Overcoming Swallowing Disorders with Erin Ward, MSCCC-SLP

Dysphagia is a swallowing condition that causes challenges when eating or drinking and can lead to serious complications, such as choking or pneumonia infections caused by aspiration. In this episode, Erin Ward, a speech-language pathologist from MUSC Health Florence Outpatient Rehabilitation Center, talks about this condition and treatments offered at MUSC Health

 

"The most important thing is keeping your regularly scheduled doctor's appointments, your annual appointments and mentioning to your doctor anything that you feel is different or might possibly be a problem. Don't ignore it and just brush it off. If you're coughing more with liquids, let the doctor know. If you feel like there's something stuck in your throat when you swallow, let the doctor know."
– Erin Ward, Speech Language Pathologist, MUSC Health

Topics Covered in this Show

• To combat symptoms of dysphagia, Ward offers patients a variety of therapies and lifestyle changes from exercises that address the underlying impairments and can help them restore their normal swallowing abilities.
• Ward has a bachelor's and master's degree in communication disorders and focuses on dysphagia in the MUSC Health Florence Outpatient Rehabilitation Center, which includes conducting swallow studies on Tuesdays and Thursdays.
• She says many patients with dysphagia feel a lump in their throat when swallowing and may experience coughing and choking when eating or drinking and difficulty swallowing certain textures or liquids.
• Risk factors and causes of the condition include Parkinson's disease, head and neck cancer, stroke and neurological conditions, like multiple sclerosis. Radiation therapy for cancer treatment can affect swallowing and voice.
• Through modified barium swallow studies, Ward is able to diagnose the condition, but bedside evaluations may also be used as a diagnostic tool.
• During modified barium swallow studies, patients consume different textures and consistencies of food and liquids, and a radiologist observes their swallowing on a live X-ray. This method helps determine the severity and type of dysphagia.
• Patients should seek this type of study if they are experiencing aspiration of food or liquid into the trachea, have frequent coughing or choking when eating or drinking, have a persistent feeling of something stuck in the throat or have recurrent pneumonia, especially right lower lobe pneumonia.
• MUSC Health offers a variety of treatments for dysphagia, from dietary modifications to swallowing therapy exercises and techniques.
• eSTIM (electrical stimulation) and myofascial release massage are specialized therapies that offer positive results for many. Ward is one of the few in the area to provide myofascial release therapy technique, which reduces muscle tension in the head and neck.
• Many patients are able to move on from rehabilitation appointments in a few weeks or months.

Read the Show Transcript

[00:00:00] Erin Spain, MS: Welcome to Advance with MUSC Health. I'm your host, Erin Spain. This show's mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Dysphagia is a swallowing condition that is more than an occasional feeling of food or drink going down the wrong pipe. It can cause challenges when eating or drinking at every meal and can even lead to serious complications such as choking or pneumonia infections caused by aspiration. Erin Ward, a speech-language pathologist from the MUSC Health Florence Outpatient Rehabilitation Center, is an expert in the diagnosis and treatment of speech and swallowing disorders. She joins me today to talk about this condition and treatments offered at MUSC Health and why people with symptoms should be evaluated. Welcome to the show.

[00:00:57] Erin Ward, MSCCC-SLP: Thank you for having me.

[00:00:58] Erin Spain, MS: Well, share with me your background and expertise in helping patients with swallowing conditions.

[00:01:05] Erin Ward, MSCCC-SLP: I have a bachelor's degree in communication disorders. And a master's degree in communication disorders as well. I've been focusing on dysphagia in the dysphagia clinic at the Outpatient Rehabilitation Center at MUSC. So, along with treating patients in the clinic, I also do outpatient swallow studies on Tuesday and Thursday mornings at the hospital.

[00:01:34] Erin Spain, MS: So let's talk specifically about the variety of symptoms that someone may experience that you would say, hey, you need to come in and get checked out for your swallowing. You may have a swallowing condition.

[00:01:45] Erin Ward, MSCCC-SLP: So typically, what I see in the outpatient population typically are anywhere from about 30 to 60 years old and they normally tell me I feel a lump in my throat when I swallow. A lot of times, they're referred to me by the GI doctors, and I see a lot of upper esophageal issues in that population. The other signs and symptoms would be coughing and choking when you're eating or drinking. So, a lot of times, doctors will refer people for modified barium swallow studies if they're complaining that they're getting choked during meals or they're coughing with their liquids.

