The Japanese Journal of Dysphagia Rehabilitation
Online ISSN : 2434-2254
Print ISSN : 1343-8441
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The Japanese Journal of Dysphagia Rehabilitation
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Original Paper
  • Yoshimitsu INOUE, Mirai HIHARA, Mie TAKANO, Asuka SUGITA, Misaki TAJIM ...
    2020 Volume 24 Issue 2 Pages 113-120
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Purpose: The purpose of this study was to examine the relationship between the ability of deglutition and the possibility of home discharge in elderly patients with cardiovascular disease who were admitted to an acute care hospital.

    Methods: The design of this study was a retrospective cohort study. We analyzed the characteristic of each factor by calculating risk ratios which are thought to affect the possibility of home discharge: age (≥ 75 or < 75 years old); presence or absence of history of hospitalization for deglutition pneumonia; presence or absence of cohabiting family; meal form before hospitalization; meal assistance or none before hospitalization; presence or absence of dementia; modified water swallowing test at speech therapist (ST) intervention (MWST: 0–3 or ≥ 4); repetitive saliva swallowing test at ST intervention (RSST: 0–2 or ≥ 3); eating and swallowing grade (Fujishima's grade) at ST intervention (Gr < 7 or ≥ 7); food intake level scale at ST intervention (Lv < 7 or ≥ 7).

    Results: The risk ratio (95% CI) of factors that prevent discharge to the home for which significance was shown by the statistical test: There were three factors “Age > 75 years” 8.5 (1.2–60.8), “Eating and swallowing grade < 7” 3.0 (0.9–9.4) and “dementia” 2.8 (1.2–6.1).

    Conclusion: Among the multiple deglutition function evaluations, only eating and swallowing grade was found to be an independent factor for the possibility of home discharge. The reason why eating and swallowing Gr became a factor in home discharge is because it is an index for comprehensively evaluating swallowing function and ability.

    These results suggest that smooth discharge can be adjusted by using the eating and swallowing grade from an early stage of hospitalization.

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  • Yu TAZAWA, Takeshi MURAKAMI, Satoshi HORIGUCHI
    2020 Volume 24 Issue 2 Pages 121-129
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Objective: Recently, it has been found that exacerbation of COPD is related to aspiration. Accordingly, to prevent COPD it is important to investigate how specific respiratory and swallowing functions are related to exacerbation of COPD. In this study, we investigated swallowing function in addition to respiratory function for outpatients with COPD, and examined the relation between these investigation functions and exacerbation history.

    Method: The subjects were 34 outpatients (29 males, 5 females) with COPD. If exacerbation was diagnosed as such according to the criteria of the Japan Respiratory Society and hospitalization was indicated, there were 11 people who had a history of exacerbation and 13 people who had no history of exacerbation. We evaluated MASA. In addition, we investigated the presence of penetration/aspiration when swallowing 10 mL of liquid by videofluoroscopic examination of swallowing. In the spirometry, Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 s (FEV1), % Forced Expiratory Volume in 1 s (%FEV1), Peak Expiratory Flow (PEF), etc. were considered. Next, we examined the optimum cut-off value (co) that can classify the presence or absence of exacerbation history most effectively for each item (function), and the relationship between each function and exacerbation history. In the statistical analysis, we used Fisher's exact test or χ2 test, and examined significant relationships between each item and exacerbation history.

    Result: %FEV1 (co: 42.0%, p<0.05) had a significant relationship with exacerbation history. There was no significant relationship between exacerbation history and MASA, FVC, PEF.

    Discussion: The MASAs were considered not to reflect the history of exacerbation in the subjects of this study where decline in swallowing function did not become obvious. On the other hand, %FEV1 was significant, although PEF was not significant. This is because PEF reflects only expiratory flow rate, but FEV1 etc. reflects expiratory flow volume as well as expiratory flow rate; that is, in terms of airway-protection against aspiration, it is important to consider expiratory flow volume as well as expiratory flow rate.

