Article

Dysphagia Rehabilitation in Japan

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Abstract

This article describes the features of Japanese dysphagia rehabilitation, particularly where it differs from that in the United States. Many kinds of professionals participate in dysphagia rehabilitation; nurses and dental associates take important roles, and the Japanese insurance system covers that. Videofluorography and videoendoscopy are common and are sometimes done by dentists. Intermittent catheterization is applied to nutrition control in some cases. The balloon expansion method is applied to reduce pharyngeal residue after swallowing. If long-term rehabilitation does not work effectively in dysphagia due to brainstem disorder, the authors consider reconstructive surgery to improve function.

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... The dysphagia screening tests were performed according to the evaluation criteria of the Japanese Society of Dysphagia Rehabilitation. We performed the repetitive salivaswallowing test (RSST) [6,15,16] and water-swallowing test (WST) [6,17] (Figure 1). ...
... The RSST is used to study the ability of the patient to spontaneously and repeatedly swallow, which is highly associated with aspiration [6,15,16]. The RSST is a simple test and relatively safe to carry out. ...
... The time taken to empty the cup was measured, and the drinking profile and episodes were monitored and evaluated as: (1) the patient could drink all of the water in one gulp without coughing; (2) the patient could drink all of the water in two or more gulps without coughing; (3) the patient could drink all of the water in one gulp, but with some coughing; (4) the patient could drink all of the water in two or more gulps, with some coughing; or (5) the patient often coughed and had difficulty drinking all of the water [18]. The RSST is used to study the ability of the patient to spontaneously and repeatedly swallow, which is highly associated with aspiration [6,15,16]. The RSST is a simple test and relatively safe to carry out. ...
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Nutritional status is well-known to influence patient recovery after resection of head and neck cancer (HNC). The influence of preoperative nutritional status on dysphagia was assessed in patients who underwent surgical resection of HNC along with the assessment of nutritional status during the acute and subacute phases. Eighty-six patients underwent surgical resection and dysphagia assessments (repetitive saliva-swallowing test, water-swallowing test, and functional oral intake scale) and had their tongue pressure assessed five times (before surgery, after 1–2 weeks, and 1, 2, and 3 months after surgery). The nutritional status was assessed according to the body mass index, total protein, and albumin. The prognostic nutritional index was calculated from preoperative data, and the subjects were classified into three groups: Low-risk, Attention and High-risk groups. After surgery, the nutritional status index values were low, and the High-risk group showed significantly lower values in comparison to the other two groups. The water-swallowing test and functional oral intake scale findings were worse than they had been preoperatively until 2 months after surgery, and a significant correlation was noted between the postoperative nutritional status and the presence of dysphagia. The results indicated that the preoperative nutritional status of HNC patients influenced their ability to ingest/swallow, which in turn influenced their nutritional status after HNC resection.
... Dysphagia is also a serious medical condition in latestage Alzheimer's disease [3]. To treat dysphagia, diet modification (e.g., use of food pastes) and postural adjustment (e.g., reclining) are commonly advised in Japan [4,5]. ...
... Postural adjustment is a basic therapeutic strategy used when rehabilitating patients with dysphagia in Japan [4,5]. No studies, however, have yet systematically assessed perceived swallowing difficulty during postural adjustment. ...
... Therefore, a lot of bed side screening tests predicting dysphagia have been developed. The repetitive saliva swallowing test (RSST) [9,10] and the modified water swallow test (MWST) [11,12] are both simple and convenient screening tests for aspiration. In addition to these tests, the simple swallowing provocation test (SSPT) [13] and the cough test [14][15][16][17] are reportedly useful for screening for silent aspiration. ...
... RSST was conducted according to published protocols [9,10]. The first and second finger pads had to be placed gently on the laryngeal prominence. ...
