Purpose: Measurement of lip motion with a compact 3D camera and swallowing dynamics by videofluoroscopy (VF) were performed simultaneously. Synchronization and analysis were performed to clarify the relationship among the distance between angulus oris, swallowing time and swallowing quantity.
Methods: The compact 3D camera was the Microsoft XBox One Kinect Sensor® (Kinect). Development software provided by Microsoft Corporation was used. The face surface of the subject was automatically recognized. A program was created to obtain the three-dimensional coordinates of the both-sides angulus oris and record the distance between the angulus oris. Kinect verified the accuracy and reproducibility of the mannequin distance between the angulus oris under certain conditions.
We examined the most suitable conditions for the measurement of subjects. Based on the verification results, the information obtained by the video and audio synchronization software ELAN was synchronized and analyzed. The subjects were 12 adult men (average age 27.8±1.2 years) with no abnormal swallowing function. Four types of samples were used: barium sulfate suspension 5 mL, 10 mL, 15 mL, and 20 mL. One-way analysis of variance and Pearson’s product-moment correlation coefficient were calculated for the amount of displacement (displacement) and swallowing quantity, swallowing time and swallowing quantity during swallowing. The position of holding the sample in the oral cavity (holding position), lip motion and swallowing quantity were examined by Friedman’ s test.
Results: The optimum conditions (distance 120 cm, rotation angle 10°). The measurement with Kinect had the highest accuracy, with a standard deviation of ±0.52 mm for the distance between the angulus oris and a difference of 0.47 mm between the measurements with Kinect and the actual measurement. There were significant differences and correlations between swallowing and displacement (p＜0.01, r＝ 0.56). There was a significant difference between swallowing quantity and holding position (p＜0.01). However, with respect to the other items, no significant difference was observed.
Conclusions: This study clarified the measurement accuracy and reproducibility of the distance between the angulus oris by Kinect. A system that can measure and synchronize lip motion and swallowing dynamics at the same time was constructed. The swallowing quantity and the displacement were significantly different and correlated, and the swallowing quantity and the holding position were significantly different. On the other hand, there was no significant difference in the other items.
Purpose: Our hospital has been working on early oral intake with team medical care since April 2015, to investigate the effect of early oral intake with team medical care on length of hospital stay and oral intake at discharge in inpatients with aspiration pneumonia.
Methods: A retrospective cohort study was performed in 380 patients aged 65 and over who were admitted to our hospital with aspiration pneumonia from April 2014 to March 2018. Patients who died were excluded. Diagnosis Procedure Combination (DPC) data including age, gender, required care level, living place before hospitalization, A-DROP (Age, Dehydration, Respiratory failure, Orientation disturbance and blood Pressure) at hospitalization, number of days from hospitalization to oral intake, presence of rehabilitation, fever after starting oral intake, length of hospital stay, the Functional Oral Intake Scale (FOIS) at discharge, presence of oral intake at discharge, and discharge destination were investigated retrospectively. We classified the subjects into the group without team medical care (2014) and the group with team medical care (2015-2017), and examined changes in both groups. We examined the effects of team medical care and early oral intake on length of hospital stay and oral intake at discharge statistically. A p-value ＜0.05 was determined to be statistically significant.
Results: Mean age was 85.9±7.0 years, and there were 208 men (55%). In univariate analysis, significant differences were observed in A-DROP at hospitalization, presence of rehabilitation, FOIS at discharge, oral intake at discharge, and length of hospital stay, between the group without team medical care and the group with team medical care. In multivariate analysis, factors affecting length of hospital stay were required care level (β ＝－0.215), living place before hospitalization (β ＝ 0.146), presence of team medical care (β ＝－0.151), start of oral intake within 2 days after hospitalization (β ＝－0.134), presence of rehabilitation (β ＝ 0.145), fever after starting oral intake (β ＝ 0.202), FOIS at discharge (β ＝－0.280), and discharge destination (β ＝－0.184). Factors affecting oral intake at discharge were age (odds ratio, OR ＝ 1.039), presence of team medical care (OR ＝ 3.196), and start of oral intake within 2 days after admission (OR ＝ 4.095).
Conclusion: Starting early oral intake while in acute care may improve not only patients’quality of life but also reduce length of hospital stay.
Purpose: Japan is becoming a super-aged society and aspiration pneumonia is a major cause of death among older adults. We aimed to evaluate the oral care and eating function of community-dwelling older adults aged 65 years and over. Furthermore, we attempted to clarify whether the provision of educational guidance regarding oral care and swallowing exercises could change their awareness of health management for eating function.
Methods: One hundred and seventeen older adults enrolled in this study. We provided the participants with guidance about methods for oral care, massage of the salivary glands, and exercises for the muscles around the oral cavity related to swallowing. Before and after the educational program, the participants completed a questionnaire about oral care, eating function, and awareness of management of oral health.
