Abstract
In this paper we examined a treatment approach to hemiplegia with feeding and swallowing disorders and classified the approach in three stages. A 92-year-old female patient with pseudobulbar palsy due to Ischemic stroke was being fed with a nasogastric tube since contracting aspiration pneumonia. We evaluated her swallowing ability to determine the possibility of oral feeding. Although some choking occurred after swallowing water, the patient showed fairly normal gag reflex and cough reflex. Because the patient was not Impaired at the pharyngeal level, we believed it might be possible for her to feed orally under certain conditions. However, the patient was unable to close her lips, and bolus transport function was impaired; she could only swallow food without chewing. In Stage I (Dec. 2001-Nov. 2002) patient was able to swallow to some degree when we made use of compensatory strategies such as arranging her alignment, flexing her neck, and selecting foods that were easy to swallow. Although the patient was able to feed orally in this manner, because this approach did not require her voluntary effort, she became lethargic and refused to eat, especially when she was not fully alert, and consequently her food intake decreased. To address this situation and increase her food intake, we decided to try to stimulate her chewing function and thereby raise her alertness level. Because the patient was fond of rice, we prepared rice balls which she was able to eat safely, chewing while closing her lips in Stage 2 (Dec. 2002-May 2003). In addition, we employed the cognitive approach in order to stimulate the patient's sensory functions. e.g., by varying the saltiness and texture of her food. As a result, improvement was seen in swallowing and bolus transport function on the affected side. However, the patient's ability to chew and close her lips was still insufficient when eating soft foods like pudding because she had relied on assisted feeding. Therefore, to achieve the goal of self-feeding by spoon, we worked with the patient to identify variations of touch and pressure in the mouth during Stage 3 (June 2003-Dec. 2003). As a result of this treatment, she became able to form and swallow bolus successfully while controlling her own head position. We conclude that the patient's lethargy dissipated as her cognitive processes was activated, leading to a gradual improvement in her oral level function. By stimulating sensory function via “active touch”, the system of perception and response is established and maintained, a process in which independent physical elements come to work together as a unit. The results of this study suggest that use of physical therapy simply to aid and guide patients with dysphasia due to pseudobulbar palsy is not sufficient, but that approaches which stimulate cognitive function appear effective.