Article
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Many elderly patients with pneumonia have aspiration pneumonia. Therefore they must temporarily abstain from oral intake. However, it is difficult to predict whether or not they will be able to start oral intake. The reason is the standard method to evaluate deglutition about pneumonia patients has not been established. In this study we aimed to develop a simple and convenient method that predicts the prognosis of oral intake as nutrition among elderly patients with acute stage pneumonia. Participants were 77 inpatients fasting due to aspiration risk with acute pneumonia. (86.0 ± 7.7 years; range 68-105 years; men: n = 34, women: n = 43) during September 2011 and August 2013. Their consciousness levels were determined by Glasgow coma scale (GCS) and swallowing function and cough reflex were evaluated by repetitive saliva swallowing test (RSST), modified water swallow test, simple swallowing provocation test and cough test. Oral intake status at discharge was considered as the objective variable, and these tests were considered as explanatory variables. Then receiver operating characteristic (ROC) curve and the area under the curve (AUC) for each was done. From the ROC curve analysis, GCS ≥14 had the largest AUC (0.79) with a sensitivity and specificity of 0.71 and 0.80. That was followed by RSST ≥1, AUC (0.77) with a sensitivity and specificity of 0.81 and 0.67. These results suggest that GCS and RSST could be useful screening tests for prognostic prediction of oral intake capability in elderly patients with acute pneumonia.
... However, these methods are invasive and are not always available because of the lack of facilities or personnel. The repetitive saliva swallowing test (RSST) [11,12] and the modified water swallow test [13] are simple and convenient screening tests for aspiration. In rehabilitation medicine, evaluation and treatment strategies for swallowing function based on muscle activity data have recently received attention for the implementation of dysphagia-targeted approaches [14,15]. ...
... The RSST was conducted according to published protocols [11,12]. The first and second finger pads were placed gently on the laryngeal prominence. ...
... In 2006, the Japanese Ministry of Health, Labor and Welfare introduced a new insurance system for DR. 11 In the rehabilitation, a doctor or dentist judges whether patients have dysphagia or not. After the judgment, nurses, dental hygienists or therapists carry out a DR session every day. ...
Article
AimTo clarify the effects of dysphagia rehabilitation on oral intake after aspiration pneumonia in older adults.Methods The present retrospective observational study used data from the Japanese Diagnosis Procedure Combination inpatient database. We identified patients who were admitted to acute care hospitals with aspiration pneumonia. Patients were subdivided into those with and without dysphagia rehabilitation. The main outcome variable was total oral intake on discharge. We carried out multivariate logistic regression analysis to assess the effect of dysphagia rehabilitation on the outcome, with adjustment for patient backgrounds. We also carried out analyses based on pneumonia severity, and the timing and duration of dysphagia rehabilitation.ResultsWe identified 22 819 patients with dysphagia rehabilitation and 75 555 patients without dysphagia rehabilitation. The rates of total oral intake on discharge were 78.0 and 75.2%, respectively. The multivariate regression model showed that the dysphagia rehabilitation group had a significantly higher proportion of total oral intake on discharge (odds ratio 1.32; P < 0.001). Mild pneumonia patients had a higher odds ratio for total oral intake associated with dysphagia rehabilitation than patients with moderate and severe pneumonia (odds ratio 2.27; P < 0.001). Among patients who underwent a short period of dysphagia rehabilitation, those with early rehabilitation were more likely to achieve total oral intake at discharge than those with late rehabilitation.Conclusion The data suggest that dysphagia rehabilitation had a positive effect on total oral intake in elderly patients with aspiration pneumonia. Dysphagia rehabilitation showed greater benefit in patients with mild pneumonia than with more severe pneumonia. Geriatr Gerontol Int 2014; ●●: ●●-●●.
... In Japan, home dental care became possible with the establishment of a new fee for home-visit care in 1988. Dentists often perform videoendoscopy (VE) [4] and the number Geriatrics 2022, 7, 37 2 of 8 of VEs performed during home dental care has increased since 2005 [5]. Thus, a system to support older patients undergoing medical treatment has been established. ...
