Post-Polio Health (ISSN 1066-5331)
Vol. 12, No. 1, Winter 1996
New Swallowing Problems in Aging Polio Survivors
Carl A. Coelho, PhD, Gaylord Hospital, Wallingford, Connecticut
In the normal swallowing process, three phases are typically described. The oral phase involves food being placed in the mouth, chewed if necessary, and positioned or formed into a ball (bolus) which is then moved backwards to the anterior faucial arch, an area near where the tonsils are, or used to be, and where the swallow response is triggered. During the pharyngeal phase, three things happen simultaneously. The tongue pumps the bolus back into the pharynx, the epiglottis, (a chunk of cartilage near the base of the tongue), slams down on top of the airway, the larynx (voice box) elevates slightly, and the vocal chords close. These activities prevent aspiration (food or liquid from entering the airways). If the synchrony of any of these is disturbed in any way, significant problems can occur. At the same time, the third and final phase of swallowing is occurring, a coordinated muscular activity which transports the bolus through the throat where a small sphincter (muscle) at the top of the esophagus called the cricopharyngeus relaxes (dilates) so that the bolus can enter the esophagus and eventually the stomach.
In 1988, three individuals triggered my interest in swallowing problems of post-polio individuals. They had a mean age of about 53 and were between 30 and 60 years post-onset. All complained of coughing and the sensation of food sticking in their throats. Examination found that some had reduced strength in oral musculature, some had problems with pharyngeal transit, and others had a delayed swallow response. Although there was no aspiration, all three were judged to be at risk. In 1991, a project I was involved with sent out a questionnaire to post-polio individuals. Twenty-nine of the 109 respondents reported periodic or consistent problems with their swallowing. Of 21 studied, 20 had some type of swallowing dysfunction, some with multiple problems. Nine had problems with bolus control or weakness of the musculature, four had a delayed swallow response, and 17 had problems with pharyngeal transit. While none aspirated, two were judged to be at significant risk.
Problems with swallowing reported in the literature .
In 1991, a study published in The New England Journal of Medicine was conducted by Barbara C. Sonies, PhD, and Marinos C. Dalakas, MD. They followed 32 individuals. Only 14 of the 32 reported swallowing problems, but when examined 31 had objective signs of difficulty with swallowing. Problems were found during the pharyngeal phase, with pooling in the valleculae, the V-shaped space formed by the base of the tongue and the epiglottis. Two individuals with pooling aspirated.
Another paper published in 1991 by Alice Silbergleit, MA, et al, studied 20, post-polio individuals with a mean age of 49, 17 to 66 years post-onset of acute polio. Of these, 75% percent were noted to have reduced pharyngeal transit and pooling. Some also reported problems with esophageal motility and weakness of the oral musculature. Two individuals aspirated.
Interaction between breathing and swallowing.
Breathing and swallowing are reciprocal functions. When swallowing occurs, breathing halts. Seventeen of the 20 individuals in our study who had swallowing problems also had significant problems with decreased breathing capacity. There were some individuals with minimal swallowing problems, while others with very significant problems. Both groups also had moderate or severely reduced breathing capacities. It can be concluded that, although breathing problems can complicate or hinder swallowing, one cannot be predicted from the other. Significant breathing problems will not necessarily predict swallowing problems.
Currently, we are studying seven of the 15 of the original group of 21. We did a breathing assessment, a swallowing evaluation, and a vocal assessment because we are now looking at problems with voice. We measured strength and function of the oral musculature, ran a modified barium swallow, conducted pulmonary function testing, and voice testing.
Of six individuals who demonstrated swallowing problems during the initial assessment, three demonstrated an increase in the severity of their swallowing problems, and three remained essentially unchanged. Generally speaking, those individuals who were most severely involved from the initial assessment were the individuals who demonstrated the most significant progression. Again, there was no aspiration, but the two who had been at risk previously, were judged to have increased risk. All five of the individuals who had significant breathing problems earlier had their breathing capacity diminished over the four-year period.
The modified barium swallow procedure is absolutely critical, not only for diagnosis, but also for focusing on the management of swallowing problems. It defines the physiology of the swallow. In addition to the standard modified barium swallow (MBS) procedure, we added what we call stress testing. Just because an individual goes through the standard MBS procedure and does not have difficulty does not mean that over the course of a normal meal they will not experience difficulties. In the stress testing, we increase the quantity of liquids, purées or solids for swallowing, and attempt to tax the swallowing system. We have also tested people after a full meal when there might be some fatigue, or we bring them in after a normal workday when there might be a fatigue factor as well.
Compensatory positioning or relatively minor adjustments in posture during swallowing can significantly affect the swallow. Basic changes, such as dropping the chin or turning the head can help, the rationale being that many times the weakness in the pharynx is unilateral (on one side) and that by turning the head, the weakened side of the pharynx is shut off, forcing the bolus to go down the more intact, stronger side. Other management suggestions include dietary modifications and avoiding meals when fatigued. Longitudinal monitoring of swallowing problems, including pulmonary function testing is recommended.
DR. Coehlo referred to studies conducted by Barbara C. Sonies, PhD, Chief of Speech Language Pathology, and Marinos C. Dalakas, MD, Neurologist, at National Institute of Neurological Disorders and Stroke (NINDS) at the National Institutes of Health. Dr. Sonies contributed Chapter 8, "Long-Term Effects of Post-Polio on Oral-Motor and Swallowing Function in Post-Polio Syndrome," edited by Lauro S. Halstead, MD, and Gunnar Grimby, PhD.
The additional insights below are extracted from Dr. Sonies' chapter.
It appears that some individuals have speaking or swallowing problems of which they are unaware and which slowly emerge in the same manner as has been seen with limb muscles. This progression of symptoms in limb muscles may cause new disabilities. However, swallowing problems and associated complications, such as aspiration pneumonia, can be life-threatening.
Many, but not all, individuals with swallowing problems report having had acute bulbar polio. It appears that the more severe the original condition, the greater the likelihood of new problems. In their study of 32 individuals, 31 had some difficulty with swallowing, even though only 14 reported being aware of symptoms. It should be noted that the severity of the swallowing problems were significantly greater than those who did not. Normal aging does not cause changes in speech and swallowing, so any new signs of problems most likely are due to neuromuscular changes.
Common complaints reported by post-polio individuals included: intermittent choking on food, pills sticking in the throat, difficulty swallowing pills, food sticking in the throat, coughing during meals, and difficulty swallowing.
Individuals with suspected swallowing problems should seek an evaluation from a speech pathologist with expertise in dysphagia (swallowing). This evaluation will include a thorough history of eating, a clinical examination of swallowing, and a videofluorographic examination of the oral and pharyngeal swallow. Persons with complaints of indigestion may need evaluation of the esophagus - which can be done during the modified barium swallow study.
None of the individuals in the follow-up study at NINDS aspirated. Credit for improvement is given to the cooperation between therapists who developed the treatment plans and polio survivors who carried out suggested strategies.