[Purpose] This study examined whether initial screening tests for dysphagic patients in an acute care hospital can predict the recovery of oral intake. We also analyzed risk factors associated with silent aspiration (SA) that bedside screening tests sometimes fail to detect due to absent outward signs such as coughing or choking.
[Subjects and Methods] We retrospectively analyzed 314 dysphagic patients (average age 67.1 years) who were treated by speech-language-hearing therapists during 2007 and 2008. The initial examinations used to test swallowing function were the Repetitive Saliva Swallowing Test (RSST) and the Modified Water Swallowing Test (MWST). We divided the patients into two groups based on their dietary status at discharge: 1) good outcome patients who regained full oral intake and 2) poor outcome patients who required tube feeding. We compared the good outcome group to the poor outcome group using the initial examination results of RSST and MWST together with consciousness levels at the start of training, the Dysphagia Severity Scale, presence/absence of tracheotomy, videofluoroscopy (VF) findings, videoendoscopy (VE) findings and aspiration/SA.
[Results] One hundred eighty-seven patients (59.6%) had good outcomes, whereas 127 patients (40.4%) had poor outcomes. The good outcome patients had a younger average age and clearer consciousness. Of patients with RSST ≥ 3 times/30 seconds and MWST score ≥ 3, 87.9% regained full oral intake. On the other hand, 7.5% of those with MWST score of 4 and 6.8% of those with MWST score of 5 were overestimated despite having SA. Diagnoses among the SA group include pseudobulbar palsy, post-thoracotomy, head and neck cancer treated with chemoradiation, brainstem lesions, degenerative neurologic disease, and dermatomyositis. Other SA risk factors were associated with pneumonia before training (n＝25), vocal fold paralysis (n＝14), and tracheotomy (n＝16).
[Conclusion] This study found that RSST and MWST were useful screenings for swallowing disorders and also could predict the recovery to oral intake within acute care hospitalization days. Screening tests for dysphagia require attention to the risk factors of SA; and patients with suspected SA should be examined with VF or VE before the start of oral intake.
This study investigated the coherence of minced food with grated yam sol. Sol samples were prepared using grated yam sol and mixed gel-sol samples were prepared by 4-mm cubic gels (rupture stress of 1.43 (±0.14)×104N/m2) with grated yam sol. The present study used powdered yam to add viscosity to liquids, and sol samples with three different hardnesses were prepared (resembling the hardness of salad oil, plain yogurt and mayonnaise). Furthermore, mixed gel-sol samples were prepared with sol samples with three different hardnesses and with 4-mm cubic gels accounting for 50% by volume of the sample. Physical properties, sensory evaluation and videofluorographic examination of swallowing of these samples were investigated. The oral sensation results obtained by sensory evaluation were found to be greatly affected by the physical properties of the sol part of the mixed gel-sol samples. The results of the videofluorographic examination of swallowing demonstrated that, in the case of sol samples, the harder the sample, the slower the transit speed of the sample from the mid pharynx to the hypo-pharynx. Also, in the case of both the sol samples and the mixed gel-sol samples, the higher the stickiness in oral sensation and the adhesiveness in textural properties, the longer it tended to take from the onset of hyoid bone movement to when the sample reached the piriform sinus. With the mixed gel-sol sample whose sol part had a hardness resembling that of salad oil, two subjects tested were found to have some pharyngeal residue of the gel after swallowing. On the other hand, with the mixed gel-sol sample whose sol part had a hardness resembling that of mayonnaise, none of the subjects tested were found to have any pharyngeal residue of the gel after swallowing. These findings indicated that, in the case of using grated yam to add coherence to minced food of about 4 mm, preparing the sol part to have a hardness resembling that of plain yogurt and mayonnaise reduces the possibility of the minced food forming pharyngeal residue.
Purpose: The participation of dentists in the nutrition support team (NST) of acute-care hospitals, such as university hospitals, enables assessment of oral function and dysphagia rehabilitation, which is required for initiation of oral feeding.
The purpose of this study was to elucidate the impact of oral functions on feeding methods and the role of dentists in NST.