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The demand for home dental care is increasing, but how it should be involved in the continuation of life at home for elderly people who need care has not been examined. Therefore, we examined whether items examined by dentists can affect hospitalization and death. The study included 239 patients with oral intake. They were divided into regular and non-regular diet groups, and ages, nutritional statuses, activities of daily living (ADLs), Charlson Comorbidity Indexes (CCI) and swallowing functions were compared. The nutritional statuses and ADLs of the three groups at the first visit and after one year were compared. The groups included those with stable, declined and improved diet forms. Factors influencing hospitalization and death over three years were examined. Nutritional status, swallowing function, CCI and ADLs were worse in the non-regular diet group. The declined diet form group had lower ADL levels and nutritional statuses at the first visit. A proportional hazards analysis showed significant differences in the changes in diet form for the stable and declined groups related to hospitalization (hazard ratio (HR): 6.53) and death (HR: 3.76). Changes in diet form were thought to affect hospitalization and death, and it is worthwhile to assess swallowing function in home dental care.
... 16,19,20 Moreover, clinical practice of dysphasia requires multidisciplinary approaches, and oral professionals can play a significant role in the diagnosis and care of dysphagia patients. [21][22][23] Even though the patients with OSAS report some symptoms related to abnormal swallowing, swallowing dysfunctions can be regarded as subclinical. 13 This is because their physical status is not compromised as much as those in the elderly populations. ...
Article
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This study aimed to investigate the prevalence of clinical symptoms related to abnormal swallowing in a large sample of obstructive sleep apnea syndrome (OSAS) patients. Oropharyngeal symptoms for abnormal swallowing were assessed by a self-administered questionnaire in 507 consecutive patients (females: 65, males: 442; mean age: 49.6 ± 12.6 years old) with clinical symptoms of OSAS, enrolled for cardiorespiratory evaluation. Overall, 16.2% of patients (82/507) had at least one symptom for abnormal swallowing and 6.3% (32/507) had two or more symptoms. The most frequent symptom was difficulty with coughing up phlegm during or after a meal (8.3%). Demographic, sleep, and clinical variables did not differ between the patients with and without abnormal symptoms. The results of the current study showed that 16% of middle-aged OSAS patients reported pharyngeal symptoms related to abnormal swallowing, regardless of the severity of OSAS.
... An objective assessment of dysphagia was carried out using the repetitive saliva swallowing test (RSST), which detects patients who experience aspiration. 13,14 The patients were asked to perform saliva swallows (dry) as many times as possible in 30 seconds. If the patient was unable to perform three consecutive swallows, he or she was likely to have dysphagia associated with aspiration. ...
Article
Purpose Prevention, early detection and effective rehabilitation of dysphagia are important issues to be considered in an aging society. Previous studies have shown conflicting findings regarding the association between dysphagia and its potential risk factors, including age, malnutrition, oral conditions, lifestyle and medical history. Herein, we assessed the prevalence and association of dysphagia with potential risk factors in 50- to 79-year-old adults dwelling in a community in Japan. Patients and methods In this study, there were 532 participants (185 males and 347 females). Participants who responded positively to the question “Do you sometimes choke on drinks/food such as tea and soup?” or those who presented with abnormal repetitive saliva swallowing test findings were diagnosed with dysphagia. The data collected from these participants included the following: number of teeth, occurrence of oral dryness, age, body mass index, serum albumin concentration, smoking, drinking and exercise habits, presence of diseases, such as diabetes mellitus and hypertension, and questions from the Mini–Mental State Examination. Results Dysphagia was observed in 33 males (17.8%) and 76 females (21.9%). To explore the effect of the potential risk factors on the prevalence of dysphagia, a model was built by multivariate logistic regression analysis. Using the forced entry method, oral dryness (odds ratio [OR] =3.683 and P=0.003 in males; OR =1.797 and P=0.032 in females) and the number of teeth (OR =0.946 and P=0.038 in males) were found to be significantly related to dysphagia. Conclusion This cross-sectional study demonstrated associations between oral conditions and dysphagia. Factors such as oral dryness and number of teeth may contribute to dysphagia more so than aging, lifestyle and comorbidity in community-dwelling adults over the age of 50.
... The reclining posture changes the inlet of the larynx position and makes it higher than the inlet of the esophagus and this change works to keep the pharyngeal retention in the piriform sinus and inhibit aspiration after the swallow. 9 After this process, patients are able to proceed safely with a second or third swallow, or apply some swallowing maneuvers to improve pharyngeal clearance. The reclining posture also helps the dysphagic patients hold a bolus in the pharynx without aspiration. ...