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  • Emi WATANABE, Tae TOKOI, Hideharu TSUJI, Ryoko SHIDO, Haruka WAKABAYAS ...
    2020 Volume 24 Issue 2 Pages 130-142
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Objective: Since the publication of the Japanese Dysphagia Diet 2013 (JDD2013), standardization of the dysphagia diet criteria has been progressing in Japan. Because texture-modified diets are described not with physical property values but with words, their interpretation differs among people, especially for Codes 3 and 4 of JDD2013. Further development of JDD2013 depends on the establishment of a physical method of measuring dysphagia diets with multiple ingredients. In this study, the hardness of dysphagia diets prepared based on Code 4 of JDD2013 was measured, and the reference value of the hardness of Code 4 was determined.

    Methods: Samples consisted of 199 ingredients from the soft diet (not eligible for JDD2013) and 156 ingredients from the dysphagia diet (eligible for Code 4 in JDD2013). Both diets were lunches served in a nursing home in Kyoto City for 27 days. A speech-hearing therapist, registered dietitian, and licensed cook at the nursing home considered if the dysphagia diets were appropriate for JDD2013. The mastication ability of most individuals who consumed the dysphagia diet (Code 4) had been declining. One ingredient was placed on the stage using a creepmeter (RE2-3305C, Yamaden Co., Ltd.) and a 5-mm-diameter cylindrical plunger was plunged into the sample. Samples were kept at 20±2℃using a 20-N load cell, and the plunging rate was 1 mm/s. Hardness was calculated from the highest point among the distortion factor of 0–90%. Each measurement was repeated five times, and the average was calculated.

    Results: Of 156 ingredients in dysphagia diets (Code 4), the hardness of 150 was lower than 200 kPa. Of 199 ingredients of soft diets, 81 had a hardness of ≥ 200 kPa. The difference between the dysphagia diets (Code 4) and the soft diets was evaluated by the measurement method of this study. Ingredients from the commercial Universal Design Food (crushed with gums) were measured for comparison. Though the hardness of carrot and potato was less than 200 kPa, mushroom and meat had a hardness of ≥ 200 kPa.

    Conclusions: This measurement method could be a new evaluation method of Code 4 of JDD2013.

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  • Jumpei FUJIMOTO, Tatsuya NAKAMURA, Saori KISHI, Minoru INADA, Akiko KA ...
    2020 Volume 24 Issue 2 Pages 143-152
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Aim: This study aimed to clarify the relationship between swallowing dynamics and post-swallow residue in persons with severe spastic cerebral palsy (CP) and profound intellectual disability by comparing the movement of the mandible, hyoid bone and tongue in persons with CP and healthy adults.

    Subjects and Method: Twenty-four healthy adults and 22 persons with severe spastic CP and profound intellectual disability underwent a videofluoroscopic examination of swallowing while swallowing 3 to 5 mL of paste food. The range of movement in the horizontal and vertical directions of the mandible and hyoid bone during pharyngeal swallow were measured using frame-by-frame analysis in the coordinate plane with the second and fourth cervical vertebrae as the reference line. Additionally, the duration of tongue contact with the palate and posterior pharyngeal wall along seven equiangular radial lines emanating from the center of the tongue were timed using frame-by-frame analysis. Furthermore, the post-swallow residue in the valleculae and piriform sinus was measured using a pixel-based measure. Referenced at the mean 95% confidence interval upper bound of the residue of the healthy adults, persons with severe spastic CP were classified into four groups: non-residue in valleculae (NRval), residue in valleculae (Rval), non-residue in piriform sinus (NRps), and residue in piriform sinus (Rps). The results were compared using the Kruskal-Wallis test with Dunn's multiple comparison test, and Spearman's correlation coefficients were calculated between the residue in each area and each measurement.

