Problems may include difficulties with:
Chewing and Swallowing
Chewing problems occur because the person doesn't have adequate strength or the ability to chew solid food. It's helpful to choose foods that don't require chewing, such as pureed meats, vegetables, and fruit. Therapists focus on increasing strength by exercising the muscles of the cheeks, jaw, and tongue.
Swallowing problems, also known as dysphagia, occur because of decreased ability to control food as it moves from the mouth into the stomach. The extent to which swallowing is a problem varies from patient to patient. The most severe form is the inability to swallow saliva. Another problem is increased time to elicit the swallow, which can prevent safe drinking of liquids and eating of solid foods. Water and ice chips may not even be safe at this time.
Signs of swallowing problems include coughing, choking, wet voice sound, and congestion, among other signs. A swallowing problem may lead to saliva, bacteria, or food entering the lungs (aspiration), which can lead to pneumonia. Therapists assess each patient for possible swallowing problems and help determine appropriate guidelines, such as types of foods or eating strategies to make the eating process safe and enjoyable. Special tests, such as a videofluoroscopy swallow study (FSS) or fiberoptic endoscopic evaluation of swallow (FEES), may also be done.
These tests allow the therapist to “see” the food passing from the mouth to the stomach. They will help show if a swallowing problem is present and what therapy strategies to use. The test then will help the team decide if eating by mouth is safe. In certain circumstances a person may not be able to take food or drink or medicine by mouth (NPO) and may require an alternate feeding source such as an NG tube or G-tube.
Nutritional problems can occur as a result of the eating problems described above. To receive adequate nutrition, alternate feeding methods are sometimes used. A registered dietitian will assess each patient and, along with the doctor, select the feeding formula best suited for the patient’s nutritional needs.
Small, thin tubes, called feeding tubes, can be inserted in the nose (nasogastric or NG tubes) and run to the stomach, or can be inserted directly into the stomach (G-tubes or PEG tubes). All necessary calories, nutrients, medications, and water are given through the tube in the form of the feeding formula. Tube feedings follow different schedules depending on therapy sessions, tolerance, sleep, and individual needs. As chewing and swallowing skills improve and eating begins, the calories from the tube feedings are decreased until the patient can take all of the necessary calories and liquids by mouth. This may take some time as each patient progresses at a different rate.
Head, Neck, and Trunk Control
Controlling movement of the head, neck, and trunk can be a problem because of impaired strength, impaired coordination, abnormal muscle tone, and fatigue. These deficits result in poor positioning of the head, neck, and trunk; decreased endurance for sitting upright; and inability to complete a meal due to fatigue.
Therapists may recommend positioning devices to support the body for natural and comfortable sitting. Strength, coordination, and endurance will be a major focus during therapy.
Cognition problems, such as decreased attention and memory can prevent safe eating. The patient may be unable to control the amount and speed of eating (impulsivity) or they may lose track of what they are doing (distraction).
Therapists may recommend that distractions be eliminated as much as possible to allow the patient to concentrate on eating. In addition, compensation techniques such as cue cards and verbal reminders may be used to help the patient eat safely.
Oral sensation problems can interfere with eating in two ways. First, the lack of oral sensation may prevent the person from feeling food in his or her mouth, resulting in food collecting in the mouth (pocketing), and food falling out of the mouth. Secondly, heightened sensation can make food uncomfortable or difficult to tolerate.
Smell and taste may be impaired, making eating less enjoyable. This may result directly from the brain injury or as a result of certain types of medications.
Vision problems may make it difficult for the person to locate and eat the food.
Vestibular difficulties may result in dizziness, which can lead to nausea and vomiting, thus interfering with eating.
Therapists may recommend compensation techniques, verbal cuing, desensitization, and monitoring of calories.
Seeing food on one side of the plate or tray
Using objects correctly
Grasping objects accurately
Recovery from Eating Problems
The recovery process varies from person to person. An individual treatment plan will be developed for the patient. This plan may include one-on-one feedings with only the patient and therapist or the plan may progress to involve nursing staff. After education and training for safe eating, families may become involved.
As greater independence and safety emerges, patients may be encouraged to eat with other patients in small groups. If improvements are made in chewing and swallowing, the patient’s diet will be upgraded to more normal food. The rehabilitation staff will closely monitor this progress and change the treatment plan as needed.