... In addition, eating and swallowing function were assessed by 81.2% of all respondents, and by virtually all (96.6%) of respondents providing dysphagia rehabilitation. Multiple-choice responses on the content of assessment among respondents practicing assessment revealed that a medical interview was performed by 96.4% of respondents and that a screening test including a repetitive saliva swallowing test (4,5), modified water swallowing test (6)(7)(8), and food test (6) was performed by 93.8% of respondents (Fig. 3B). Furthermore, video endoscopic examination of swallowing (VE) was performed by 43.8% of respondents, and an oral-diadochokinesis (oral-DDK) testing was performed by 34.8%. ...
Article
The need for domiciliary dental care (DDC) for people requiring long-term nursing care is increasing as the super-aged society of Japan grows still older. Dysphagia diagnosis and rehabilitation are becoming more important in DDC; thus, the need for prostheses used for dysphasia rehabilitation is presumed to be increasing. To identify DDC trends in Japan, as well as the need for prostheses and dental technicians for DDC, we sent a self-administered questionnaire to dentists providing DDC and analyzed responses from 138 dentists (valid response rate, 39.8%). The results showed that 37.7% of respondents reported treating ≥50 patients per month. The most frequently performed procedures were removable prosthetic treatment and oral care, followed by dysphagia rehabilitation. Use of palatal augmentation prostheses was experienced by 54.3% of respondents, and most indicated that the prostheses were effective for improvement of oropharyngeal function. The rates of cooperation with primary care doctors and nursing care professionals were 76.8% and 85.5%, respectively. Only 6.5% of respondents reported accompanying dental technicians to DDC. The present analysis of trends in DDC indicates that oral care and dysphagia rehabilitation have become more frequent and that cooperation with healthcare professionals other than dental technicians has increased in recent DDC.
... 10 However, these examinations can be performed in only a limited number of facilities because they are invasive, they present environmental equipment problems, and there is a shortage of skilled staff. The repetitive salivaswallowing test (RSST) 11,12 and the modified water-swallowing test 13,14 are often used as simple screening tests for dysphagia and aspiration. Among dysphagia screening tests that are used to evaluate whether oral food intake should be restarted in patients with acute pneumonia, the RSST (cutoff value, once) has been reported to be the most useful due to its sensitivity of 81% and specificity of 67%. ...
Article
Background: The incidence of community-acquired pneumonia (CAP) is relatively high in elderly subjects. Cough peak flow (CPF) is an objective indicator of cough strength, and CPF evaluation might be useful to assess whether food intake can be restarted. We aimed to examine whether cough strength assessed with CPF can be used as an indicator of the aspiration risk when restarting food intake in elderly subjects with CAP. Methods: This cross-sectional study included 82 elderly subjects with CAP between August 2016 and March 2018. CPF was measured using a peak flow meter, and we performed the repetitive saliva-swallowing test (RSST), which is a videoendoscopic evaluation of swallowing and is used to assess dysphagia and aspiration. Receiver operating characteristic (ROC) curve analysis was performed. The cutoff value was determined, and the area under the ROC was calculated. Results: The areas under the RSST and CPF curves were 0.87 and 0.83, respectively. The RSST value for identifying the aspiration risk was 2.5 swallows. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 70.0%, 71.7%, 2.5, and 0.42, respectively. The CPF for identifying the aspiration risk was 190 L/min. The sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 82.6%, 69.4%, 2.7, and 0.25, respectively. Conclusion: Our findings suggest that cough strength assessed with CPF can be used as an indicator of the aspiration risk when restarting food intake in elderly subjects with CAP and that CPF evaluation is not inferior to the RSST. However, CPF evaluation should be performed together with swallowing screening tests to determine the aspiration risk.
... 6 Nuestras intervenciones consistieron en cambios posturales durante la alimentación, los cuales tienen un efecto inmediato en la eficacia y seguridad de la deglución orofaríngea. 7 Estos cambios son considerados la primera línea del tratamiento porque son relativamente fáciles de realizar, y la mayoría de los pacientes no tiene problemas para el movimiento de cabeza y cuello. 3 El cambio postural más utilizado en nuestros pacientes fue la maniobra de chin tuck; durante esta maniobra el paciente baja el mentón hacia el tórax, esta postura disminuye la distancia entre la base de la lengua y la pared faríngea, estrechando la entrada a la vía aérea y ampliando la vallecula permitiéndole capturar el bolo durante la fase faríngea y prevenir la aspiración. ...
