The Mendelsohn maneuver is a well-known exercise designed to treat reduced swallowing function caused by aging or dysphagia as an indirect therapy for rehabilitation. Although the maneuver is intended to improve laryngeal elevation of the hyoid bone, it is difficult for patients to understand what they are doing and to perform the elevation properly by themselves. Therefore, the authors developed a biofeedback (BF)-based training system for elderly people to elevate the larynx. The purpose of this study was to develop a training system, SFN/3A, and to evaluate its effectiveness in swallowing rehabilitation. The subjects were 10 healthy adult males (23.0±1.3 y/o, mean±SE) and 4 elderly males (89.8±5.5 y/o, mean±SE) in a healthcare facility for the elderly. Healthy subjects were divided into two groups, one with biofeedback and the other without biofeedback. Healthy subjects with BF and elderly ones carried out the laryngeal elevation task in the following sequence: 1) without BF, 2) with BF and 3) without BF, while healthy people without BF carried out the same task without biofeedback. Each subject was required to keep the laryngeal elevated position for 5 seconds per trial. The parameters for analysis were: 1) amount of laryngeal elevation [mm], 2) duration of laryngeal elevation [s] and 3) duration of high elevation [s]. The amount of laryngeal elevation of the healthy group with BF and without BF tended to increase and exhibited no significant change, respectively, throughout the steps. Duration of laryngeal elevation did not change significantly throughout the steps in the healthy groups, while duration of high elevation tended to increase in the same groups. Thus, we considered that healthy subjects could master laryngeal elevation easily thanks to the biofeedback training. In the elderly people, all the parameters tended to increase or increased significantly between steps 1 and 2, while duration of high elevation decreased significantly between steps 2 and 3. Therefore, we considered that the elderly people could not master the elevation only by means of this 5-minute training. In conclusion, the biofeedback training system was verified to be effective for both healthy and elderly groups, but elderly people should take this training repeatedly to master the elevation of the larynx.
We developed a dysphagia rehabilitation maneuver, “soba slurping-like training”, using a feeding tube, suitable for elderly persons and patients with limited neck movement. The aim of the present study was to evaluate the effect of this maneuver on submental muscles, infrahyoid muscles, and sternocleidomastoid muscle, by comparing EMG activity when performing this maneuver and traditional maneuvers such as “Shaker Exercise” and “Mendelsohn Maneuver”.
Surface EMG was measured from 16 normal subjects with an average age of 22.2 years old in three muscle groups.
The original EMG signals while performing the “soba slurping-like training” maneuver or other traditional ones were smoothed with a time constant of 100 ms by the RMS （root mean square） method. To compare EMG activity between maneuvers, mean values of %MVC for each individual in each muscle group were measured and were statistically analyzed using one-way analysis of variance and multiple comparison of Bonferroni. In submental muscles, the mean value of %MVC of the “soba slurping-like training” maneuver was as high as that of “Shaker Exercise”, and in infrahyoid muscles was two-thirds of that of “Shaker Exercise”. On the other hand, in the sternocleidomastoid muscle, the EMG activity of the “soba slurping-like training” maneuver was significantly low compared with “Shaker Exercise”. In conclusion, we consider that “soba slurping-like training” is an effective dysphagia rehabilitation maneuver for elderly persons and patients with limited neck movement.
[Purpose] The purpose of this study was to clarify the factors that promote and obstruct dysphagia nursing in nursing visits, and how it was influenced by the length of the visiting nursing experience.
[Methods] This study was approved by the ethics committee of our university. We conducted participant observation in visiting nursing and unstructured interviews of 7 visiting nurses. As a result, 25 categories were obtained as promoting factors and 37 categories were obtained as obstructing factors. Then we conducted a questionnaire about the 62 categories among 228 visiting nurses.
