How can posture contribute to safer swallowing? A multidisciplinary review

Safe swallowing is a topic of concern for many healthcareprofessionals who help in the day-to-day care of those who are living withchallenging conditions such as motor neurone disease (MND), Parkinson’s, or MultipleSclerosis (MS). Safe swallowing may also be a consideration when rehabilitatingafter a brain injury or stroke, and it can affect other groups such as theelderly or those with postural needs.

There can be numerous reasons for these challenges in swallowing including cognitive decline, difficulties with controlling the muscles in the mouth, or challenges with postural control that can affect the ability to self-feed and swallow safely.

This article offers an overview of the challenges some individuals may face when swallowing, the associated risks, as well as practical interventions and insight into ideal posture and positioning for optimal safe swallowing.  

IMAGES

Our Experts

Jenny Rolfe is a senior OT, who has been practising since1997 and completed her MSc in Neurorehabilitation in 2007. Her expertise lies in postural management and assessment. In the recent Accora webinar titled Optimising posture and positioning to support safe swallowing: a multidisciplinaryapproach¹, she was joined by speech and language therapist, Jen Benson.

Jen Benson is an award-winning Speech Therapist specialising in adult neurological conditions, communication, and swallowing. She is registered with HCPC (Health and Care Professions Council), RCSLT (Royal College of Speech and Language Therapists), and ASLTIP (Association of Speech and Language Therapists in Independent Practice), and has her own consulting business.

Top 5 takeaways on safe swallowing

1 – The normal swallow

According to Norfolk and Norwich University Hospitals, “on average you swallow 580 times a day in order to eat, drink, and manage saliva.”²  Often we don’t even notice that we’re doing it, but when challenges with the anatomy of swallowing occur it can have a far-reaching impact on an individual’s quality of life and health. Jen Benson advises on the stages of a “normal swallow”.

‍Pre-oral stage

• “Your brain is the beginning of everything with your swallow. It's that anticipation of what is coming in terms of being able to smell the food or the sensation of having a fork or glass in your hand which is sending those signals up to your brain.”

Oral preparatory stage

• “This part of your swallow is under voluntary control-you can control whether you do this or not. Biting, chewing, and forming a bolus (ball of food) fall into this stage. Once you’ve formed a bolus and it’s ready to swallow, you move it to the back of your mouth and that’s where you trigger a swallow reflex.”

Oral stage

• “From this stage onwards, the swallowing process becomes involuntary. It’s taken over by our automatic internal controls.”

Pharyngeal stage

• “The aim of the pharyngeal stage is to protect the airway and to move the bolus quickly through the pharynx into the oesophagus.”

Oesophagealstage

• “The Oesophageal stage follows on from the pharyngeal stage to get the bolus safely to the stomach".

So, these are the stages of swallowing and a brief explanation of how it’s supposed to work when everything goes to plan…but what about when it doesn’t?

2 – Dysphagia: when swallowing goes wrong

There are many complications that can occur during the process of swallowing food or liquid. Dysphagia is the term that refers to what happens when things do go wrong, but what causes it? Jen Benson advises that: "Very often dysphagia is caused by a neurological deficit. It might also be caused by something like head and neck cancer. That's another very common cause. Sometimes it can be caused by an accident or an injury to the face or the pharynx.

“Sometimes it can be caused by cancer within the lungs that is pressing on the oesophagus or on the pharynx if it's going upwards. So, there might be many reasons for dysphagia and many reasons for the difficulties that we see."¹

Some of the difficulties individuals may face which can create issues with swallowing include:

·      Weakness in muscles of the mouth, especially the tongue, lips, and soft palate

·      Delay in triggering the swallow reflex

·      Poor pharyngeal pressure generation

·      Reduced or absent airway closure

·      Difficulty coordinating breathing and swallowing

There are numerous things that could go wrong at any of the stages in the process of swallowing but the above are some common ones to be particularly aware of.

3 - Impacts of dysphagia

There are both immediate and longer-term impacts of failure to safely swallow food or drink.

TABLE

4 - Possible solutions to dysphagia

Thickened fluids

The traditional solution for dysphagia is to thicken liquids. Jen Benson advises that there are "lots of pros and cons to thickening fluids. So, for some people, it is still a positive to have their fluids thickened.

"The idea of thickening a fluid is that it travels much more slowly, so it gives you more time to get all of those muscles in the right place at the right time to direct that bolus down the right way."¹

It could be argued that the most common objection to thickened fluids is down to personal preference. Some people simply may not like the taste or the texture and the risk with that is if an individual doesn’t like it, they’re not going to drink it. In turn, a lack of fluid can lead to numerous other complications, as such, personal preference is important to consider here. Another difficulty some patients may encounter is fluids becoming stuck in the pharynx because they are thicker and slower moving. This increases the risk of aspiration to or from the lungs, which is harder to disperse than a thin liquid, and raises the risk of infections developing in the chest.

Specialist drinking vessels

One solution which can mitigate the risk of unsafe swallowing is different drinking vessels. The type of drinking vessel you choose will significantly impact the posture of your head and neck, which affects swallow safety.

Generally, we want to avoid drinking vessels with spouts, or where you have to tip your head back to operate them: "if you think when you've done rhesus training in the past, the thing that they tell you to do if you're trying to resuscitate somebody is to tip their head back to open up the airway. We don't want to open up those airways. We want to close them off if we can. So, head tilted ever-so-slightly forward is what we're aiming for, or neutral in the midline."¹

Cups where a patient won’t need to tip their head back while swallowing are optimal, so Jen advises considering ones where you can “get your nose in” as best practice.

IMAGE

5 - Is there an 'ideal posture' for swallowing?

OT Jenny Rolfe explains the importance of pelvic posture in aligning the rest of the body for safe swallowing.  

IMAGE

"If we get that pelvis in that neutral position, it places our spine in a more neutral position, a more natural position, which allows our head to be in a good position. We think about the pelvis as a foundation [...]. We cannot address the head position without addressing the pelvic position. If the pelvis is in the wrong position, it's likely that the head is going to be in the wrong position."¹

VIDEO

The most important aspect?

Jen Benson asks us not to forget the experiential aspect of eating and drinking. It’s a multi-layered experience with social, cultural, emotional, and sensory elements to it, not only a means of gaining nutrition. She urges healthcare professionals to consider how both issues with swallowing and potential interventions can impact this experience.

"I think the most important thing for all of us is optimising that quality of life. Eating and drinking is very often something that gives people pleasure. I think it's easy to lose that aspect when you're looking at this kind of management. And, actually, some of our patients may not have an awful lot of other things in their lives that give them that quality."¹

Final reflections

It’s all very well to develop a list of dos and don’ts around best practices in swallowing, but perhaps it’s just as important to consider how any risk mitigation measures will affect other areas of the individual’s quality of life, and their sense of identity.

There’s no one-size-fits-all approach here because every individual’s swallowing challenges and needs are slightly different. The physiological realm of the nose, mouth, and throat is incredibly complex. So, when we consider questions like “Are straws safe for those with difficulty swallowing?” or “Should I feed someone in a tilted position?” the answer is and must be - it depends. There is no substitution for an individual swallowing assessment and a sincere effort to understand the wider implications for that person of both the problem but also potential solutions.