[00:02:30] Erin Spain, MS: Are there risk factors for developing this? And what are the different causes?

[00:02:34] Erin Ward, MSCCC-SLP: People who have Parkinson's disease are at high risk for swallowing difficulties. I have a lot of referrals from oncologists, head and neck cancer patients. A lot of times, they want me to do a modified barium swallow study prior to their treatment and then after their treatment so we can kind of compare and see. How they look, they're swallowing. A lot of times, the radiation is harsh, and it can affect swallowing and voice. And then the other population that I see would be neurological, like stroke, head injury. Those types of patients, also patients with MS, multiple sclerosis, are at high risk to have problems with swallowing.

[00:03:21] Erin Spain, MS: Tell me about the actual diagnosis of dysphagia.

[00:03:25] Erin Ward, MSCCC-SLP: So the three types of dysphagia would be the oral dysphagia, pharyngeal dysphagia, an esophageal dysphagia. When I diagnose someone with dysphagia is when I do the modified barium swallow studies or at the bedside. A lot of times, they already have a diagnosis of dysphagia from the doctor when they come in to get the swallow study.

[00:03:48] Erin Spain, MS: You have mentioned swallow studies several times, so walk me through that. What happens during one of these studies?

[00:03:54] Erin Ward, MSCCC-SLP: So during a modified barium swallow study, before I start, I mix different textures and different consistencies that I'm going to give the patient. So I need something pureed. I need something that's mechanical soft. So for pureed, I usually use applesauce and we mix everything. with barium so we can see, and we watch the patient swallow. A radiologist is in the room, so it's basically like a live X-ray. So, we have puree, we have soft texture, we have a harder texture, like a graham cracker, for example. And then there are three different consistencies of liquids that we use. We use a honey thick, a nectar thick, and then a thin liquid. So we give the patient samples of all these different textures and consistencies, and we see how they do with each different consistency or texture.

[00:04:54] Erin Spain, MS: When should a patient seek out a swallowing study or evaluation like the one you just described and that you do at MUSC Health?

[00:05:02] Erin Ward, MSCCC-SLP: If you are having symptoms of aspiration, that would be a good indication that you probably need to have a modified barium swallow study. So aspiration means that the food or liquid is going down your trachea instead of your esophagus. I see people aspirate thin liquids, just regular liquids. Like water all the time because they're not heavy. They go down quickly. Our bodies don't really have time to process what's going on. If you are coughing. Almost every time you drink, or almost every time that you eat, that would be a good indication that you probably need to have a modified barium swallow study. If you constantly feel like there's something stuck in your throat, that could be another indication that you would benefit from a swallow study.

But all of us probably at least one time a day, for me, I will notice that, you know, I'm drinking and I'm not sitting exactly all the way upright or I take a huge sip, and I feel something go down the wrong way. If that happens occasionally, and you feel it, and you cough, that's a good thing. That means you have sensation, and you feel it. But if it's happening repeatedly, or if you've been diagnosed with pneumonia, especially right lower lobe pneumonia, then that's typically aspiration pneumonia — definitely need a modified barium swallow study with that.

[00:06:34] Erin Spain, MS: So what could happen if this condition is left untreated, if they don't come in and see someone like you and get some treatments and some help? What are some of the consequences?

[00:06:44] Erin Ward, MSCCC-SLP: The most detrimental would be recurrent pneumonia. So, just aspiration pneumonia after aspiration pneumonia, because often if you're older and you're in a hospital bed, you're not moving around, it's really hard to treat that, especially repeatedly over time. Another thing that can happen if you have dysphagia and it's not treated, you could choke. So if you have residue, there are certain sorts of spaces in your throat where things can collect, and if you have residue there and you take another bite of food or swallow a drink of liquid, then you could get the food lodged in your trachea and choke.

[00:07:30] Erin Spain, MS: So, it can be quite serious, but you have treatments. Treatments that can help people. This may involve medications, possibly surgery or changes to the patient's diet and speech therapy. Can you walk me through some of these common treatments that are offered to patients?

[00:07:47] Erin Ward, MSCCC-SLP: So, the most common thing probably that we do is I recommend what type of diet the patient needs to be on and what type of liquid consistency the patient needs to be on. So, most of the time, the first thing I do is I recommend the safest diet texture and the safest liquid consistency for the patient.