Results: Seventy-seven participants (33 men, 44 women; mean age 76.3±6.1 years) returned completed questionnaires (response rate 65.8%). Among the participants, 21.0% lived alone, 90% ate three meals per day, and 62.3% had dentures. Before the intervention, the participants brushed their teeth with toothpaste an average of 2.4±1.1 times per day, most commonly after breakfast or before going to bed. Approximately 40% of participants showed some symptoms of impaired eating function, for example choking, taking a long time to eat, or having difficulty eating hard foods. Among the participants, 35.1% were aware of swallowing exercises and 41.6% were aware of health care for eating function. After the educational intervention, 74% of the participants showed an improvement in their awareness of health care for eating function and there was a significant increase in the average frequency of daily toothbrushing events among the participants (p ＝ .000). 31.2% of participants expressed an intention to continue swallowing exercises.
Conclusion: This guidance improved the awareness of the participants about health care for eating function. However, since it was difficult to establish knowledge through a single educational session, it would be preferable to provide regular guidance on oral care.
Purpose: This study used the Japanese version of the short sensory profile (SSP-J) to clarify whether desensitization therapy alleviates tactile hypersensitivity in elderly patients. The purpose was to examine whether changes in the state of rejection and mouth opening affect oral function.
Subjects and Methods: Patients who had been admitted for diagnosis of dysphagia and had received swallowing training by a speech-language-hearing therapist (ST) were selected according to: 1) those who had difficulty in independent oral care; 2) those who had difficulty in oral care and eating with an assistant nurse due to rejection response of tactile sensitivity; and 3) those who had been diagnosed as having dementia. The patients who fulfilled all criteria were extracted. The age ranged from 65 to 82 years old according to SSP-J.
Training continued with oral care 5 times a week for 5 weeks, after desensitization therapy with ST. We evaluated sensory stimulation response by SSP-J, and oral function by the Revised Oral Assessment Guide (ROAG). In addition, the change in rejection during desensitization therapy and the change in opening retention during oral care were recorded.
Results: The subjects of this study were 20 persons. After desensitization therapy, tactile hypersensitivity in SSP-J and rejection decreased. Oral function of the patients with tactile sensitivity improved, especially for the saliva index. In 8 cases, an opening holder was not needed and finally oral care was accepted.
Discussion: Continuous desensitization therapy reduced tactile hypersensitivity in the elderly patients. The results of this study are considered to be better than those of a previous study. In desensitization therapy, it is suggested that continuing training with a certain frequency of intervention may improve the outcome compared with extending one intervention time. For patients who did not respond to desensitization, it was necessary to construct a new desensitization therapy that introduced other superficial and special sensory stimuli.
After desensitization therapy, oral care became possible because the patients could open the mouth easily. The saliva item in ROAG was improved, resulting in a wetter oral cavity.
Purpose: This study aimed to clarify the features of pre-swallow bolus transport in persons with severe motor and intellectual disabilities (SMID) by comparing movement of the jaw, tongue and hyoid bone in persons with SMID and healthy adults.
Subjects and Methods: Seven healthy adults and 14 persons with SMID underwent videofluoroscopic examination of swallowing while swallowing 3 to 5 mL of paste food. The range of movement of the jaw, tongue and hyoid bone during pre-swallow bolus transport were measured in the coordinate plane with the second and fourth cervical vertebra as the reference line. The onset and termination of jaw and hyoid movement in the vertical direction, and tongue movement in the centripetal and centrifugal directions along seven equiangular directions emanating from the center of the tongue were timed using frame-byframe analysis. Persons with SMID were classified in two groups: the normal-transport (NT) group that needed the same number of transport cycles as healthy adults, and the disordered-transport (DT) group that needed more transport cycles than healthy adults. The results were compared using the Kruskal-Wallis test with Dunn’s multiple comparison test.
Results and Discussion: Each group included 7 subjects. Multiple comparison showed the duration of the intercuspal phase was significantly shorter in the DT group than in healthy adults (p ＝ 0.015) and the NT group (p＝0.002), and the duration of contact of the anterior area of the tongue and hard palate was significantly shorter in the DT group than in healthy adults (p＝0.023) and the NT group (p＝0.001). Furthermore, the bolus transit time was significantly longer in the DT group than in healthy adults (p＝0.001) and the NT group (p＝0.001). The timing of termination of the intercuspal phase of the DT group was immediately after the onset of hyoid upward movement which also represents the appearance of tongue pressure. The results suggest that instability of the jaw shortens the duration of the intercuspal phase and results in shortening the duration of contact of the anterior area of the tongue and hard palate, which has an important role as an anchor when the tongue propels the bolus posteriorly.
Conclusion: In persons with SMID that needed more transport cycles than healthy adults, the duration of the intercuspal phase and the contact of the anterior area of the tongue and hard palate were significantly shorter, and the bolus transit time was significantly longer than in healthy adults and persons with SMID that needed the same number of transport cycles as healthy adults.
Some special needs patients have masticatory dysfunction such as swallowing food whole. However, there are no standard treatment methods for masticatory dysfunction. It is important for mastication to receive the input of sensory information about the food such as its softness and crispness when biting using the front teeth. Therefore, we created a new method of treatment for masticatory dysfunction by checking the food that the patient can and cannot chew. In addition, we combined food that they can chew with food they cannot chew and gave it to the patient. In this study, the patient with masticatory dysfunction was able to chew better with the new method.
