Background/Purpose:　In recent years, the term “crushable with the tongue” has been commonly used to describe the hardness of food in Japan. However, this phrase has never been examined in relation to relevant tongue ability and food rheology. Thus, we assessed tongue pressure, which indicates the processing ability of the tongue. The purpose of this study was to clarify the relationship between crushable food hardness and tongue pressure.

　Methods/Participants:　We categorized the study into two surveys. In study I, a probe for measuring tongue pressure was fixed to the table of equipment for measuring physical properties and loaded at a speed of 1 mm/s with 10%–85% measurement strain. Then, we calculated the relational expression between the values obtained by each measuring equipment. In study II, 48 healthy university students were enrolled as subjects, and their age, sex, body condition, and level of teeth correction were recorded. We tested their swallowing function with the Repetitive Saliva Swallowing Test, followed by their hand strength, tongue pressure, and jelly crushing ability. We prepared jellies with a hardness of 60,000 N/m², 80,000 N/m², 100,000 N/m², and 120,000 N/m², and jelly shape was determined using the same probe for tongue pressure measurement, using two types of gelling agent.

　Results:　In study I, there was a strong positive correlation between the numerical values obtained by the physical property-measuring equipment and by the tongue pressure-measuring equipment (r ＝ 0.999, p＜0.01), and the regression equation was y ＝ 1,799.3x＋2,388.6 (x: value of tongue pressure-measuring equipment, y: value of physical property-measuring equipment [N/m²]). In study II, the tongue pressure required for crushing increased with hardness, although the degree of change varied depending on the gelling agent used. The regression line obtained in study II did not match that in study I, but the actual hardness at which foods could be crushed with the tongue exceeded the estimated hardness at the pressure levels tested.

　Conclusions:　Our study determined that by using the equation y ＝ 1,799.3x＋2,388.6, the upper limit of hardness of foods that can be crushed with the tongue can be estimated simply by measuring the tongue pressure.

　In this study we developed a novel quantitative evaluation method for tongue motor function using a hanging scale, which has the advantages of easy introduction and low cost. The maximum value at which gauze can be held by the tongue and palate, measured with a hanging scale, is called the “maximum holding force” and is used as a new evaluation index. Thirty-seven inpatients aged 65 years or older (21 males and 16 females, mean age 77.1±5.9 years) participated in the trial of our method. The relationships between the maximum holding force and existing indexes, such as maximum tongue pressure, tongue pressure during effortful swallowing, number of left and right tongue movements, and oral diadochokinesis of /ta/ and /ka/, were investigated. Regression analysis was performed to evaluate the accuracy of the regression equation, to obtain the maximum tongue pressure from the maximum holding force. The maximum holding force was significantly correlated with maximum tongue pressure, tongue pressure during effortful swallowing, number of left and right tongue movements (p＜0.001), and repetition of the monosyllable /ta/ (p＝0.016). The regression equation was obtained as maximum tongue pressure (kPa)＝ 6.678＋7.457×maximum holding force (kgf) (p＜0.001) with 0.713 coefficient of determination. The intra-rater reliability of the maximum holding force was 0.95 (p＜0.001), and the inter-rater reliability was 0.93 (p＝0.003) on average. We concluded that the maximum holding force is a useful index reflecting the motor function of the tongue and that our method can provide a quantitative assessment in clinical practice at low cost.

　Purpose:　The purposes of this study were to clarify the reliability and validity of the score of practice using the “Structural Items of Protocol for Percutaneous Endoscopic Gastrostomy Removal for Older People” among the nurses working in long-term institutions and in an acute geriatric hospital.

　Methods:　The subjects analyzed in this study were 372 nurses working in long-term institutions and 339 nurses working in an acute care hospital specialized in the elderly.

　The method was to create and use an index to evaluate the “practical level” of nurses by the “Structural Items of Protocol for Percutaneous Endoscopic Gastrostomy Removal for Older People” (hereafter “Structural Items for Removal of PEG”). This evaluation structural index consists of criteria for 1) initiation of oral administration, 2) face sheet, 3) assessment sheet, and 4) care sheet, and answers to each item were obtained using a 4-point Likert Scale. Furthermore, answers to “Case Management Index of Dysphagia (26 items, a 5-point Likert Scale) ” and “Degree of Case Management for Dysphagic Patients” (hereafter “Case Management for Dysphagic Patients”) by Visual Analogue Scale (VAS, 1 item) were also obtained. Regarding the analysis method, the reliability of this evaluation index was verified by internal consistency, and the validity was verified by criterion-related validity and construct validity. This study was performed with the approval of the ethics review committee of each related institution.