After that, if they need to, I recommend that they come in for swallowing therapy. A lot of speech pathologists are certified in e-stim. The e-stim that I use is called vital stimulation, so there are electrodes that are placed on the patient's throat in different positions depending on what the issue is, and I will have them do swallowing exercises while the electrical stimulation is on. Another technique that I use is called myofascial release. So, this is a manual technique. The fascia is the tissue in between the muscle and the skin, the fibrous tissue, so a lot of times, that will be tight, and it will create restrictions. in swallowing.

And so I'll do the manual technique. It's a massage technique that could kind of break up some of those adhesions in the fascia. So myofascial release, vital stem, swallowing exercises. There are three, four or five main types of exercises that I teach and use to strengthen the muscles. And so we'll do a course of this therapy, depending on the person. For example, there are some contraindications. If a patient has a pacemaker, for example, I would not do e-stim on that patient. So just, depending on the patient, I'll create a plan, do a course of therapy, and then we'll repeat the modified barium swallow study, which is the fun part, to see if they've made progress. And if we can advance their diet and their liquid consistency.

[00:09:47] Erin Spain, MS: So there is rehabilitation here. People can get better and put some of these symptoms behind them.

[00:09:54] Erin Ward, MSCCC-SLP: Right. Especially, I forgot to mention all of the positioning strategies that we usually teach patients. Some people do better with a straw. Most people, I find do better without a straw as long as there's no lip weakness. Sometimes, people don't realize how much they're taking in through a straw, and it's hard to control. So, strategies would include cup sips or straw sips, tilting your head down, tilting your head back, looking either to the left or right. Those aren't as common, but just different strategies. Also, if people are getting some food collected in one of those spaces that I talked about, we might recommend the strategy of alternating food and liquid boluses to try to clear that space out to make it safer.

[00:10:43] Erin Spain, MS: So, how long is a typical course of therapy and treatment, and when can people start to get some relief?

[00:10:50] Erin Ward, MSCCC-SLP: I usually recommend twice a week for four weeks starting out, and I just kind of monitor the patient and see how they're doing, and then we could repeat the modified barium swallow study, or sometimes I'll do it after eight weeks, just depending on what they're telling me. A lot of times, I'll ask them, Are you coughing less frequently? And if that's happening, then we can usually do it quicker. Or sometimes it takes longer. And so I'll wait two months.

[00:11:21] Erin Spain, MS: Is there ever a time when medications or surgery would be the next step?

[00:11:25] Erin Ward, MSCCC-SLP: Medications usually are for esophageal dysphagia. So, I see a lot of people that have reflux. And when you have reflux, it constantly irritates one of your muscles that is supposed to not jut out in the esophagus. But when you constantly irritate that muscle and that muscle is trying to hold down the reflux, it will sort of jut out and become hard and so it'll narrow your esophagus. So, for esophageal dysphagia, a lot of times if the patient has a reflux, reflux medication is very important. If they have the top of their esophagus is narrow, so it's not opening wide enough, a lot of times, I'll recommend a GI consult, and a lot of times, they'll do A dilatation of the top of the esophagus to make it wider. That's not a permanent fix, but it can give the patient relief, and sometimes, they'll go back and have it done when they need to.

[00:12:33] Erin Spain, MS: Tell me about people that you are seeing come through to do this type of rehab and some of the success stories.

[00:12:39] Erin Ward, MSCCC-SLP: My favorite success story that I see right now is almost 90, and he lives in an assisted living facility. His swallow was so bad when I did his initial modified barium swallow study that I thought he needed a feeding tube. He was aspirating pretty much everything, so I wanted him to get a feeding tube. Well, his family wanted to try the therapy first before we went to that extreme measure. So we did. And he has not gotten pneumonia. He follows all the recommendations. He is on thickened liquids. He always uses his thickened liquids. He does his exercises twice a day, every day. And he says that he's so glad that he doesn't have to be on a feeding tube because of the therapy. And he comes to see me every Friday.

[00:13:32] Erin Spain, MS: People over the age of 50 are much more likely to develop it. Is there anything we can do to prevent this and other swallowing conditions?

[00:13:42] Erin Ward, MSCCC-SLP: The most important thing is keeping your regularly scheduled doctor's appointments, your annual appointments, and mentioning to your doctor anything that you feel is different or might possibly be a problem. Don't ignore it. And just brush it off. If you're coughing more with liquids, let the doctor know. If you feel like there's something stuck in your throat when you swallow, let the doctor know.

