[Dysphagia] pontine CVA

[dierbergerj at einstein.edu (Jennifer Dierberger)]

We are treating a 45 year old patient with a pontine CVA.  Her
videoswallow revealed severely delayed to absent pharyngeal swallow
characterized by minimal hyoid elevation and absent excursion, 
significant pooling of puree in vallecula which spilled to pyriform and
pooled at the UES, resulting in frank aspiration without sensory
response. Our question is relating to the site of lesion. We expect
hypertonicity with a pontine infarct vs. hypotonicity with a lower
brainstem lesion. However, they present similarly on video.  Therefore,
how do we know if the muscles are hyper or hypo-tonic? And, if we have
that information, how does that affect treatment? 
If, for example, the patient has spasticity (which an EMG may show).
Does that interfere with the effectiveness of strengthening exercises?
Should the increased tone be treated first?

Thanks for any input,

Jennifer Dierberger MA CCC-SLP
Moss Rehab Hospital