Integrated yoga therapy for swallowing difficulties (dysphagia) (case study 1.)

Swallowing seems natural, right? 

A client came from Lisbon to Hungary to solve her swallowing difficulties with me as her therapist. Her condition is going on for around 5 years with chronic episodes, when she is absolutely unable to eat solid food. Sometimes it gets better, but in the crisis (stresssful times in her life), she is not able to eat any solid food (only liquids), because it gets stuck in the back of her throat and on the left side. Because of the experience of the food got stuck, her throat 'closes' and the muscles of swallowing become very stiff and painful. The crisis moment also creates panic reaction, shallow breathing, adrenalin rush and hyperventillation. After, she is not able to eat more solids, sometimes for months. And when she has some temporary relief, she always needs someone elses company or something (could be alcohol or anything) to detract her attention from the process of swallowing. Her self-esteem, her independence and her trust in her own body got compromised based on the disfunctional swallowing process. She feels dependent, because she always needs some company to complete a seemingly natural physiological process. 

In the last 5 years, she tried all the conventional and alternative methods of medicine to find the solution to her swallowing difficulties (the surgical removal of her tonsils, nasal septum surgery, sessions with psychologists and psychiatrists, treatments with medicine, acupuncture, craniosacral therapy, meditation, voice therapy etc.) with no long term success. Therefore (after her friends, who were travelling through Hungary gave her my contact) she decided to visit Pécs for three weeks, to dedicate her time to solve her problem, once and for all. 

Symptoms

There is a visible pattern in her case, which step by step has led her to her swallowing insufficiency with solid foods, doesn't matter, how diligently she was chewing her food. Our very intensive three weeks work together made it completely clear, that somehow, very suprisingly, every emotional and physical trauma, injury, muscle pain and disfunction has a common denominator and that is her throat.

All the muscular disfunctions and muscle pain created by the emotional and physical traumas and injuries are located at one exact myofascial line and that is the 'deep front line'. 

A myofascial line is working like a 'tensegrity structure'. It means, if any part of the line changes, it has an effect on the complete line. In my clients case, every change on the 'deep front line' had a negative effect on her swallowing difficulties, because every change on this line had an indirect effect on the hipertonicity of the muscles, responsible for swallowing. 

A tensegrity structure

The muscles, which have a direct effect on swallowing difficulties

The hypertonic muscles directly creating the dysphagia for my client are parts of the 'deep front line', connected by myofascia. These muscles are the ones from the suprahyoid muscle group (digastric and mylohyoid especially) and from the infrahyoid muscle group (sternohyoid, omohyoid especially), which are responsible for moving the hyoid bone, while swallowing. The jaw muscles also have a very important role in the issue (masetter and temporalis especially). The swallowing disorder is based on the hypertonicity of these muscles because they are overworking. When a muscle is overworking it gets 'shortend'  ('shortening' is a very simple and innacurate world to define what really happens) and this creates the following effects:

1. The 5th cranial nerve (CN V, the nervus trigeminus) has got compressed. This completely changed the swallowing biomechanics.

2. The 12th cranial nerve (CN XII, nervus hypoglossus) has got compressed. This changed the tounge biomechanics which would be essential for functional swallowing.

3. The 9th cranial nerve (CN IX, nervus glossopharyngeus) has got compressed. This also changed the functional swallowing biomechanics.

4. The 10th cranial nerve (CN X, nervus vagus) has got compressed. This compression changed the functional biomechanics of the uvula, the cricopharyngeus muscle (which supposed to relax, while swallowing) and the soft palate. What is very important for us here, if this nerve is 'blocked', the airway will not be closed in the moment of swallowing, so the bolus can go into the 'wrong direction' (and this could cause suffocation).

5. The 7th cranial nerve (CN 7, nervus facialis) has got compressed, which also created a disfunctional swallowing process.

6. The nervous system has created a protective muscle spasm and soreness, whenever my client tried to use the overworking muscles of swallowing. This protective muscle spasm and soreness could also be created instantly, when my client felt stressed. (There is a good example for this issue in her life. When in an argument she supposed to protect herself and her point of view, she could not speak up, because she felt that she literally could not use her voice, because her voice 'stuck' inside her throat.)

The cranial nerves and their functions

Because all of these factors the normal, functional biomechaniscs of swallowing changed drastically. The result of the altered biomechanics is that my client swallowed the bolus of food before the airway could close, before the natural swallowing process begun, therefore the bolus went into the direction of the airway (and that could easily lead to suffocation, as it almost happened with her in certain cases). After this experience it is easily understandable, why she did not want to try to eat solid food again, for a long time.