If you're supposed to be on medication for reflux, it's important to stay on the medication. It's also important to, of course, take all of your recommended medications if you're on blood thinners or if you're on high blood pressure medication, all those things that can help prevent you from having a stroke because a lot of times, if you have a stroke, you'll develop swallowing problems. Also, the patient could be aware of possible signs of head and neck cancer by talking to the doctor about those different things because I see a lot of patients, like I said earlier, with head and neck cancer.

Dental visits are important. It's important to see your dentist every year or every six months because, a lot of times, those are the professionals who actually pick up on the oral cancers. From what I've seen. So lots of things that we can do preventatively. Also, we shouldn't make a habit of eating and drinking while we're lying down. Eating and drinking while sitting up is better for your body just to let gravity take its natural course that way. So those are some preventative things.

[00:15:26] Erin Spain, MS: The therapy that you provide and that you can administer and teach patients, is this the gold standard, and is this something that people should seek out?

[00:15:36] Erin Ward, MSCCC-SLP: I know that a lot of speech therapists provide electrical stimulation, but I don't know of any other speech pathologists in town who have been to the myofascial release training that I went to. I'm not sure, but I went in Tampa, Tampa, Florida, and I learned from a physical therapist. So he kind of brought that world To me, the physical therapy world of hands-on, touching the patient. Before I had been to that course, I really didn't touch my patients. And that's something that is very important to patients, is to feel your touch. And so, the myofascial release, the massage technique therapy, I don't know, I haven't heard of anyone else that does that around here, but that has been so beneficial to me and to my patients because they have just found so much relief from muscle tension.

A lot of times, if people have swallowing problems or neurological conditions or problems with their muscles, they'll have all this tension that they hold in their head and neck, and it can affect their swallowing. So, the myofascial release has been very helpful, and I know that a lot of speech therapists don't do that yet because That's just starting to come over from the physical therapy world as a modality.

[00:17:05] Erin Spain, MS: And what does that look like? You're actually massaging the neck and throat area?

[00:17:09] Erin Ward, MSCCC-SLP: I do skin rolling, I do massage on the back of the neck, I do massage around the sides of the neck. I know certain things to be careful for, I know how to, it's very light pressure. It's something that you shouldn't just try to do on your own. You shouldn't just say, Oh, I think I need to massage my trachea because you can press too hard. It's light pressure, and you have to be very careful around the carotid arteries, so it's not something that you should go home and just try to do. But with training and when I see the patients, I do teach them how to do their own massage.

[00:17:47] Erin Spain, MS: Is there anything else that you want to add that you think is important for patients to hear or know?

[00:17:52] Erin Ward, MSCCC-SLP: I want patients to know that it's always possible to get better. There are always different things that we can try. And with a positive attitude if what we try at first doesn't work. Then we can try something else. We can do different techniques. We can do different positioning strategies. I can refer patients to different professionals. If I can't figure out what's going on or if I can't help the patient, I can get them to someone who can. So I guess what I want to say to patients is, Don't be afraid of it. Patients always tell me, I don't understand why I would go to a speech therapist if I have trouble swallowing. It's just part of our realm that we do, and it's not painful. The therapy is not painful. Sometimes it's a lot of work, but there are a lot of benefits, so I just want to put that out there to them that it's not something scary and it's something that could benefit you. Your quality of life. Your quality of life.

If you start doing therapy when you first notice that you're having problems, your muscles could be stronger so that you don't have to have a feeding tube, so that you don't get pneumonia, so that you don't have to lie in the hospital, especially when COVID was really bad, and then patients would develop aspiration pneumonia on top of that. That was very dangerous. Swallowing therapy can definitely improve your quality of life because we love food. People love to eat and drink.

[00:19:25] Erin Spain, MS: What do you do to optimize your health and live well?

[00:19:27] Erin Ward, MSCCC-SLP: So I see the doctor every year for a checkup. I see my dentist every six months. I exercise. I do barre. I don't like Pilates, but I do Pilates. I love yoga. I do yoga. And I work out with a personal trainer maybe once a week, maybe twice a week. And I love fruit. I eat fruit all the time. I do not drink alcohol. And I just try to be as healthy as I can.

[00:20:02] Erin Spain, MS: Erin Ward, thank you so much for coming on the show and explaining this really fascinating therapy and condition and all the patients that you're able to help. We really appreciate it.

[00:20:13] Erin Ward, MSCCC-SLP: You're welcome. Thank you for having me. I enjoyed it.

[00:20:20] Erin Spain, MS: For more information on this podcast, check out advance. muschealth.org.