Ride For Life: New therapy helps reteach skill to swallow

Catriona Steele jokes that the goal of her research is to send each of her patients to Weight Watchers. Steele studies swallowing, a fascinating function that goes virtually unnoticed thousands of times each day, with every bob of an Adam's apple and every chain-reaction contraction of the 25 muscles it takes to push saliva or food out of the mouth.

Her patients, unfortunately, are acutely aware of swallowing. Specifically, the absence of it.

Steele, of the University of Toronto's department of speech pathology, does research at the Toronto Rehab hospital. Most of her patients are recovering from strokes or other brain injuries, or slowly losing the battle against Parkinson's disease or muscular dystrophy or a dozen other degenerative neurological disorders.

All too often, she said, they live on pablum, thickened liquids or mush; in extreme cases they can get food into their bodies only through a feeding tube surgically inserted in their stomachs.

For nine months following his stroke, John Hale "ate" every meal through a tube. He carried around a cup, sometimes discreetly concealed in a paper bag, to spit out saliva. Every day, with religious regularity, he poked at the back of his throat with a silver "swallowing stick," an instrument that looks like a tiny golf driver that is meant to stimulate the gag reflex in the hopes of triggering swallowing.

It failed miserably. Hale continued pouring cans of food down the tube, sneaking in an occasional glass of wine.

Then he was introduced to Steele, who put him through a new, intensive therapy meant to retrain muscles by using biofeedback. She showed him he could swallow, albeit weakly. She also gave exercises that would rebuild his muscles until he learned to swallow again — exercises he practises with the verve of a religious fanatic.

After only eight sessions, the tube was gone. Hale, a retired Hydro employee who also ran an engineering consulting business, swallowed a cup of strawberry yogurt, savouring the sensation of taste and texture.

"It was just marvellous. It was delicious," he said.

Soon it was scrambled eggs, shrimp, cups of tea. He's gained five kilograms in the three years since receiving the therapy — despite regular rounds of golf — and jokes that for the first time in his life, he's going on a diet.

"When you regain the ability to eat, it's a huge joy," he said.

In fact, the students who train with Steele are forced to spend the day eating mush to get a sense of how unsatisfying it is, how it leaves you thirsty and how it affects the quality of life.

We're born knowing innately how to swallow and do it like breathing, regularly and without thought. But despite millennia of practice, scientists aren't entirely sure how it works.

They know there are 25 muscles involved. They know that a little flap of tissue at the top of the throat shields the airway from errant food.

Steele, who is a Ph.D.-trained speech language pathologist, can expertly draw a freehand facial profile and the snaky tubes bending gently as they move from the nose and mouth down into the lungs and stomach.

But they don't know how it all fits together. What triggers the brain to send out electrical messages telling muscles to swallow? What is the order of their movement? Are there variations? How does it co-ordinate the little flap? Do the muscles weaken as we age?

Why, with diseases like Lou Gehrig's or Parkinson's, does our brain suddenly forget something we've done effortlessly since birth?

Steele's research focuses on switching on swallowing again. Electrodes on the patient's neck pick up on the electrical impulses running through the throat muscles during swallowing. Patients watch the signal on a monitor, trying valiantly to swallow with enough force to meet a target line.

It's like weight training, but for your throat.

"By working with a signal, you can get control of whatever muscle you're working with," she said. "It's like knowing a software code. If it's not working, can you dissect it and make it work by running the instructions separately?" Steele said.

"You're taking an automatic program and making it manual."

Case reports, coming out of the States mostly, suggest that the therapy is incredibly effective. Patients who were once unable to swallow — had to spit saliva, couldn't sleep for the choking — were able to get the muscles fully functioning again.

Steele has begun using the treatment on her own patients and has achieved similar successes.

In fact, progress is notable in just 11 intensive sessions, usually spanning only two weeks. By six months, many patients have returned to eating soft foods; the feeding tube is gone.

Steele's patients tell her that while they can swallow, they're never quite the same and still have to think about doing something the rest of us do very naturally.

In fact, Hale has to think about swallowing and he can't manage fibrous oranges or chewy steak or raw carrots. He's also had to relearn how to cough when he's choking to effectively clear whatever is blocking his airway.

The therapy is being used in an international study looking at its effectiveness and the importance of treatment intensity. It involves seven countries and five sites in Canada, including Trillium Health Centre in Mississauga.