　Results:　The overall score of Cronbach’s coefficient in all items of each sheet of the “Structural Items for Removal of PEG” was 1) 0.916, 2) 0.969, 3) 0.982, and 4) 0.977 in the long-term institutions and 1) 0.921, 2) 0.977, 3) 0.983, and 4) 0.975 in the acute geriatric hospital, respectively. Regarding the validity of both groups, there was a significant correlation between the total score of each major item of the “Structural Items for Removal of PEG” and the score of all items and the “Case Management for Dysphagic Patients,” or the total score of major items of the case management index for dysphagia and the score of all items (p＜0.001).

　Discussion:　As described above, the reliability and validity of the “Structural Items for Removal of PEG” in nursing practice were statistically evaluated.

　Aim:　The purpose of this study was to evaluate the effect of intensive dysphagia rehabilitation on poststroke dysphagia in elderly hospitalized patients.

　Methods:　This study was conducted in 14 hospitals. Patient selection criteria included aged 65 years or older, newly admitted to hospital in the recovery rehabilitation unit, first onset of dysphagia by poststroke within 60 days from onset, and food intake level scale (FILS) ≤ 7. Eligible patients were randomly assigned in a 1:1 ratio to receive either intensive dysphagia rehabilitation (1 h/day) or standard dysphagia rehabilitation for 1 month. Several endpoints including FILS, food form, repetitive saliva swallowing test, modified water swallow test, presence of nasogastric tube and occurrence of aspiration pneumonia during hospital stay were assessed at baseline and after intervention.

　Results:　Of the 55 patients who underwent randomization, 28 patients were assigned to receive standard dysphagia rehabilitation (44±14 min/day) and 27 patients to intensive dysphagia rehabilitation (60±12 min/day). The number of patients whose FILS score improved significantly increased in the intensive group (81%, 22/27 patients) compared with the standard group (57%, 16/28 patients). Regarding food form, the number of patients who were capable of eating standard cooked rice or whole porridge did not significantly increase after intervention in the standard group (4 patients to 10 patients), but significantly increased (2 patients to 11 patients) in the intensive group. The number of patients who suffered from aspiration pneumonia was significantly smaller in the intensive group than that in the standard group. There were no significant differences in other endpoints.

　Conclusions:　We conclude that intensive dysphagia rehabilitation may provide further improvements for post-stroke dysphagia.

　Objective:　As there are few hospitals and nursing homes providing dysphagia diets that have texture measuring devices, texture-modified diets in the Japanese Dysphagia Diet 2013 (JDD2013) are not described based on physical properties but by text explanations. Therefore, the interpretation of these descriptions differs among facilities, especially for Code 4 of JDD2013. In this study, two types of simplified evaluation methods for determination of hardness of food were investigated: one method using a rod and an electronic scale (scale method) and the other using a cap with a protrusion and a PET bottle (PB method).

　Methods:　Thirty-four types of processed foods and fresh foods were used as samples. They were cut into 20 mm long, 20 mm wide and 10 mm tall pieces. Samples were placed on the stage using a creepmeter (RE2-3305C, Yamaden Co., Ltd.) and a cylindrical plunger of 5 mm diameter was plunged into the sample. Samples were kept at 20±2℃, and the plunging rate was 1 mm/s. Hardness was calculated from the highest point as the distortion factor of 0–90%. In the scale method, the sample placed on the electronic scale was compressed using a rod of 5 mm diameter, and the maximum weight displayed until the rod penetrated the sample was measured. In the PB method, a cap with a cylindrical protrusion of 5 mm diameter was attached to a PET bottle, and the bottle was filled with water so that the pressure at the tip of the protrusion when the bottle was inverted was 100 kPa or 200 kPa. When the tip of the protrusion placed in the center of the sample could penetrate the sample, the hardness of the food was estimated to be ＜100 kPa or 200 kPa.

