Rehabilitation of swallowing in post-acute traumatic brain injury: preliminary results after 4 months

Background: In patients with severe traumatic brain injury (TBI), the anatomic and physiologic status of the swallowing mechanism may be impaired, so rehabilitation treatment is needed. When cognitive-communicative and behavioural impairments are also present, the rehabilitation of dysphagia is more complex and challenging. For this reason many patients required nutritional supplement through percutaneous endoscopic gastrostomy (PEG) or nasogastric tube. The aim of our study was to determine the efficacy of intensive rehabilitation treatment and its correlation with cognitive status in patients with dysphagia due to severe TBI, in rehabilitation setting. Method: Fifteen subjects, mean age 36.2, with dysphagia, in stable conditions after severe TBI, with nutritional supplement through PEG, consecutively admitted to rehabilitation setting between 1998 and 2001 was enrolled for this study. Clinical bedside swallow evaluation and fiberoptic endoscopic evaluation of swallowing (FEES) were performed at admission. The Rancho Los Amigos (RLA) level and trachestomy was also recorded. The specific rehabilitation treatment included oral motor exercise, different swallowing techniques, positioning, diet modification, and pulmonary rehabilitation (chest percussion, ventilatory muscle training, etc.). Main outcome measure were the removal PEG and oral intake of food. Results: Loss of bolus control, delayed swallowing reflex, and a severe reduced tongue control and mandibular movement occurred most commonly at admission to our department. At admission the average mean RLA was 4.1 (SD 1.3). After 4 months, the swallow rehabilitation treatment determined a complete recovery of swallowing in 7 (46%) patients (FEES negative, PEG removal, increase average RLA level of 1.7). Six patients seemed to present a significant improvement, but not complete recovery of initial swallowing deficit (FEES negative; increase average RLA level 0.9; they still required nutritional supplement through PEG). In this phase there is no significative related to placement tracheostomy. Conclusions: Our study demonstrates that cognitive/behavioral impairments are one of the main factors related to start eating and achieve total oral feeding in rehabilitation setting. In fact, when the patients improve cognitive status, the intensive swallowing rehabilitation can be effective with an early resumption of oral ingestion.