Article
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Introduction: Swallowing disorders are a common problem in older adults. Unfortunately there are few studies that determine the effectiveness of the various treatments of oropharyngeal dypshagia in terms of optimal frequency and duration of treatment. Objectives: To determine the modifications in the Aspiration Penetration Scale and the incidence of pneumonia due to bronchoaspiration after the interventions performed in our study group. Material and methods: A retrospective, cross-sectional, observational and analytical study was carried out, in which patients admitted to the Hospital Español de México with oropharyngeal dysphagia were studied as patients undergoing dynamic swallowing tests, defining the exercises to be carried out by the patient according to their requirements. Between four and 12 weeks later a control study was performed. Results: A total of 53 patients were included. During the control test, a 5.66% decrease in aspiration with clear liquids was obtained; 11.32% with carbonated liquids; 24.53% with semisolids and 20.93% with solids. Conclusions: Our study demonstrated a statistically significant decrease in the penetration-aspiration scale with carbonated liquids, semisolids and solids with rehabilitation exercises in patients with oropharyngeal dysphagia.
... 19 SLHT performs swallowing rehabilitation involving indirect and direct training, which is intended to safely regain oral intake. 20 In our hospital, SLHT participates in the multidisciplinary perioperative care team after esophagectomy and works actively in swallowing function screening and rehabilitation to overcome postoperative dysphagia. It has not yet been established whether these swallowing interventions need to be introduced into the ERAS program after esophagectomy. ...
Article
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Dysphagia after esophagectomy is the main cause of a prolonged postoperative stay. The present study investigated the effects of a swallowing intervention led by a speech–language–hearing therapist (SLHT) on postoperative dysphagia. We enrolled 276 consecutive esophageal cancer patients who underwent esophagectomy and cervical esophagogastric anastomosis between July 2015 and December 2018; 109 received standard care (control group) and 167 were treated by a swallowing intervention (intervention group). In the intervention group, swallowing function screening and rehabilitation based on each patient’s dysfunction were led by SLHT. The start of oral intake, length of oral intake rehabilitation, and length of the postoperative stay were compared in the two groups. The patient’s subgroups in the 276 patients were examined to clarify the more effectiveness of the intervention. The start of oral intake was significantly earlier in the intervention group (POD: 11 vs. 8 days; P = 0.009). In the subgroup analysis, the length of the postoperative stay was also significantly shortened by the swallowing intervention in patients without complications (POD: 18 vs. 14 days; P = 0.001) and with recurrent laryngeal nerve paralysis (RLNP) (POD: 30 vs. 21.5 days; P = 0.003). A multivariate regression analysis identified the swallowing intervention as a significant independent factor for the earlier start of oral intake and a shorter postoperative stay in patients without complications and with RLNP. Our proposed swallowing intervention is beneficial for the earlier start of oral intake and discharge after esophagectomy, particularly in patients without complications and with RLNP. This program may contribute to enhanced recovery after surgery.
... Based on the patient's general condition and oral function including the severity of dysphagia and oral health status, the physician made the final decision on the type of oral intake by consensus with dentists. The Dysphagia Severity Scale (DSS) [24] was used to assess the severity of dysphagia with swallowing endoscopy. The DSS is a 7-point scale that does not necessarily require swallowing angiography or swallowing endoscopy; lower scores indicate more severe dysphagia [25]; the lower the score, the more severe the dysphagia. ...