　Results:　Measurements obtained using a creepmeter showed that the hardness of the samples was 7 to 564 kPa. Spearman's correlation coefficient between the values obtained using the scale method and hardness by a creepmeter was 0.956 to 0.969, showing a strong positive correlation. In the PB method, hardness was estimated in the following three levels: ＜100 kPa, 100―200 kPa, and ≥ 200 kPa. However, the results of the PB method and hardness by a creepmeter did not agree for seven samples.

　Conclusions:　Both the scale method and the PB method can be used as simplified evaluation methods to determine food hardness for the dysphagia diet Code 4.

　Purpose:　The purpose of this study was to clarify the relationship between the amount of muscle activity in the jaw and hyoid muscles, the amount of muscle activity in the mylohyoid muscle while in the sitting position, and difficulty in swallowing.

　Method:　The subjects were 10 healthy adults. First, we measured muscle activity during posture maintenance. Then, we asked the subjects to perform the task of swallowing in nine postural patterns to identify difficulty in swallowing. Nine sitting posture patterns were set, which were a combination of three neck patterns―flexion at 20°, neutral position, and extension at 20°―and trunk inclination at 80°, 70°, and 60°. Difficulty in swallowing was evaluated and rated on a scale of 0 to 10, with 10 indicating the easiest swallowing, equivalent to that of the resting sitting position. Muscle activity was measured for the jaw, hyoid, and mylohyoid muscles.

　Results:　The degree of dysphagia was significantly lower when trunk inclination was at 60° than when flexion was at 20°, in the intermediate position, and extension was at 20°. When trunk inclination was at 60° and neck extension was at 20°, the value of swallowing difficulty was lowest compared to the other postures. In addition, a negative correlation was observed between the activity of the jaw and hyoid muscles and the mylohyoid muscle in subjects while in the sitting posture in a reclining wheelchair. Further, the integrated electromyography value while in the sitting posture in a reclining wheelchair was weakly correlated with difficulty in swallowing. The correlation coefficient ( r ) of the jaw and hyoid muscles was r = －0.50, and that of the mylohyoid muscle was r = －0.54.

　Conclusion:　When trunk inclination is at 60° and neck extension is at 20°, the value of swallowing difficulty is low compared to other postures because the mylohyoid and sternohyoid muscles are mobilized during posture maintenance. It was shown that the relationship between the amount of muscle activity in the jaw and hyoid muscles, the amount of muscle activity in the mylohyoid muscle while in the sitting position, and difficulty in swallowing was involved because a negative correlation was observed between the activity of the jaw and hyoid muscles and the mylohyoid muscle in subjects while in the sitting posture in a reclining wheelchair. In order to avoid dysphagia, positioning with less muscle activity in the mylohyoid and sternohyoid muscles should be observed.

　Purpose:　The Tsubame (swallow) exercise was developed to maintain and promote swallowing, pulmonary function and limb motor function among community-dwelling elderly people. To confirm its applicability to patients with esophageal cancer scheduled for neoadjuvant chemotherapy (NAC) and surgery, this pilot study examined the effect when the exercise was performed by young women for 3 weeks and its intensity level.

　Methods:　The participants were 14 females with a mean age of 21. The Tsubame Exercise consists of neck, shoulder, chest and limb movements to be executed while singing lyrics containing many words that start with “p” and “t” (duration: 1 min and 11 s/time). The participants performed 1 set (4 times) of the Tsubame Exercise, with a Lifecoder GS (4-second edition) attached to measure the exercise intensity level. They were instructed to perform 3 sets every day during a 3-week period. Before and after implementation, tongue pressure, functions to produce the 3 s of “pa”, “ta”, and “ka”, maximum expiratory volume, sternocleidomastoid (SCM) and trapezius (TPZ) elasticity/stiffness, hand grip strength, skeletal muscle mass and gait speed when walking 4 m were measured using a tongue pressure meter, oral function test device (Kenko-kun^®), digital peak flow meter, myotonometer (MyotonPRO Digital Palpation Device^®), digital hand dynamometer, and a body composition analyzer (InBody270^®). The measurement values at both points were analyzed using statistical analysis software, with the significance level set at 5%.

