her head position by own efforts, it is necessary to support his/her neck and shoulders from the back to prevent the head throwing back and to help a patient to control his/her tongue position. If, however, the patient's head is inclined too far forward, it is necessary to support his/her chin with the assistant's hand from below or to use special locking collar for the head

To prevent aspiration in the process of swallowing, the "chin-to-chest" posture will help; and for patients with unilateral weakness of the tongue muscles, slight turning of the head towards the impaired side while swallowing will be helpful. When a patient is fed in the bed (if it is impossible to sit him/her in a bedside chair), the patient shall be kept in a comfortable semi-vertical position. For this purpose, raise a patient slightly to the bedhead, supporting him/her with pillows so that the body rests along the middle line. The head and neck shall be inclined forward slightly. The patient's knees shall be bent slightly with a cushion/pillow put

• Current intensity: 2.5 mA;

**8. Dysphagia patients feeding**

shall sit in an armchair while eating.

bent forward to prevent aspiration.

recovery [4, 9].

meal while eating.

**100**

underneath.

support.

It is necessary to teach a patient to take food and to lift it to his/her mouth with a hand or both hands. When a patient is not able to suck in liquids, teach him/her to drink from a spoon.

Patient shall be advised to take just a small amount of food or liquid at a time. Teach a patient to lift food or liquid to the middle of his/her mouth, not to a side, and to take food in the mouth using lips, not teeth.

It is quite important to attract patient's attention to the fact that his/her oral cavity shall be absolutely empty after each spoon or piece of food, in order to prevent food accumulation at the side with weak tongue or cheek muscles. Patient shall remove food residuals with a finger after each swallow.

When required, help a patient to clean his/her oral cavity: mucus and saliva accumulated in the mouth shall be removed with wet towel on a regular basis. Remember that the patient's teeth and dentures shall be cleaned minimum twice per day to maintain the oral cavity hygiene.

Do not give a patient drinks together with solid food. In order to reduce the risk of aspiration, drinks shall be given prior to or immediately after eating.

When a patient meets problems with food swallowing, ask him/her to cough up.

Examine the patient's oral cavity after eating. As far as a risk of aspiration still exists for a certain period of time after eating, a patient shall stay in vertical position for 30–40 minutes after the meal.

Do not feed a patient if there are any doubts concerning his/her ability to swallow. In such cases, tube feeding is required.
