Neurogenic Dysphagia

Stroke Pathophysiology

• blood clot forms and blocks blood flow to an area of the brain

• blood vessel ruptures causing bleeding into or around the brain

Stroke Disease Course & Prognosis

• in general, we expect patients in recovery from a stroke to improve

• spontaneous recovery period ~3-6 mos for gross motor function; speech/language/cog can be longer

• consider neuroplasticity

Specific Stroke Dysphagia Features

• highly variable, no two cases are identical

• affects any/all swallowing events

• cognition directly influences swallow safety and compliance

Brainstem Stroke Dysphagia Features

most likely pharyngeal swallow impairment

What is spontaneous recovery after a CVA?

• the brain’s ability to repair the area that surrounds the lesion quickly

• reprofusion, edema management, diaschisis reversal

Reprofusion

restoration of oxygnated blood to the area

Edema management

swelling goes down so oxygenated blood can return

Diaschisis Reversal

• the most important spontaneous recovery mechanism

• reverses depressed neural activity from loss of input from damaged areas of the brain

Wallenberg Syndrome Pathophysiology

secondary to an ischemic stroke in the lateral medulla (brainstem)

Wallenberg Syndrome Dysphagia Incidence

51-94% of patients experience severe dysphagia

Wallenberg Syndrome Prognosis

non-progressive trajectory but the rate of recovery is extremely variable across individuals

Wallenberg Syndrome Dysphagia Features

• difficulty triggering the swallow

• absent pharyngeal constriction (unilateral or bilateral)

• minimal or absent relaxation of the UES

Wallenberg Syndrome Nutritional Support

often requires temporary or long-term supplemental nutrition/hydration via PEG

TBI Pathophysiology

• direct head trauma, coup-contrecoup impact, puncture, or brainstem twisting forces

• causes diffuse neural damage rather than single focal lesions

TBI Disease Course & Prognosis

• non-progressive trajectory, overall recovery expected

• voluntary oral control improves alongside attention and concentration recovery

• cognitive-communication deficits typically outlast swallowing impairments

TBI Specific Dysphagia Features

• no two cases are the same

• driven heavily by cognitive-behavioral factors (impulsivity, awareness, impaired sensation and comprehension) and iatrogenic factors (tracheostomy, medications)

Dementia Pathophysiology

• impairment in cognition or cognitive-communication skills that interfere with everyday life

• dependent on the type (Alzheimer's, Frontotemporal, Vascular, Lewy Body)

Dementia Dysphagia Causes

stems from reduced muscle strength, oral sensation, motor planning, cognitive dysfunction, and oral lubrication

Dementia Disease Course & Prognosis

• progressive, degenerative trajectory with variable rates of decline

• managed primarily in SNFs and long-term care facilities

Dementia Dysphagia Features

• agnosia = loss of food recognition

• slow oral manipulation, lingual searching, and oral holding

• slow/delayed pharyngeal swallow trigger

What types of support do people with dementia need for feeding?

• increased verbal/physical cues for self-feeding

• direct assistance with utensil setup

• imitation of feeding behavior from meal partner

Motor Neuron Disease/ALS Pathophysiology

• rapidly progressive

• fatal neurodegenerative disease of motor neurons (UMN/LMN)

Motor Neuron Disease/ALS Risk Factors

• smoking

• extreme physical activity

• infectious disease

• genetics

• military service/trauma

Motor Neuron Disease/ALS Disease Course & Prognosis

• rapid continuous decline; post-onset lifespan typically 3-6 years

• supportive care planned early (tube feeding, non-invasive ventilation, AAC)

• co-occurs with progressive dysarthria and generalized weakness

Motor Neuron Disease/ALS Specific Dysphagia Features

weakness in oral structures, delayed swallow reflex, nasal regurgitation, wet/gurgly voice, coughing, aspiration, gagging

Parkinson's Disease Pathophysiology

basal ganglia degeneration causes dopamine depletion that affects many body functions (resting tremor, bradykinesia/hypokinesia, and rigidity)

Parkinson's Disease Course & Prognosis

• slowly progressive neurodegenerative trajectory

• symptoms fluctuate and temporarily improve with treatment (deep brain stimulation) and meds (carbidopa-levodopa)

Parkinson's Disease Oral Stage Dysphagia Features

• repetitive lingual rolling/pumping

• lingual/velar tremor

• ramplike tongue posture

• piecemeal deglutition

• buccal retention

Parkinson's Disease Pharyngeal Stage Dysphagia Features

• delayed trigger

• reduced pharyngeal constriction/elevation

• vallecular/pyriform sinus residue

• penetration/aspiration

Parkinson's Disease Sensory & Esophageal Dysphagia Features

• elevated sensory thresholds (reduced sensation)

• PE segment dysfunction

T/F: dysphagia from neurological disorders reflects the underlying sensorimotor characteristics of the neurological deficit

true

Treatment of neurogenic dysphagia relies heavily on understanding the _________ process

neurologic

In the absence of an overt neurological disease, how should we go about dysphagia that seems neurogenic?

it should be considered reflective of an underlying neurological cause until proven otherwise

Many forms of neurogenic dysphagia can change over time, and we need to pivot according to…

• recovery

• degeneration and decline in function