　Results:　The intensity level of the Tsubame Exercise was 1.41±0.13 METs. The task (continuously performing the exercise for 3 weeks) completion rate was 79%. On comparing the pre- and post-implementation values of 11 participants with a task completion rate of 70% or higher, tongue pressure and gait speed significantly increased after intervention (p＜0.05). SCM and TPZ elasticity and stiffness decreased after intervention, and the differences in SCM stiffness (left), TPZ stiffness (both sides), and TPZ elasticity (right) were significant (p＜0.05). On the other hand, frequency of producing “pa” significantly decreased after implementation (p＜0.05).

　Discussion:　The intensity level of the Tsubame Exercise was shown to be low. However, it was suggested that tongue pressure and gait speed increased, and TPZ elasticity and stiffness decreased after continuously performing it for 3 weeks. In future, it is necessary to examine effects such as the frequency of interactions with people as the number of utterances of /pa/ decreased after implementation.

　Dermatomyositis is an autoimmune disease characterized by cutaneous symptoms and muscle weakness in the proximal muscles of the extremities. Dysphagia as a complication may also be one of the symptoms. Medication is usually successful, but there are still cases in which surgery is indicated. We experienced a case of severe dysphagia in dermatomyositis requiring a long period to resume oral intake. The patient underwent balloon dilatation training (balloon therapy), which is one of the feeding and swallowing rehabilitation treatments, and attained full oral intake after 3 years. We present the clinical course of the prolonged and refractory swallowing rehabilitation.

　The patient was a male in his 60s with dermatomyositis (anti-OJ antibody positive). He had complained of pain in both shoulders, upper arms, and neck for 2 months prior to hospitalization. At the first visit, he suffered from skin lesions and muscle weakness in the trunk and proximal limbs, and was unable to keep the upper limbs elevated. Serum creatine kinase was elevated. In addition, he had dysphagia caused by obstruction of food passage and nasopharyngeal reflux.

　At the beginning, he had persistent poor general condition and severe dysphagia, and was unable to undergo active swallowing rehabilitation. Significant aspiration, nasopharyngeal reflux, pharyngeal residue, and esophageal inlet obstruction were noted on videofluoroscopic (VF) examination of swallowing. He was treated with glucocorticoids and intravenous immunoglobulin, but his dysphagia remained impaired regardless of additional balloon therapy. After discharge from the hospital, only indirect swallowing training was continued. When reduction of the risk of aspiration was confirmed by VF, direct swallowing training was started and the balloon therapy was resumed. He was able to eat a soft food after about 2 years in total, and to drink freely after about 3 years, thus becoming completely independent with respect to oral intake.

　Although glucocorticoids for dermatomyositis were maintained, he achieved complete oral intake by direct and indirect training and persistent balloon therapy. It is important to continue feeding and swallowing rehabilitation despite prolonged impaired oral intake.

　Case:　The patient was a man in his 80s.

　History of present illness:　The patient experienced difficulty swallowing and felt that he was choking while having a meal. After a month, he visited his local clinic, and was diagnosed with dysphagia of unknown cause. Two months after the diagnosis, he was referred to our hospital to do swallowing exercises.

　Intervention and clinical course:　Initial videofluoroscopic examination of swallowing (VFSS) revealed significant cricopharyngeal dysfunction. In order to widen the upper esophageal sphincter, esophageal dilation with a balloon was performed for 3 months. VFSS performed after the exercises showed improved cricopharyngeal dysfunction, and the exercises were discontinued. However, the patient returned with dysphagia 3 weeks later due to exacerbation of dysphagia, and swallowing exercises were resumed. Since the symptoms were similar, the patient performed the Mendelsohn maneuver as a swallowing exercise for 2 months in order to widen the narrowed upper esophageal sphincter. Interferential current stimulation was used concurrently to facilitate the swallowing reflex during the Mendelsohn maneuver. VFSS performed after the exercise showed that the cricopharyngeal dysfunction was improved. However, cricopharyngeal bar (CB) was identified as a bolus moved through the esophagus. VFSS with a liquid swallow demonstrated a change of the duration of esophageal opening from 0.20 s prior to the swallowing exercises to 0.33 s after balloon dilation and 0.43 s after the Mendelsohn maneuver. After the balloon dilation, the bolus remained in the oropharynx as the upper esophageal sphincter opened. After the Mendelsohn maneuver, improved timing of opening of the upper esophageal sphincter was demonstrated, and the bolus moved through the esophagus as the upper esophageal sphincter opened. The frequency of these exercises was reduced from twice a week to once a week. After 3 months, the symptoms of dysphagia remained well-controlled.