If the timing of the swallowing process is right, the tounge blocks the oral cavity, the soft palate blocks the nasal cavity, the epiglottis blocks the larnyx and the upper esophageal sphincter (UES) relaxes. After the bolus of food went into the right direction, the airway opens up again. If the timing of the swallowing is messed up, because of the nerve compression caused by the overworking muscles, the food goes into the throat before the swallow is initated, so the airway does not close off. In this case the bolus of food can go into the direction of the airway, which can cause suffocation. 

Another important factor of the issues is that the overworking muscles of swallowing became 'weak' (an improper defination again), therefore the parts of the bolus of food got stuck in my clients throat and stayed there for days. 

Obviously the analysis of the complex process of the 2 seconds swallowing (which includes 17 components, 30 pairs of muscles and 6 cranial nerves) should take much more time, just lets be satisfied with this simple explanation, which is important to understand our case study.

Causes

Now, we see the details of my clients issue, we also need to see the causes which led to the problem. 

It is very important to understand that the causes of my clients dysphagia is not only based on muscular disfunctions. It is deeply connected with emotional traumas, which have helped to create the muscular disfunctions along the deep front myofascial line.

Without claiming to be exhaustive, lets see the muscular, fascial, neurological and emotional causes of my clients dysphagia!

In the beginning of the relationship she started to feel pain in her toe flexor muscles, on the left side (flexor hallucis longus and flexor digitorum longus) radiating into the sole of her feet. This was a sing that she has issues with her deep front myofascial line.  

The relationship with her boyfriend was since the beginning, emotionally, physically and psychologically very intense. 

Her family life and relationship was also very much unhealthy and dysfunctional since very young. 

These circumstances created on her instability, fear, anger and pain that got deeply rooted on her emotional spectrum.

My client also has some fear for deep water due to some traumatic water experiences in her childhood.

She also had a car accident, when the seat belt damaged her muscles of the chest and neck (possible whiplash also included). This created breathing difficulties for her in the acessory muscles of breathing and in the diaphragm, which is also an important part of the deep front myofascial line. 

Her smoking habits and nosehedge-warp (deviatio septi nasi) also made her breathing mechanics more disfunctional.

Years before she has visited me in Pécs, my client had a tounge piercing, which shortend her tounge. As she said, she had some difdiculties to stretch her tounge before. As I've explained before, the tounge has a very important role in swallowing. 

After she broke up with her boyfriend, she had jaw pain and temporomandibular (jaw) joint disfunction. This could create the inhibitation on the vagus nerve (CN X).

The condition of her jaw muscles went even worse when she had a trauma to her head, which created some reference pain, radiating to her jaw. After the jaw muscles became disfunctional, other muscles begun to compensate for them and after they became overworking too, swallowing solid food also became impossible. 

The proof that the problem is based on muscular disfunctions is when she drunk alcohol, it helped her to relax the hypertonic muscles and created some temporary relief. In these cases, she was able to swallow solid food again, but still with the compromised biomechanics.

The two problematic area (swallowing and breathing difficulties) has always met when she had some stressful situations in her life. When the stress level was high, the muscles became hypertonic, the bolus of food stuck in her throat, the shallow, hyperventillation type breathing and the panic reaction has begun. After this shocking experiences, she did not want to try solid food again for a long time.

Therapeutic procedures

The first step was quite simple: we needed to decrease the compression on the cranial nerves by working on the 'shortened', hypertonic muscles. I used two protocolls to do this. 

The first was to apply ischemic pressure on the triggerpoints of the involved muscles to increase the blood flow. After this, I used 'muscle energy technique' (the MET is a manul therapy technique which requires the clients active participation to relax the muscle trough the reciprocal inhibition created by isometric contraction) and myofascial manipulation on the involved muscles.

As we went deeper into the massage therapy and understood the problem better, we realized that the following muscles have key roles in solving my clients dysphagia:

 1. The masseter:

2. The temporalis:

3. The suprahyoid muscle group, especially the digastric muscle:

4. The infrahyoid muscle group, especially the sternohyoid, omohyoid muscles:

5. The diaphragm, especially because it is connecting the lower and the upper part of the deep front line, around the 11-12th thoracic vertebra. Here, you can find the adrenalin glands, which have a fascial connection with the diaphragm. Therefore any disfunction in the diaphragm can create an increased stress reaction. 

6. The accessory muscles of breathing, especially in the clavicular and sternal region, for example the scalenus, sternocleidomastoideus. Also the rectus abdominis and the quadratus lumborum. 

7. The subbocipital muscle group, the trapezius (especially the upper fibers) and the levator scapulae. These are very important muscles, because for example the overworking trapezius has a direct effect to the hypertonicity of the omohyoid.