Methods: The study population comprised 80 patients who consulted the NST of our hospital for malnutrition, between December 2005 and November 2008; clinical-statistical analysis was performed for these patients. The relationships between oral feeding, oral function, and consultations with dentists were analyzed by logistic regression analysis.
Results: The 80 patients were mostly elderly persons, and their primary diseases were mostly head and neck tumors. In 56% of the patients, nutrition was provided only through tube feeding, and no oral nutrition was given. Of the 80 patients, 64% had poor oral hygiene, and 42% had oral soft tissue disorders such as stomatitis. Logistic regression analysis of the impact of oral function on oral feeding revealed that the following factors could be used as significant variables: dysphagia, oral soft tissue disorders, and history of aspiration pneumonia (p＜0.05). In addition, logistic regression analysis of consultations with dentists revealed that the following factors could be used as significant variables: poor oral hygiene, dysphagia, and tracheotomy (p＜0.05).
Conclusion: These results suggest that oral function disorders such as dysphagia and stomatitis affect the nutrition method used for hospitalized patients and that participation of dentists in NST is advantageous for oral assessment and dysphagia rehabilitation.
[Purpose] The aim of this study was to clarify the effectiveness of certified nurses (CNs) for quality improvement in dysphagia nursing by ward nurses.
[Methods] This study was approved by the ethics committee of our university. A survey was conducted CNs and their ward nurses at 4 months and 1 year 4 months after the CN was certified by the Japanese Nursing Association. A questionnaire survey of CNs and their ward nurses was conducted by mail using a quality assessment scale developed for dysphagia nursing (QASDN). The QASDN for ward nurses consisted of 64 items and six factors: “Ⅰ: assessment of swallowing function”; “Ⅱ: assessment and practice for planning to leave the hospital”; “Ⅲ: risk management and practice of dysphagia rehabilitation”; “Ⅳ: practice of dysphagia rehabilitation for pharyngeal dysphagia”; “Ⅴ: evaluation and coordination”; and “Ⅵ: assessment of risk management.” The QASDN for CNs consisted of 69 items and seven factors. The QASDNs for ward nurses and for CNs were rated on a scale of five.
[Results] 1. The mean scores of total, factor Ⅱ, factor Ⅲ, factor Ⅳ, and factor Ⅴ of QASDN for ward nurses at 1 year and 4 months after CNs started activity in their hospitals were significantly higher than at 4 months (p＜0.05). The mean scores of the five factors excluding factor Ⅱ for the ward nurses group of CNs with above-average scores on QASDN were significantly higher than for the ward nurse group of CNs with below-average scores on QASDN (p＜0.05). 2. From the results of multiple regression analysis, the significant factors in the sum score of overall QASDN for ward nurses at 1 year and 4 months after CNs started activity were in turn the length of their dysphagia nursing experience, the length of their clinical nursing experience, and the above-average QASDN scores of CNs.
[Conclusion] These results suggest that the nursing quality of CNs favorably influenced quality improvement of dysphagia nursing by ward nurses in the hospital.
Purpose: Disuse atrophy of swallowing-related organs due to an excessive decrease in swallowing frequency is suspected to occur in patients with poor oral intake, especially elderly people. However, swallowing frequency in elderly or dysphagic patients during daily life has not been examined previously. We developed a small swallowing frequency meter that does not restrict daily activities and can work for a long time. This study assessed the validity of the swallowing frequency meter.
Subjects and Methods: The subjects of this study were 10 healthy young people. The swallowing frequency meter consisted of a laryngeal microphone, which was placed on the neck during recording, and an MP3 recorder. The number of swallowing times was counted by auditory judgment of the sound recorded by the meter and visual judgment of the sound waveform. Two examiners (A and B) participated in this study. We examined: 1) the concordance rate between the number of swallowing times counted by videofluorography and that counted by the frequency meter. Examiner A counted the number of swallowing times on videofluorography, and examiner B counted the number of swallowing times on the frequency meter; 2) the concordance rate between the number of swallowing times counted by the subjects themselves and that counted by the frequency meter. Both examiners A and B counted the number of swallowing times on the frequency meter.