Article
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Stroke and poor oral health are common in older people, and the brain injuries associated with stroke are often accompanied by a decline in oral function. In this study, we investigated the characteristics of stroke patients who could not recover oral ingestion until discharge and the association between improved oral health, swallowing function, and nutritional intake methods in acute care. The subjects were 216 consecutive stroke patients who were admitted to Tokyo Medical and Dental University hospital and received oral health management. Nutritional intake, dysphagia, and oral health were evaluated using the Functional Oral Intake Scale (FOIS), Dysphagia Severity Scale (DSS), and Oral Health Assessment Tool (OHAT), respectively. Patients in the tube feeding group (FOIS level 1–2, N = 68) tended to have a worse general condition, fewer functional teeth, and a worse DSS level than those in the oral nutrition group (FOIS level 3–7, N = 148). Multiple analysis with improvement in FOIS score as the dependent variable showed that number of functional teeth (odds ratio [OR]: 1.08, p = 0.04) and improved DSS (OR: 7.44, p < 0.001) and OHAT values (OR: 1.23, p = 0.048) were associated with improvement in nutritional intake methods in acute care. Therefore, recovery of swallowing function and oral health might be important for stroke patients to recover oral ingestion in acute care.
Article
Dysphagia prevalence has increased with increasing elderly population worldwide. Therefore, early detection of dysphagia has become increasingly important. Repetitive saliva swallowing test (RSST), modified water swallowing test (MWST), and cervical auscultation, which are convenient for non-experts to assess eating and swallowing and have been frequently used in Japan since 20 years. Using aspiration and pharyngeal residues, the objective of this study was to elucidate the efficacy of the three screening tests performed by non-experts in patients who had swallowing disorders. In total, 102 patients with cerebrovascular diseases who were suspected of having dysphagia were assessed. A swallowing team assessed their swallowing capabilities; videofluoroscopy and screening tests were performed. RSST, MWST, and cervical auscultation were performed by junior dentists who were non-experts in dysphagia. Sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio in each examination were evaluated using results of aspiration in videofluoroscopy and pharyngeal residues. For aspiration, the highest sensitivity with cervical auscultation (VES) was 93.7%. For pharyngeal residue, the highest sensitivity with cervical auscultation (VES) was 84.3%. For piriform sinus residue, the highest sensitivity with cervical auscultation (VES) was 86.4%. Despite being evaluated by a non-expert, the sensitivity of cervical auscultation (VES) and MWST was ≥ 80%, suggesting their effectiveness as prescreening tests, although the range of specificity was 25.5–68.4% in all examinations. These tests are easy to perform and useful to screen for aspiration or pharyngeal residues before precision tests.
Article
Aim: The present study examined the cervical, thoracic and lumbar spines, and shoulder girdle range of motion (ROM) of dependent older adults to clarify the influence of these variables on swallowing function, in order to evaluate the efficiency of ROM training to maintain older adults' swallowing function. Methods: A total of 37 (mean age 86.8 ± 6.2 years; 11 men; 26 women) dependent older adults were included in the study. The level of swallowing function was assessed using the Functional Oral Intake Scale. The following ROM were measured three times to calculate the mean: the cervical spine (flexion, extension, rotation and lateral bending); thoracic and lumbar spines (flexion, extension, rotation and lateral bending); and shoulder girdle (flexion, extension, elevation and depression). In order to compare ROM, the participants showing Functional Oral Intake Scale scores of 7 were classified as dysphagia (-), and those showing scores <7 were included in the dysphagia (+) subgroups. Results: The dysphagia (+) group showed significantly limited cervical spine (flexion, extension and lateral bending), thoracic and lumbar spines (flexion, extension, rotation and lateral bending), and shoulder girdle (flexion, elevation, and depression) ROM. Conclusions: Although strict relationships were not clarified, the results of the present study suggested the influence of some joint ROM on swallowing function. This suggests the feasibility of preventing dysphagia among dependent older adults by maintaining and enhancing the elasticity and extensibility of their muscles through cervical, thoracic and lumbar spines, and shoulder girdle ROM training. Geriatr Gerontol Int 2017; ••: ••-••.