    Results and Discussion: The mandible depressed greater and the duration of anterior tongue contact with the palate was shorter during pharyngeal swallow in persons with severe spastic CP than healthy adults. The Rval and Rps groups showed a smaller distance of anterior hyoid movement and longer duration of contact between the tongue base and pharyngeal wall than healthy adults. Residue in the valleculae correlated positively with mandibular downward distance, while the piriform sinus correlated negatively with the distance of anterior hyoid movement. It is considered that mandibular downward movement affected the tongue movement and resulted in failure of epiglottic inversion and pharyngeal constriction. In contrast, the abnormal tension of the head and neck and instability of the mandible caused failure of contraction of the geniohyoid muscle, which plays a critical role in the anterior hyoid movement, resulting in decreased movement of the anterior hyoid.

    Conclusion: Residue in the valleculae was associated with mandibular downward distance and residue in the piriform sinus was associated with the distance of anterior hyoid movement in persons with severe spastic CP and profound intellectual disability.

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  • Hiroyuki KATAGIRI
    2020 Volume 24 Issue 2 Pages 153-161
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Purpose: Dysphagia patients receiving treatment at acute care hospitals, undergoing temporary fasting or having an impaired swallowing function, are often prescribed modified diets not requiring mastication. However, this may cause patients to have a risk of reduced masticatory functions as a result of factors such as atrophy of masticatory muscles and sarcopenia. Therefore, the present study aimed to examine the effect of 4 weeks of ice-chip chewing training on masticatory functions.

    Participants and Methods: We included patients with decreased masticatory ability, who had completed treatment, achieved stable disease status, had normal cognitive function, and only received nutrition orally. They were divided into two groups, namely an interventional group of 19 patients (13 men and 6 women; mean age, 78.8±13.6 years) and a control group of 11 patients (3 men and 8 women; mean age, 83.6±8.9 years). The masticatory ability of all patients in both groups was evaluated before and 4 weeks after mastication training using ice chips, and external observations were carried out during chewing motion. The interventional group received training twice daily (i.e. once in the morning and once in the evening), 5 times a week, for a 4-week period. Each patient of the interventional group chewed 10 ice chips (1.5–2 mL) in each training round.

    Results: The masticatory ability of patients in the interventional group significantly improved after the mastication training using ice chips. In contrast, the control group showed no significant improvements in any variables.

    Discussion: We believe that mastication training using ice chips can be used to improve masticatory functions.

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  • Kiyoshi MURAKAMI, Tetsushi TAMEKAZU, Yukiko NOMURA, Yasuhiro FUJINO
    2020 Volume 24 Issue 2 Pages 162-169
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Introduction: In Japan, it is predicted that the number of patients with dysphagia will continue to increase in the rapidly aging society. Rehabilitation is the first choice for the treatment of dysphagia, but it is often found not to be effective enough in clinical practice. The purpose of this study was to examine whether transcranial Direct Current Stimulation (tDCS) can improve tongue function, which is important for swallowing.

    Subjects: Twenty healthy adults (5 males and 15 females, average age 39.7±11.9) participated in the study.

    Method: Anodal stimulation (1.5 mA, 10 min, 5 times) and sham stimulation (0 mA, 10 min, 5 times) were randomly allocated at intervals of 4 weeks, so that the subjects were blinded as to which stimulation they were receiving. During stimulation, we performed tongue strength training and oral diadochokinesis.

    Results: Anodal stimulation showed a significant increase in maximal tongue pressure and Repetitive Saliva Swallowing Test (RSST) whereas sham stimulation did not.

    Conclusion: In this study, increases in maximum tongue pressure and RSST were observed. These results suggest that tDCS is effective in improving tongue movement function.

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Short Communication
  • Kayoko ITO, Tomoki MAEKAWA, Kaname NOHNO, Makoto INOUE
    2020 Volume 24 Issue 2 Pages 170-176
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Tongue cleaners come in various shapes, such as nylon brushes like a toothbrush, scraper type, and brushes implanted with fine nylon looped bristles. Although nylon looped brushes are effective when the tongue coating is thick, there is a possibility that contamination remains even after the brush seems to be clean.