Results: 1) The concordance rate between videofluorography and the frequency meter was 100%. 2) The concordance rate between the frequency meter and the self-counting was 97.1±4.3% (A) and 98.4±4.0% (B) at rest, and 94.9±5.2% (A) and 96.2±7.9% (B) during meals.
Conclusion: These findings indicated that the frequency meter is useful for measuring the frequency of swallowing during daily life.
Objective: Physiotherapists have found that many dysphagia patients have limited range of motion of the cervix and problems with sitting posture during dysphagia rehabilitation. Therefore, physiotherapists and speech therapists examined the range of motion of the cervix, sitting posture and hump-back, and the factors related to dysphagia.
Methods: Twenty-seven patients (11 men and 16 women) who had been diagnosed as pneumonia or cerebral vascular accident participated in this study. They were requested to perform rehabilitation from October 2008 to March 2009. We classified them into I/II groups and III/IV groups by Fujishima's grading, and for each group compared whether they had sitting posture and hump-back or not, and the range of motion of the cervix. Next, we grouped sitting postures into the bed-back rest group and the sitting group, and compared the range of motion of the cervix of the dysphagia grade I/II groups with III/IV groups. Next, we classified the patients by whether they had hump-back or not, and compared the range of motion of the cervix between grade I/II and grade III/IV.
Results: As regards the range of motion of the cervix, we found significantly limited range of motion of extension, rotation and lateral bend in I/II groups, compared with those of III/IV groups. In the sitting group, we found a significantly limited range of motion of extension, rotation and lateral bend in I/II groups, compared with those of III/IV groups. But in the bed-back rest group, we could not find any such differences. In the hump-back group and normal group, the dysphagia grade was not related to the range of motion of the cervix.
Consideration: The finding of limited range of motion of the cervix in those patients whose swallowing ability had declined suggested that decreased flexibility of the cervix limits the range of motion and impairs the swallowing ability.
In the sitting posture, a decline of the ability to maintain a seated position places strain on the cervix, causing limitation of the range of motion of the cervix and impaired swallowing ability. A comparison of the hump-back group and normal group did not show a relation between limited range of motion of the cervix and swallowing ability.
Purpose: The palatal augmentation prosthesis (PAP) allows reshaping of the hard palate to improve tongue/palate contact during speech and swallowing for patients with restricted tongue mobility as a result of surgery, trauma or neurologic/motor deficit. A recent study suggested that insertion of the PAP not only increases tongue contact to the palate but also provides better pharyngeal swallowing, but little is known about the physiological changes with the PAP. This study examined, by manofluorographic evaluation, the impact of inserting a PAP on pharyngeal swallowing among healthy subjects.
Methods: Manofluorography was performed for 5 healthy subjects (4 males and 1 female, age 24–32 years) with and without the PAP. All subjects were instructed to swallow a spoonful of barium-containing jelly 3 times under each condition. The PAP was adjusted to make the anterior part of the hard palate bulge. We evaluated the following parameters: bolus flow, oral and pharyngeal manometric pressures and duration of pharyngeal events.
Results: Insertion of the PAP significantly increased the peak pressure at the base of the tongue (77.1 mmHg without the PAP, 97.3 mmHg with the PAP) and tended to increase the oropharyngeal bolus velocity.
Conclusion: This study suggested that the PAP, which provides adequate tongue contact to anchor the tongue tip, enhances the pharyngeal pressure and dynamics of pharyngeal events. The PAP is thus useful for pharyngeal dysfunctions.
Purpose: The purpose of this study was to investigate the relationship between the bedside swallowing assessment (BSA) on admission and prognosis of eating and swallowing dysfunction on discharge in a convalescent rehabilitation ward.
Subjects and Methods: The subjects were 93 patients aged between 18 and 93 years, including 54 males and 39 females, who were hospitalized in a convalescent rehabilitation ward and who received rehabilitation for dysphagia. They consisted of 33 patients with cerebral hemorrhage, 41 patients with cerebral infarction, 10 patients with subarachnoid hemorrhage, and 9 patients with traumatic head injury.