Article
Background The aim of this study was to evaluate the validity of a dysphagia screening test (DST) in patients who have undergone resection for head and neck cancer (HNC). In addition, we examined whether or not combined effects of DSTs improve the detection accuracy of penetration/aspiration.Methods Thirty-six HNC patients were participated. The DST consisted of the repetitive saliva swallowing test (RSST), the water swallowing test (WST), the modified water swallowing test (MWST), the food test (FT), and tongue pressure. A videofluoroscopic swallowing study was conducted, and the penetration–aspiration scale was used for scoring. For statistical analyses, we used the receiver operating characteristic (ROC) analysis. Furthermore, the accuracy of the determination of penetration/aspiration was evaluated by combining two or three DSTs.ResultsThe penetration/aspiration could be predicted with moderate accuracy based on MWST and FT. The area under the ROC curve (AUC) values of the MWST and FT were 0.76 (p = 0.03) and 0.80 (p = 0.050), and the sensitivity/specificity was 0.9/0.61 (MWST) and 0.8/0.8 (FT), respectively. As a result of combining 2 or 3 DSTs, the combination of “MWST and FT” was the most accurate, with an AUC of 0.87 (p = 0.02). The combination of three tests had lower accuracy than the combination of two tests.Conclusion Based on our results, it is recommended that MWST or FT be used when only one type of DST is performed. In addition, the combination of two DSTs may detect aspiration patients more accurately than one alone.
Article
Tongue pressure is reportedly associated with dysphagia. This study investigated relationships among characteristics of head and neck cancer, tongue pressure and dysphagia screening tests performed in patients with head and neck cancer during the acute phase after surgical resection. Fifty-seven patients (36 men, 21 women; age range 26-95 years) underwent surgical resection and dysphagia screening tests (Repetitive Saliva Swallowing Test, Water Swallowing Test, Modified Water Swallowing Test and Food Test) and pre- and postoperative measurement of tongue pressure at 5 time points (preoperatively, and 1-2 weeks and 1, 2, and 3 months postoperatively). Progression of cancer (stage), tracheotomy, surgical reconstruction, chemotherapy, radiotherapy and neck dissection were factors associated with postoperative tongue pressure. Data were analyzed by linear mixed-effect model, Spearman correlation coefficient and receiver operating characteristic (ROC) curve. Tongue pressure was significantly reduced 1-2 weeks after surgery, and recovered over time. Changes in tongue pressure were significantly associated with stage, radiotherapy and reconstruction. All screening tests showed a significant relationship with tongue pressure. Analysis of ROC and area under the effect curve suggested that a tongue pressure of 15 kPa can be used as a cut-off value to detect dysphagia after surgery for head and neck cancer. Our results suggest that tongue pressure evaluation might offer a safe, useful and objective tool to assess dysphagia immediately postoperatively in patients with head and neck cancer.
Article
Objectives: This study aimed to investigate the prevalence of clinical symptoms related to abnormal swallowing in a large sample of obstructive sleep apnea syndrome (OSAS) patients. Methods:Oropharyngeal symptoms for abnormal swallowing were assessed by a self-administered questionnaire in 507 consecutive patients (females: 65, males: 442; mean age: 49.6 ± 12.6 years old) with clinical symptoms of OSAS, enrolled for cardiorespiratory evaluation. Results:Overall, 16.2% of patients (82/507) had at least one symptom for abnormal swallowing and 6.3% (32/507) had two or more symptoms. The most frequent symptom was difficulty with coughing up phlegm during or after a meal (8.3%). Demographic, sleep, and clinical variables did not differ between the patients with and without abnormal symptoms. Conclusions:The results of the current study showed that 16% of middle-aged OSAS patients reported pharyngeal symptoms related to abnormal swallowing, regardless of the severity of OSAS.
Article
Objective: This study investigates the effects of a study course in oral health care on the perceptions of nursing students. The course was designed and evaluated by a multi-professional team at a Japanese nursing school. Method: The subjects were 119 nursing students. They participated in the oral health course that comprised 45h of training in 4 years. These were designed and taught by oral health professionals, a certified speech-hearing therapist, and nurses. Questionnaires were distributed to subjects to compare their perceptions and awareness about oral health care before, in between, and after the courses. A chi-square test was used to compare the data. Results: After completing the courses, more than 95% of the participants were interested in the oral health care practice and expected to collaborate with oral health professionals after getting qualified. Additionally, they understood the effectiveness of oral health care for the prevention of aspiration pneumonia and perceived that oral health care should be provided to hospitalized patients and community-dwelling older adults. Their awareness of the need to learn techniques for tooth brushing support, salivary gland massage, oral management, swallowing training, removing tongue coating, and gargling, both in theory and practice, was significantly improved. Conclusion: Multi-professional education has the potential to improve the awareness of nursing students of oral health care and promote collaborative oral health care in the future.