The patient was a special needs 12-year-old female student with Down's syndrome. The main complaint of the mother was that the patient occasional suffered from choking. The types of food she ate were mainly chunks and soft diet food at school, and chopped diet food at home.
On the first visit, we found difficulties with chewing food and lip closure. We instructed her to use her front teeth when eating big chunks of food, which is a commonly used method for special needs patients. However, the dysfunction did not improve when eating soft food. Therefore, we tried a new method by combining food she can chew and food she cannot chew, such as pickles and rice, or cucumbers and hamburgers, and so on. We instructed the caregivers to use this method when feeding the patient. After 6 months, we were able to observe chewing actions when she was eating soft food that she could not chew before.
This report suggests that this new method is effective for improving masticatory dysfunction of special needs patients.
A 63-year-old man was diagnosed with dysphagia due to amyotrophic lateral sclerosis (ALS). Symptoms of ALS onset were coordinated movement of the upper limbs, gait disturbance and weight loss. Respiratory and swallowing functions slowly decreased. The patient had to wear a non-invasive positive-pressure ventilation device while sleeping and dietary adjustments consisting of soft foods and mildly thick liquids were necessary before discharge from hospital. One month after discharge, he was re-hospitalized due to aspiration pneumonia and required intensive care. After re-hospitalization, swallowing function and tongue pressure rapidly decreased. He initiated tongue-lifting exercises, taking care to avoid overuse because the observed declines might have been caused not only by ALS, but also by disuse syndrome. Tongue strength and swallowing ability improved because of the swallowing rehabilitation exercises. Tongue-lifting exercises can help patients diagnosed with ALS and disuse syndrome.
A 69-year-old man had been suffering from dysphagia, arthralgia, limb muscle weakness and weight loss. He was hospitalized, and diagnosed with dermatomyositis and interstitial pneumonia. His dysphagia worsened in spite of drug therapy such as prednisolone and immunosuppressor, so he was referred to us for swallowing rehabilitation. He had poor pharyngeal contraction in videofluoroscopic examination. Videoendoscopic evaluation of swallowing (VE) revealed residue in the vallecula and aspiration after swallowing of water and jelly. Nasal feeding was used to improve the nutritional status. We used thickened water and jelly for swallowing rehabilitation, and did not let him do indirect swallowing training to prevent exacerbation of dermatomyositis.
After 2 weeks, pneumomediastinum was found by computerized tomography. Due to the risk of pneumomediastinum becoming worse and in view of mediastinitis, the jelly was stopped and only thickened water was applied. By examining the fatigue during swallowing, amount of water, serum creatine kinase (CK) value and VE findings, we changed his food and water. After 3 months, he finally could eat by swallowing enough assisting food and water, without thickening or nasal feeding.
For patients suffering from dysphagia, severe dermatomyositis and interstitial pneumonia, we should plan swallowing rehabilitation to prevent pneumomediastinum. It is considered that severe dysphagia with dermatomyositis needs a long time until recovery. In addition, rehabilitation treatment for dysphagia becomes more difficult in the presence of interstitial pneumonia and pneumomediastinum. In this case, to prevent exacerbation of dermatomyositis by overuse, we did not let the patient do indirect swallowing training. We performed nutritional management using nasal feeding from an early stage. By devising the contents of direct swallowing training, we prevented exacerbation of the pneumomediastinum and onset of the mediastinitis. When interstitial pneumonia merges with dermatomyositis, an elaborate plan is necessary for swallowing rehabilitation to prevent pneumomediastinum.
Aim: Clinical practice and research on swallowing rehabilitation is a new field compared with other diseases and disorders, and there are still many unknown matters. In order to develop swallowing rehabilitation in the future, it is necessary to conduct many studies and to publish the findings. The aim of this article is introduce guidelines for research reports to clinicians intending to write an article, and to provide materials for writing such articles and collecting necessary information.
Method: Many articles submitted to the Japanese Journal of Swallowing Rehabilitation are case reports, case-control studies, cohort studies and cross-sectional studies. Therefore, this article introduces the Case Report (CARE) guidelines for case reporting and the items to be included in the checklist in observational studies which were drafted in The Strengthening of Observational Studies in Epidemiology Statement (STROBE statement).
Results: Regarding the CARE guidelines, we described a 13-item checklist proposed to increase the accuracy, transparency and usefulness of case reports. As for the STROBE statement, we explained a checklist of 22 items that should be included in observational study reports, to improve the quality of research reports.
Conclusion: Ideally, all the items recommended by these two guidelines should be listed, but it is difficult to cover all of them. However, with the items indicated in these guidelines in mind, daily clinical practice could enrich medical records and lead to presentations at conferences and dissertations according to the guidelines, thus not only improving the quality of individual clinicians, but also leading to further clinical research and research on swallowing rehabilitation. We hope that this paper will help increase the number of excellent articles and eventually the further development of clinical practice and research on swallowing rehabilitation.