We compared the following factors: clinical features, cognitive function, swallowing function, activities of daily living (ADL), and discharge in patients who resumed a regular diet (oral intake group) and those who required tube feeding (tube feeding group).
Results: After completion of an inpatient rehabilitation program, 64 patients resumed a regular diet. Twenty-nine patients required tube feeding. The oral intake group was younger and they had higher Mini-Mental State Examination score and Raven's Coloured Progressive Matrices score than the tube feeding group. On the BSA, 13 patients had a normal gag reflex and there were 32 patients in whom the repetitive saliva swallowing test was good on admission, with the oral intake group tending to be better than the other group. There was no difference between the two groups in the period from onset, the period of hospitalization in our hospital, and the score of the modified water swallowing test on admission. In addition, the patients of the oral intake group could start the training with diet by 5 weeks at the latest and could resume some food three times a day by 10 weeks at the latest after hospitalization.
The ADL score in the oral intake group was higher than that in the tube feeding group. More patients in the oral intake group could return home. Even the patients with low ADL scores were able to return home if they could resume a regular diet.
Conclusion: We considered that it is possible to predict the prognosis of eating and swallowing function at discharge by using the results of the BSA on admission and evaluating the clinical course of eating and swallowing function at 4 weeks after admission.
Background and Purpose: We conducted a questionnaire to survey the current status of the clinical approach to dysphagia and nutritional support for stroke patients in acute hospitals and convalescent rehabilitation units from the viewpoint of community-based cooperation for stroke medical care.
Subjects and Methods: We sent questionnaires about dysphagia-diets, tests of swallowing and swallowing rehabilitation to 17 acute hospitals and convalescent rehabilitation units in a secondary medical service area. We assessed differences in answer to the various questions between acute hospitals and convalescent rehabilitation units.
Results: We obtained 13 responses (76%). All facilities had a considerable variety of dysphagia-diets (median 5 [range 2–7]), consisting of ready-made and/or original diets. Whereas ready-made diets were mostly offered at acute hospitals, original diets were more frequent in convalescent rehabilitation units. Tests of swallowing were conducted by speech therapists (ST) in all facilities and by multidisciplinary team members in 38% of them. Doctors did not become involved in examinations of swallowing in 23% of facilities. Swallowing rehabilitation was performed by ST (100%) and nurses (77%) during speech therapy (100%) and meals (92%). Swallowing status and diet plans mostly comprised providing verbal advice to patients (75%) and their caregivers (100%).
Conclusions: We clarified the current status of the clinical approach to dysphagia and nutritional support for stroke patients in acute hospitals and convalescent rehabilitation units. An effective approach to dysphagia and nutritional support in stroke patients requires future discussion.
Purpose: The transition between oral and pharyngeal phases is one of sites of misswallowing of lowviscosity liquids. Thickening agents are commonly used to prevent the airway from misswallowing and/or aspiration of low-viscosity liquids. In some cases, however, clinical demands cannot be satisfied partly because the transition phase cannot be adequately regulated due to shear-rate dependent viscosity of a liquid containing a thickening agent. Velopharyngeal function, in which the velum is primarily involved, plays a major role in regulating the transition phase between oral and pharyngeal phases. The purpose of the current study was to electromyographically clarify the following: 1) how velopharyngeal function during swallowing non-Newtonian fluids can be regulated, and 2) which has a greater impact on muscle activity, shear-rate dependent viscosity or viscosity measured using a B-type viscometer with rotor rotation speed of 12 rpm.
Methods: Ten healthy subjects (mean±SD: 24±2 y) without any clinical history of dysphagia joined the study. Smoothed EMG signals of the levator veli palatini (LVP) muscle were collected. Three test materials were prepared by mixing a thickening agent into commercially-available green tea as follows: two test materials had similar shear-rate dependent viscosity which was higher for one material in the range of shear rate greater than 2/s although the three materials showed a similar measure of viscosity obtained using the B-type viscometer with rotor rotation speed of 12 rpm. Each subject swallowed a certain volume of three materials 10 times, respectively. The swallowing volume was individually determined on the basis of the optimum volume for swallowing for each subject.