    We therefore compared the bacterial removal effect of nylon looped brushes with the one of brushes in which part of the loops was cut (loop-cut brush). We also evaluated the amount of bacterial residue after washing by hand for 0, 5, 10, and 30 s under running water.

    A looped bristle brush (W-1 brush, SHIKIEN) and a loop-cut bristle brush were used to scrape the surface of brain heart infusion (BHI) agar medium seeded with Staphylococcus aureus, and the number of bacteria removed by the two brushes was compared. Additionally, to examine different methods for cleaning the brushes, we compared the number of bacteria remaining on the brushes after washing by hand under running water for 0, 5, 10, and 30 s, and placing the brush under running water alone for 10 s.

    There was no statistically significant difference between the median number of bacteria removed by the looped bristle brush (2.0×1011 cfu/mL) and the loop-cut bristle brush (2.1×1011 cfu/mL), indicating that there is no difference in the bacterial removal ability between these two brushes. Investigation of the cleaning method revealed that the number of bacteria adhering to the brushes was significantly decreased after washing by hand for 5, 10, and 30 s when compared with no cleaning for both the looped bristle brush and the loop-cut bristle brush. The bacterial count of the cut bristle brush decreased by 99.9% after 5 s of washing by hand, and removed further after 10 s of washing. There was no statistically significant difference between washing by hand for 10 and 30 s for the loop-cut bristle brush. The loop-cut bristle brush had fewer bacteria attached after washing by hand than the looped bristle brush, and rubbing for at least 5 s under running water reaches 99.9% bacteria removal.

    Therefore, the loop-cut bristle brush may be a superior shape because it has a low likelihood of becoming an infection source, and its bacterial removal ability was similar to that of the looped bristle brush.

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  • Megumi ISAKA, Kumiko ICHIMURA, Yoko YASUKAWA
    2020 Volume 24 Issue 2 Pages 177-183
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Objective: This study aimed to clarify the decision-making support by certified dysphagia nurses regarding gastrostomy of elderly patients with oral feeding difficulty and their families.

    Methods: The participants were four certified dysphagia nurses with over 3 years of clinical experience who were involved in considering gastrostomy for elderly patients. Semi-structured interviews were conducted with the study participants and the results were analyzed using content analysis. The study period was between August and December 2017.

    Results: The average years of experience as a nurse was 20.0, and that as a certified dysphagia nurse was 6.8. Analysis of the results led to the creation of 321 codes, 37 sub-categories, and 11 categories. In addition, analysis of the results led to the creation of three core categories: “Support that considered the feelings of elderly patients and their families which wavered after making a decision,” “Professional support with a focus on life after discharge around the possibility of oral feeding and gastrostomy,” and “belief in guiding the best choice for elderly patients.”

    Discussion: It is important for families and medical professionals to discuss what they would like to do now, taking into account the past wishes of the elderly patient. It is also necessary to provide support considering the burden on the family in the future.

    Conclusion: The results of this study suggest that certified dysphagia nurses valued the wishes of elderly patients who wanted to eat, while struggling to determine the best choice for them. It was found that certified dysphagia nurses are providing decision support using their expertise and practical wisdom.

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  • Hiroko KIMBARA, Toshiaki TSUKATANI, Saori KOBAYASHI, Miho YAMAMOTO, Na ...
    2020 Volume 24 Issue 2 Pages 184-193
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Introduction: A variety of medicines may impair the swallowing function with observed adverse effects. On the other hand, required medicines may not be taken due to dysphagia, and the known efficacy of medicines may not be as expected. The purpose of this study is to analyze medicines proposed by the pharmacist and to consider the role of pharmacist as part of the swallowing support team (SST).

    Methods: The subjects were dysphagia patients who were examined in the case conference of SST from March 20XX to April 20XX + 3. The administration of medicine, the proposals related to medicine, achievement of pharmaceutical intervention, and the severity of dysphagia before and after the intervention were studied retrospectively.

