Introduction
Authors | Study site, period of assessment, inclusion | Study size (n) | Etiology | Mean age (range); M:F | Screen and assessment tools | Dysphagia incidence (%) | Correlating factors | Recommendations |
---|---|---|---|---|---|---|---|---|
Kirshblum et al.1999 (R) [11] | on admission to rehabilitation unit; Acute traumatic SCI | 187 | Trauma | 44.3 (15–86) 5:1 | BSE, MBT, VFSS | 22.50% | Age, tracheostomy, ventilation, anterior cervical surgery | Early diagnosis |
Wolf & Meiners 2003 (P) [26] | within 3 months of admission to spinal unit; Acute cervical lesion | 51 | Trauma 46 Non-trauma 5 | 43.4 (16–89) 2.2:1 | FEES | 80% | Brainstem lesions, NOT age or level, anterior surgery | Early treatment |
Brady et al. 2004 (R) [27] | on admission to two rehabilitation units; All cervical injuries | 131 | Trauma and non-trauma | 55.6 (17–87) 1:1.2 | BSE, VFSS/FEES | 55% | Tracheostomy, cervical spinal surgery, brain injury | Identify dysphagia using predictive factors |
Abel et al.2004 (P) [28] | on admission to spinal unit; cSCI | 73 | Trauma 56 Non-trauma 17 | 42.9(0.57–86.8) 2.3:1 | Questionnaire, MBT, VFSS | 44% | High cervical and complete injuries, tracheostomy | Early detection and monitoring |
Seidl et al. 2010 (R) [29] | Within 8 weeks of admission to trauma center; C0-C8 | 175 | Trauma 147 Non-trauma 28 | 43.45 (14–89) 4.6:1 | BSE + FNE | 16% | Level of paralysis, tracheostomy, ventilation, other injuries | SLP assessment pre-oral feeding, FNE if dysphagia is suspected |
Shin et al. 2011 (R) [10] | Inpatients admitted to spinal unit; All tetraplegic patients | 121 | Trauma 118 Non-trauma 3 | 44.93 (9–78) 6.6:1 | VFSS | 8% | Age, tracheostomy, dysphagia signs | Monitor for signs of aspiration |
Shem et al. 2011 (P) [30] | Acute cSCI within 31 days of injury | 29 | Trauma | 41 3.1:1 | BSE and VFSS | 41% | Age, tracheostomy NG tube | Early screening |
Chaw et al. 2012 (P) [31] | Within 32 days of admission to spinal unit; Acute cSCI | 68 | Trauma and non-trauma | 43 (range not given) 5:1 | BSE and VFSS within 72 h | 30.90% | Ventilation, tracheostomy, NG, age | Need good pulmonary management |
Shem et al. 2012 (P) [32] | All admissions to spinal unit; Acute tetraplegia | 40 | Trauma | 41 (23.5–68.7) 3.4:1 | BSE and VFSS | 40% based on BSE; 44% on VFSS, 14.8% with aspiration | Age, tracheostomy, ventilation, and NG tube | Early screening of all tetraplegic patients |
Lee et al. 2016 (R) [22] | All cSCI admissions to trauma center | 56 | Trauma | Not available | Bedside nurse screen and SLP assessment (decannulated) | 41% (56 patients has cSCI of which 23 had dysphagia) | Age, spinal cord injury | Elderly and cervical injury should be monitored for risk of dysphagia |
Hayashi et al. 2017 (R) [14] | Traumatic cSCI admission to spinal injuries center within 3 days | 298 | Trauma | 64 (14–91) 6.1:1 | Based on tube dependence due to aspiration | 7.0% | Age, severe paralysis, tracheostomy | Evaluate risk factors to identify dysphagia |
Ihalainen et al. 2017 (P) [33] | Acute cSCI admitted to hospital | 46 | Trauma | 62.1 5.5:1 | VFSS | 41% penetrated 33% aspirated of which 73% silent aspiration | VFSS recommended Swallow evaluated by speech and language therapist | |
Ihalainen et al. 2018 (P) [34] | cSCI admitted to hospital | 37 | Trauma | 61.2 5.2:1 | Clinical swallowing trial and VFSS on all patients at 28 days | 51.4% penetrators-aspirators; 71.4% silent aspiration | Need for bronchoscopy, lower level ACSS, coughing, throat clearing, choking, voice quality changes | Use risk factors to initiate preventative measures |
Shem et al. 2019 (P) [15] | Adult patients admitted to SCI inpatient rehabilitation unit | 76 | Trauma | 48 ± 19 | BSE and VFSS | 30% based on BSE; VFSS (n = 17) 0f which 82% dysphagia, aspiration 21.4% | Tracheostomy, invasive mechanical ventilation, nasogastric tube, history of pneumonia, and older age | Early screening in acute cSCI |
Hayashi et al. 2020 (P) [35] | Traumatic cSCI admission to spinal injuries center within 2 weeks of injury | 136 | Trauma | 65.1 ± 14.1 years | Dysphagia Severity Scale, width of retropharyngeal space | 32% | Age, ASIA motor score, tracheostomy, and swelling of retropharyngeal space | Morphological changes to pharynx affect dysphagia |
Hayashi et al. 2020 (P) [36] | Traumatic cSCI admission to spinal injuries center within 2 weeks of injury | 65 | Trauma | 67 (60–73 IQR) 14:51 | Dysphagia severity scale (DSS) and functional oral intake scale (FOIS), supported by FEES and VFSS | 35% reducing to 17% at 3 months | Severity of motor score | Monitor CSCI patients in 2 weeks after injury and those with low motor scores |
Causes of Dysphagia in cSCI
Upper Spinal Cord Anatomy/Neurology
Spinal Surgery Consequences
Respiratory Muscle Dysfunction and Dysphagia
Esophageal Impairment and Oro-Pharyngeal Dysphagia Following cSCI
Dysphagia due to Medical Management