Results: LVP muscle activity was significantly greater for one material with a lower shear rate viscosity while two materials with similar shear rate viscosity showed smaller EMG values which were not significantly different between each other.
Conclusion: It was clarified that the velopharyngeal function for swallowing non-Newtonian fluids could be regulated according to the difference in shear-rate dependent viscosity, not with the viscosity obtained by the B-type viscometer with rotor rotation speed of 12 rpm.
This study evaluated the eating and swallowing functions and manners of 54 children (44 boys and 10 girls, mean age 5.6 years) with autistic spectrum (ASD) diagnosed by a pediatrician and who had been attended the learning facility at Regional Rehabilitation Centers for Children with Disabilities for more than 1 year and received feeding service, with the following results:
1. As for the eating/swallowing functions, the swallowing function was successfully acquired by all children examined but the food-trapping/masticating functions failed to be acquired by about 20% of them.
2. As for the eating/swallowing function in relation to intellectual development, differences were observed according to the level of intellectual retardation, and a significant difference was observed between mild and moderate growth disorders (p＜0.05) as well as mild and severe growth disorders (p＜0.01).
3. Concerning the eating manners, food-cramming, whole-swallowing or washing-down habit was habitually observed in about 20% of the children examined, but almost no episodes of piling food were observed in any of them.
4. Washing-down and food-cramming habits were observed less often in older children, that is, those who have received medial care for a longer period, with no significant difference.
These results revealed that the food-trapping/masticating functions are more closely related to the level of intellectual development than the child's age, suggesting difficulty in acquiring feeding functions. Some differences were noted in the washing-down and food-cramming habits according to the remedial period, suggesting that repeated instructions in the remedial practice may help to encourage improved eating manners.
It was also revealed that washing-down and food-cramming habits are closely related to the child's medical care period, suggesting that repeated instructions are effective in medical care.
The possible relationship between characteristic symptoms of ASD such as deviated sensation and unbalanced diet with feeding functions or manner remains to be examined in future.
[Introduction] As a treatment method against dysphagia due to organic defect after resection of lingual malignant tumor, palatal augmentation prosthesis (PAP) has been reported in a lot of clinical cases. However, we recently experienced 3 cases of dysphagia after resection of lingual malignant tumor, against which PAP failed but lingual augmentation prosthesis (LAP) applied in the mandible succeeded to improve the symptom as reported hereinafter.
[Case report] Case 1: Sixty-nine-year-old man treated with total resection of lingual movable region, left sided neck dissection and lingual reconstruction with pectoralis major flap. The oral examination revealed that the region of tongue except for lingual root was completely reconstructed with skin flap with no mobility. The videofluorography (VF) showed no pulmonary aspiration but almost all test meal ingested was retained on the oral floor. When LAP in which the reconstructed tongue is covered by a floor to ensure the flow route of food ingested was applied, the retained food on the oral floor was wholly diminished, successfully resulted in the improvement of disturbed swallowing.
Case 2: Sixty-four-year-old man treated with subtotal resection of the tongue, bilateral upper neck dissection and lingual reconstruction with pectoralis major flap. VF revealed weakened contact of tongue with hard palate at swallowing and failed delivery of the ingested food into the pharynx with the subsequently retained contents on the oral floor. In order to reduce the space created by the organic defect of tongue involved, PAP and LAP were applied to the maxilla and mandible respectively with the improved retention of food on the oral floor after swallowing.
Case 3: Seventy-two-year-old man treated with subtotal resection of the tongue, bilateral neck dissection and lingual reconstruction with pectoralis major flap. VF revealed difficulty in swallowing solid food due to decreased lingual mobility, suggesting a possibility of the disturbed preparation stage for swallowing. In order to prevent a potential dropping of the chewed food onto the lingual side, LAP in which the lingual side of left mandibular molar is supplemented with resin was applied with the resultant easy swallowing of solid food and the improved dysphagia during the preparation stage.
[Conclusion] In patients with a relatively extended region of lingual defect or limited movement, the symptoms of which may often fail to be improved by PAP alone, it was suggested that the application of LAP can be served as an effective therapeutic measure as indicated by the 3 cases mentioned above.