    Results: 51 dysphagia patients (median, 82 yo) were examined by SST and 42 out of 51 (82%) took medicines which might impair the swallowing function. The most common medicine which might impair the swallowing function was the sleeping drug and the antipsychotics. The most commonly administered medicine which might improve the swallowing function was angiotensin converting enzyme inhibitors. Pharmaceutical proposals were made to 29 patients and 25 were intervened. SST suggested the cancellation or reduction of medicines which might impair the swallowing function to 10 patients; changing the administration of medicines to 9 patients and, adding medicines with good effect for swallowing function and/or changing medicines to 7 patients. The average score of food intake level scale (FILS) in 25 pharmaceutical intervened patients was 4.5 before intervention and 5.9 at discharge. Average score improved 1.4. The score in 26 non-pharmaceutical intervened patients was 5.1 before intervention and 6.3 at discharge. Improvement was 1.2 indicating a statistical insignificant change compared to the pharmaceutical intervention group.

    Conclusion: Many patients are administered medicines which may unknowingly impair the swallowing function. Therefore, pharmaceutical proposals must be carefully considered and administered for dysphagia patients. It is wished the pharmacist plays a role as part of SST pointing out medicines which may impair the swallowing function, proposing alternative medicines and, safely and firmly supporting the administration of medicines to dysphagia patients.

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Case Report
  • Michiko TAYA, Yoichiro AOYAGI, Mao OGAWA, Eriko MIZOKOSHI, Makoto HIRU ...
    2020 Volume 24 Issue 2 Pages 194-201
    Published: August 31, 2020
    Released: December 31, 2020
    JOURNALS FREE ACCESS

    Introduction: There have been few reports of dysphagia and swallowing rehabilitation in Ramsay Hunt syndrome caused by varicella-zoster virus. We report three cases of patients with dysphagia due to lower cranial neuropathy.

    Case 1: A man in his 70s complained of sore throat, dysphagia, and hoarseness. Videoendoscopic examination of swallowing (VE) and videofluorography (VF) revealed left vocal cord paralysis, poor pharyngeal contraction, a large amount of pharyngeal residue, impaired passage of upper esophageal sphincter (UES), and silent aspiration. High-resolution manometry (HRM) showed a reduced intrapharyngeal pressure during swallowing, reduced UES pressure at rest on both sides, and high pressure below the UES on the healthy side. He was diagnosed with left glossopharyngeal and vagal nerve disorders and underwent direct training with the head rotated to the unaffected side.

    Case 2: A woman in her 70s complained of sore throat, swallowing difficulty, hoarseness, and right ear eruption. VE and VF showed right soft palate and vocal cord paralysis, poor pharyngeal contraction, and a large amount of pharyngeal residue. HRM showed a reduced intrapharyngeal pressure during swallowing on both sides, and a slight reduced UES pressure at rest on the affected side. She was diagnosed with right glossopharyngeal and vagal nerve disorders.

    Case 3: A man in his 60s complained of right posterior neck pain, hoarseness, and dysphagia. He had right soft palate paralysis and vocal cord paralysis. VF showed a large amount of pharyngeal residue. HRM showed a reduced intrapharyngeal pressure during swallowing, and a reduced UES pressure at rest on both sides. The nasopharyngeal pressure increased during head rotation to the affected side. He was diagnosed with right glossopharyngeal, vagal, and accessory nerve disorders.

    Discussion: The common findings of these three cases were poor pharyngeal contraction, vocal cord paralysis, and bolus retention in the piriform recess sinus. HRM showed a reduced intrapharyngeal pressure during swallowing on both sides, and a reduced UES pressure at rest on the affected side. Nadir UES pressure and UES relaxation time were in the normal range. VF and HRM are useful for physiological evaluation of dysphagia and decision-making for swallowing rehabilitation in this syndrome.

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