[Results] 1. Valid responses to the questionnaire were obtained from 159 visiting nurses. The average length of their visiting nursing experience was 4.2±2.9 years, and 67.9% had less than 5 years’ visiting nursing experience. 2. There were 10 promoting factors: visiting nurses “have a responsibility for dysphagia nursing,” “collect patient information by observing the patient and through cooperation with other medical staff members,” “predict patient’ s swallowing function at outcome,” “decide methods to ease the burden on the caregiver,” “avoid risks related to dysphagia,”“create an opportunity to acquire the knowledge,” “confirm patient’ s and caregiver’ s wishes,” “cooperate with doctors and nurses,” “cooperate with speech-language-hearing therapists (ST) and physical therapists (PT),” and “caregiver provides great care.” 3. There were 8 obstructing factors: visiting nurses have “insufficient knowledge about dysphagia and indirect therapy,” “difficulty assessing the swallowing function in a short time,” “difficulty predicting a patient’ s swallowing function at outcome,” “difficulty deciding care methods according to dysphagia,” “fear of risk related to dysphagia,” “patients with anticipatory stage problem,” “limited care time and no record systems for dysphagia nursing,” and “caregiver provide inadequate care.” 4. Compared with visiting nurses who have over 5 years of visiting nursing experience, dysphagia nursing practiced by those with under 5 years of experience was obstructed by “insufficient knowledge about dysphagia and indirect therapy,” and was promoted by “cooperating with ST and PT.”
[Conclusions] These results suggest that there is a need to promote the ability to make clinical judgments, and that record systems and a manual for dysphagia rehabilitation are needed for cooperation among many medical personnel to improve the quality of dysphagia nursing.
[Purpose] Neck angle and body posture are known to influence swallowing; however this influence has not been sufficiently clarified. Previous reports investigating this influence have considered the anatomical viewpoint, but not muscular activity, of the pharynx. This study aimed to clarify the influence of a change in neck angle on the activity of pharyngeal and neck muscles.
[Method] We evaluated 19 healthy adult men (aged 25-46 years; mean, 32.5 years). The seated participants were made to swallow 5 cc of water while holding the neck in 5 conditions of median and flexion (20 and 40 degrees) and extension (20 and 40 degrees), and the suprahyoid, infrahyoid, and sternocleidomastoid muscle activities were measured through surface electromyography; the duration of muscle activity and muscle integration value were also estimated.
[Result] Although the muscle activity of the suprahyoid and infrahyoid muscles significantly increased duration at 40 degrees of extension compared with the other angels, the muscle activity of the sternocleidomastoid muscle did not significantly differ at any of the angles. Moreover, the suprahyoid, infrahyoid and sternocleidomastoid muscles showed a higher muscle integration value at 40 degrees of extension than at other angles.
[Conclusion] Although, muscle activity could indicate that swallowing was difficult at 40 degrees of extension, the effect of neck flexion could not be confirmed. The activity of the suprahyoid, infrahyoid and sternocleidomastoid muscles during swallowing changes with an alteration in the neck angle. Therefore we suggest the importance of the evaluation of the range of motion for flexion and extension as well as suitable intervention in patients with dysphagia.
Purpose: The purpose of this study was to investigate the influence which posture change of a head has on thyroid cartilage movement during swallowing using ultrasonography (US), and, to examine whether thyroid cartilage movement recorded by US becomes a simple and effective evaluation index of the time of position adjustment of the head.
Subjects and Methods: Subjects were 9 healthy male adults (25.4±5.3 years of age). They sat in a fixed position on a chair with the back and head in contact with the wall. The position of the subjects was changed in two ways: alteration in the mid-position of the head and neck (Mid P), and the maximum extended position of the head (Ext P). The ultrasonography probe was applied to the left side of the thyroid cartilage. The ultrasonography device was adjusted so that the uppermost portion of the thyroid cartilage appeared in the center position of the ultrasonography monitor. The length of time that the thyroid cartilage moved in one cycle of swallowing was divided into three phases: elevation, rest, and descent. The time of each phase was measured and the total time of the movement was determined by the sum of the times of the three phases. The means of three measures for each phase or total time were used data analyses.