　Discussion:　In the present case, idiopathic cricopharyngeal dysphagia was suspected due to the presence of CB. Both the opening of the upper esophageal sphincter and its timing are important in improving cricopharyngeal dysfunction. By managing the patient while monitoring the progress of the swallowing exercises, we were able to prolong the duration of esophageal opening and improve the coordination of the organs involved in the process of swallowing.

　Introduction:　We report a case of multiple system atrophy in which oral ingestion was successfully introduced in the complete lateral decubitus position (CLDP).

　Case:　The patient was an 87-year-old male with multiple system atrophy diagnosed 4 years prior. The patient had undergone gastrostomy.

　Course:　The patient was independent in oral ingestion on admission. Due to gradually progressive dysphagia, enteral feeding was initiated through gastrostoma on Day 79 after admission. Swallowing rehabilitation in the conventional position (supine position angled at 30° with neck flexion) was initiated on Day 90. However, swallowing rehabilitation was suspended because an increased body temperature was observed 3 days later; only enteral feeding was continued. After the increased body temperature was resolved, videoendoscopic evaluation of swallowing (VE) was performed to fulfill the wish for oral ingestion by the patient and his family on Day 213. The Hyodo score was 7 in both the conventional position and CLDP. As the neck was elevated due to rigidity, we considered that swallowing rehabilitation in the CLDP would be preferable. On Day 217, swallowing rehabilitation therapy was initiated. The post-clinical course was uneventful without a fever. VE was performed again on Day 254. No apparent finding of aspiration pneumonia was observed. On Day 278, the patient could ingest orally with assistance from a nurse.

　Discussion:　Prior to swallowing rehabilitation in the CLDP, a fever related to aspiration pneumonia was observed in this case. This possibly occurred because dysphagia and the rigidity of the neck both resulted from multiple system atrophy. According to the findings of preceding VE, the conventional position could also have been an option. However, due to the rigidity of the neck, swallowing rehabilitation in the CLDP was indicated. After 2 months of swallowing rehabilitation in the CLDP, the patient could ingest orally. An advantage of the CLDP is that the method seems sufficiently simple for medical staff who are not swallowing therapists to assist patients with dysphagia. As observed in this case, the CLDP may be applicable for other diseases in which swallowing rehabilitation in the CLDP has not been described to date. Standardized criteria are also warranted for further application of the CLDP.

　Introduction:　We report a patient who achieved oral intake by direct swallowing training after wearing the AGO Cap™ (AGO Cap) chin external fixation device.

　Case:　A woman in her 80s was admitted to the hospital with Alzheimer’s disease and interstitial pneumonia.

　Course:　Interstitial pneumonia worsened and the patient’s consciousness decreased on Day 2. A speech-language-hearing therapist intervened on Day 3 to evaluate swallowing function. The general condition became unstable, and long-term bed rest, increased sputum volume, and delirium appeared. The patient repeatedly dislocated the temporomandibular joint (TMJ) while at rest, and was able to self-repair. The patient's general condition improved and direct swallowing training was started on Day 21. Bilateral dislocations of the TMJ with difficulty in self-repair appeared on Day 28. We tried a chin cap and a TMJ brace to prevent re-dislocation after manual reduction, but adaptation was poor. Therefore, direct swallowing training was performed with the AGO cap in place. The anterior protrusion of the head and neck with thoracic kyphosis improved, resulting in an enhanced amount of opening and mastication. When the AGO cap was not attached, the amount of opening was small and mastication was slow, and the distance between the upper and lower incisors gradually prolonged and dislocated. The patient continued swallowing training using the AGO cap, and finally achieved oral intake on Day 38. The patient's general condition deteriorated on Day 47 just before scheduled discharge, and she died on Day 51.

　Discussion:　The AGO cap has sufficient fixation force to prevent re-dislocation, and is easy to put on and take off with little discomfort during wearing. In the case of habitual temporomandibular joint dislocation with dementia, the cap is expected to have the psychological effect of dispelling the fear of dislocation and assisting the acquisition of swallowing function. Swallowing training after AGO cap placement may contribute to the improvement of swallowing function, especially during the preparatory and oral phases. The AGO cap is expected to be applied to patients even with difficulty in closing the mouth, in addition to TMJ dislocation.