8. Other muscles along the deep front myofascial line like the big toe and other toe flexors (flexor hallucis longus, flexor digitorum longus).

After we have been working on these muscles for enough time to release them and we have built up the bodily awareness, we created a self-massage sequence for my client, to release this muscles on her own, if needed (basically to teach a client to this, requires most of the work). 

We have created another, basic neck decompression/traction exercise for her and also a relaxation and breathing exercise to practice on her own regularly. With this protocoll, she can generally improve her breathing mechanics and decrease the muscular and neurological tension in her life.

We reached the breaktrough in her case, when we combined these three elements (massage, decomression, breathing-relaxation) with a forth. This forth element was three classical yoga exercise to improve her tounge and jaw biomechanics. 

For stretching her 'shortend' tounge and fix her temporomandibular joint syndrome (TMJ) caused by the 'shortend' muscles of her jaw, we used an asana called Simhasana (the lion roar pose). We had the information that my client was not using her own regular voice frequency, which led us to the conclusion that the vocal cords are also included in her problem (dysphagia patients are regular visitors in the offices of voice therapists). The Simhasana was a perfect solution for this type of difficulties, because we could affect the vocal cords too.

The second yoga exercise was the Kechari Mudra. In this exercise my client moves her tounge back- and upwards, into the direction of the soft palate and the uvula. After she has created this activation or seal (mudra means seal in sanskrit) I just asked her to breath deeply. The movement of the tounge has an indirect corrective effect on the position of the head, trough the alignment of the neck and jaw muscles. It also has an indirect effect on the muscles of the chest to decrease their hypertonicity and it helps to fix the disfunctional tounge mechanics which plays an important role in swallowing (the tounge supposed to block the oral cavity while swallowing). As I mentioned earlier, the mostly overworking muscles in her case were the jaw muscles, the digastric (suprahyoid group) and the sternohyoid and omohyoid (infrahyoid group) on the left. The cause or the outcome of this (it is not completely clear which one in this case, but it does not really matter, considering our results) is that the natural position of the head is compromised. This forces the neck and the jaw muscles to compensate and it will make them overwork. 

The third yoga exercise is the Sitali Pranayama. In this exercise my client rolled her tounge and was breathing trough it. The goal here is to strengthen the muscles of swallowing to make them able to create enough force to move the bolus of food into the right direction (so the bolus will not stuck on the back of the throat).

In the end of our therapy session, my client practiced relaxation and breathing exercises to understand and use the virtual 'respiratory areas' ('belly breathing', 'ribcage breathing', 'full yogic breathing'). After the first time of these breathing exercises she was really suprised to be able to breath 'so much' air in (when she is stressed, she feels, this abaility decreases). This was a new dimension for her and we will explore this territory more, because I think, this is the key factor for her to keep the positive changes we have achived for a long period of time. We recorded an audio sequence for her to practice at home to improve her breathing abilities.

Lastly, our therapeutic procedure also included eating together every day. We have begun with some food she could easily swallow, then we moved to the more 'complicated' dishes. 

Our results

The first experiences of the massage therapy (when we were working on the muscles of the jaw and neck) were very intensive, even cathartic. Different emotions broke out (mostly fear, anger and uncertanity), which could create even 30-60 minutes long, continuous sobbing. She has relived a lot of memories from her past which she needed to process, and she did, in form of a diary. She recorded every therapy sessions. Her dysphagia recived a limelight, therefore the crisis came back again and she could not eat solid food again for a time (she could not escape from the problem anymore).

For the 2nd week of our therapy, we could dominate her crisis again. In the beginning of the 2nd week, after the massage therapy could release the cranial nerves and the yoga exercises had a 'reboot' effect on the swallowing biomechanics, we reached our breaktrough. In our 'meal session' she just realized how to eat properly. Because of her mindfullness and because of the long term experience of the disfunctional swallowing biomechanics, she could differentiate between the functional and the disfunctional way of swallowing. She realized the proper tounge and jaw biomechanics and most importantly, she could consciously rule her swallowing again. She could finally control it on her will. 

After this experience she only needed two things. To practice her exercise protocoll correctly and to increase the number of her positive eating experiences. 

The assimilation of the life changing emotional experiences she just preceived in our theree weeks therapy is going on continuously. She just drew some serious conclusions, which can help her solve her life crisis behind her swallowing difficulties. The swallowing issue was only the 'top of the iceberg'. Behind her dysphagia, she has much more serious problems to resolve. The most important result of our three weeks tharapeutic work is that now nothing can get in her way to focus on the really important inner emotional processes. After five years,  the dysphagia problem will not limit her anymore to create the necessary changes and take the right steps in her life.