Results: We acquired clear images of the thyroid cartilage and its movement by ultrasonography. The means of the elevation and rest times showed no significant difference between the two head positions. The mean of the descent times was 0.73±0.15 sec in Mid P and 0.94±0.15 sec in Ext P, with the latter time being significantly longer than the former (p＜0.05). The mean of the total times was 1.51±0.11 sec and 1.89±0.15 sec in Mid P and Ext P, respectively, with the latter being significantly longer than the former (p＜0.01).
Conclusion: Using the analysis of thyroid cartilage movement during swallowing as depicted by ultrasonography, it became clear that the descent time, as well as the total time of the thyroid cartilage movement in Ext P was longer than those in Mid P. Ultrasonograhy of the thyroid cartilage movement during swallowing may be useful for appropriate positional adjustment of the head during a meal because ultrasonography is easy to use in real time at bed side swallowing evaluation.
[Purpose] Closure of the lips is critical for the normal swallowing process. However, it is unclear how swallowing dynamics are altered when food is swallowed with the lips open. This study examines the optimal volume for a swallow of water as a preliminary study of lip status-dependent changes of swallowing dynamics. Furthermore, when the thing was inserted between lips also in the time of lips opening, it aimed at investigating whether the same optimal volume for a swallow as the time of lips closing can be obtained.
[Subjects and Methods] Subjects were 22 healthy adults without swallowing disorder (12 males and 10 females; mean age, 21.9±2.7 years). While in a supine position with the head in a mid-position, subjects’ lips were parted in 4 ways in a random order: 1) close, 2) open minimally with a piece dental cotton roll placed horizontally between the lips, 3) open largely with a piece of dental cotton roll placed vertically between the lips, and 4) following an instruction that the lips were parted voluntarily approximately 1 cm without the use of a piece of dental cotton roll. Subjects were instructed to mimic a swallowing action, and then an examiner poured 10 ml of water onto the bottom of the oral cavity using a syringe. The subjects were instructed to drink the water of the quantity which can be drunk comfortably at once. The remaining water was flushed from the mouth into a paper cup, which was weighed on an electronic scale. Accordingly, the volume of swallowed water or the optimal volume for a swallow was calculated by subtraction.
[Results] The optimal volume for a swallow was 9.38±1.75 ml with the lips closed, 9.39±1.87 ml with the lips opened minimally using a cotton roll, 9.28±1.73 ml with the lips opened largely using a cotton roll, and 8.59±2.13 ml with the lips parted voluntarily.
[Conclusions] The optimal volume for a swallow was decreased when the lips were parted voluntarily without a cotton roll (p＜0.01). However, if a piece of cotton roll was placed between the parted lips, the volume was restored to that obtained when the lips were closed.
We followed the developmental process of oral movement, gross motor skills and self-feeding motivation of two infants with Down Syndrome. Video recorded feeding training scenes were used for assessment.
Case 1: Spoon feeding started at 5 months old before head-up. Sitting skill was acquired at around 1 year 3 months old. Thereafter, the tongue moved in the right and left directions and the jaw was thrust in order to melt snacks. The softness of food determined her oral movement of either sucking or chewing. The tongue moved properly and she could chew at 1 year 9 months old. Self-feeding started at 1 year 7 months old. Exaggerated tongue protrusion lasted for the next 2 years.
Case 2: Spoon feeding started at 6 months old before head-up. Sitting skill was acquired at around 1 year old. Around that time, she blew food, bit spoons, and swallowed the food. The softness of food determined her oral movement, either sucking or chewing. She could chew at 1 year 6 months old. Self-feeding started at 1 year 6 months old. Exaggerated tongue protrusion lasted for the next 2 years.
We found that after sitting both children had bad oral movement until they started to walk and exaggerated tongue protrusion became a habit because of immature lip closure skill, though they both acquired chewing skill. Therefore, lip closure is not essential in order to be able to chew. Self-feeding started at around 1 year 6 months old. It is suggested that in children with mental retardation, bad oral movement may occur before they walk. Therefore it is necessary to start feeding therapy before walking and to introduce indirect therapy as well as teach cooking skills to mothers as a part of daily therapy.