Clinical Presentation and Assessment of Dysphagia in cSCI
Paper | Population | Tool used | Dysphagia characteristics |
---|---|---|---|
Bekelis et al. 2010 Case report [79] | 61-year-old male Traumatic cSCI C1-C3 fusion (posterior approach) | FEES and VFSSS | Bilateral vocal cord paresis; at 1 month reduced epiglottic inversion, reduced hyolaryngeal elevation, and hypokinesis of pharyngeal wall Required PEG and returned to modified diet |
Cumpston and Bock 2015 Case report [80] | 84-year-old male Traumatic SCI C1-2 fusion (posterior approach), projection of screw seen at C1 into retropharynx | VFSSS | ↓ pharyngeal constriction & laryngeal elevation Minimal tongue base retraction Required PEG & resolved spontaneously |
Dettling et al. 2013 Case report [81] | 16-year-old male Traumatic SCI—halo fixation | FEES & VFSSS | ↓ soft palate movement, pooling secretions, aspiration Required NGT & resolved spontaneously |
Dick et al. 2020 Experimental case series [82] | 4 patients Two traumatic and two non-traumatic cervical spine injuries | VFSSS (quantitative measures) | ↓ anterior hyoid excursion, ↓ pharyngeal constriction, ↓ UES opening, ↑ pharyngeal wall thickness Three returned to oral diet, one remained NBM |
Hamilton et al. 2022 Prospective observational [83] | 20 traumatic cSCI patients | VFSSS | ↓ pharyngeal constriction, ↑ time to reach peak hyoid excursion, delayed and incomplete laryngeal vestibule closure |
Miles et al. 2021 Retrospective observational [78] | 62 patients (traumatic & non-traumatic (85% cervical spinal injuries) | 62 FEES 11 VFSS | ↓ pharyngeal constriction &↓ hyoid displacement, ↓ UES opening with residue, aspiration & secretion accumulation |
Screening and Assessment of Dysphagia in cSCI
Domains | Category | Sub-category |
---|---|---|
Injury risk | Comorbid | Brain injury/cognitive deficit |
Level of injury | Cervical SCI C1-C7 | |
Severity of injury | Complete/incomplete injury | |
C-spine surgery | Anterior or posterior cervical spine surgery | |
Clinical risk | Intubation | > 48 h |
Tracheostomy | Cuffed or uncuffed tube | |
Ventilation | Requiring up to 24-h ventilation | |
Nutrition | Reduced nutritional intake | |
Urgency | Chest infection | Recent chest infection |
Pyrexia | Spiking pyrexia | |
Oral hygiene | Increased need for oral care | |
Suction | Increased need for suction |
Instrumental Assessment
Treatment Approaches for Dysphagia After SCI
Clinical Management of Dysphagia in cSCI
Timing | Intervention | Literature/Evidence |
---|---|---|
Early interventions | Secretion management (hypersalivation vs. dry mouth) | |
Tracheostomy manipulation for swallow therapy | [102] | |
Rehabilitation | Treating the neurological impairments—swallow exercises | |
Ear Nose Throat surgeries, e.g., vocal fold augmentation | ||
Respiratory therapies incl. EMST | ||
Cough therapies | [109] | |
Emerging Therapies | ||
Respiratory Muscle Training | [110] | |
Abdominal functional electrical stimulation | [111] | |
Acute Intermittent Hypoxia | [112] |
Swallowing and Respiratory Muscle Training
Abdominal Functional Electrical Stimulation
Acute Intermittent Hypoxia (AIH)
Barriers to Rehabilitation
Implications for Clinical Practice
SLP Service Provision
1. Access to Speech–Language Pathology for a minimum of five days a week for patients with communication and swallowing difficulties on admission is mandatory and should be part of the multidisciplinary team assessment |
2. A baseline assessment must include case history, cranial nerve assessment, secretion management, voice, communication (both speech and language), cognition, oral health, swallowing, associated respiratory function and outcome measures |
3. The therapist may be required to undertake instrumental assessment, as appropriate, including videofluoroscopy, Fibreoptic Endoscopic Evaluation of Swallow (FEES), Ultrasound, manometry and surface EMG for the assessment of laryngeal function and airway patency for management of weaning, dysphagia and communication difficulties |
4. The rehabilitation process should include: a. targeted and physiologically specific therapeutic interventions b. biofeedback tools to enhance patient involvement, e.g., surface EMG, FEES, respiratory muscle strength training c. opportunities for oral trials d. optimizing secretion management and oral care e. improving breath support for phonation f. access to alternative and augmentative communication g. utilizing above cuff vocalization |
5. There should be access to instrumental assessment of swallow, either FEES (during acute phase when tracheostomy is placed and patient is extubated) and VF for returning to oral intake or to support tracheostomy and ventilator weaning |
6. The assessment of voice and breath support for adequate communication is essential |
7. Other areas will include rehabilitation of swallow, communication and advice on mouth care |