Article
Objective: The objectives of the study were to clarify the characteristics of dysphagia and the incidence of pneumonia in Myotonic dystrophy type 1 (DM1) patients, and to investigate the relationship between the development of pneumonia and the DM1 patient's background, especially concerning swallowing function evaluated by endoscopy. Methods: The subjects were 88 DM1 patients who underwent swallowing function evaluation. The severity of disease in DM1patients was assessed based on the muscular impairment rating scale (MIRS), and the number of CTG repeats. Patients were divided into two groups; those who developed aspiration pneumonia within two years after swallowing assessment and those who did not develop aspiration pneumonia. Swallowing function was assessed using the food intake level scale (FILS), repetitive saliva swallowing test (RSST), the modified water swallowing test (MWST), and the Hyodo score. Results: Onset of pneumonia within two years of assessment was observed in 22 cases (25%). Age, FILS, and Hyodo score were significantly different between pneumonia and non-pneumonia groups. There was a significant difference in swallowing function tests such as FILS, RSST, and Hyodo score between males and females. The Hyodo score cutoff value for predicting pneumonia within two years was determined by ROC analysis. A cutoff value of 6 was found to have a sensitivity of 0.545 and a specificity of 0.833 (area under the curve=0.722). Conclusion: It is important to evaluate the swallowing function of DM1 patients by endoscopy to prevent aspiration pneumonia. In addition, male patients are more likely to deteriorate in swallowing function and should be carefully monitored.
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131名の機能的嚥下障害患者の「反復唾液嚥下テスト」(the Repetitive Saliva Swallowing Test: RSST)と嚥下ビデオレントゲン造影(videofluorography:VF)所見を比較し,RSSTの妥当性を検討した.RSSTはVF所見と相関が高く,カットオフ値として3回/30秒間が妥当であると思われた.誤嚥の有無の判別に関する感度と特異度は,0.98,0.66と,感度が非常に高かった.摂食・嚥下障害の診断・評価としては,まずRSSTでスクリーニングを行い,3回/30秒間未満の場合はさらに詳細な病歴,身体所見をとり,必要と判断されればVFを行い,治療方針を決定するのが適当である.
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Aspiration of oral secretions and their bacteria is increasingly being recognized as an important factor in pneumonia. We investigated whether oral care lowers the frequency of pneumonia in institutionalized older people. Survey. Eleven nursing homes in Japan. Four hundred seventeen patients randomly assigned to an oral care group or a no oral care group. Nurses or caregivers cleaned the patients' teeth by toothbrush after each meal. Swabbing with povidone iodine was additionally used in some cases. Dentists or dental hygienists provided professional care once a week. Pneumonia, febrile days, death from pneumonia, activities of daily living, and cognitive functions. During follow-up, pneumonia, febrile days, and death from pneumonia decreased significantly in patients with oral care. Oral care was beneficial in edentate and dentate patients. Activities of daily living and cognitive functions showed a tendency to improve with oral care. We suggest that oral care may be useful in preventing pneumonia in older patients in nursing homes.
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The videofluorographic swallowing study (VFSS) is the definitive test to identify aspiration and other abnormalities of swallowing. When a VFSS is not feasible, nonvideofluorographic (non-VFG) clinical assessment of swallowing is essential. We studied the accuracy of three non-VFG tests for assessing risk of aspiration: (1) the water swallowing test (3 ml of water are placed under the tongue and the patient is asked to swallow); (2) the food test (4 g of pudding are placed on the dorsum of the tongue and the patient asked to swallow); and (3) the X-ray test (static radiographs of the pharynx are taken before and after swallowing liquid barium). Sixty-three individuals with dysphagia were each evaluated with the three non-VFG tests and a VFSS; 29 patients aspirated on the VFSS. The summed scores of all three non-VFG tests had a sensitivity of 90% for predicting aspiration and specificity of 71% for predicting its absence. The summed scores of the water and food tests (without X-ray) had a sensitivity of 90% and specificity of 56%. These non-VFG tests have limitations but may be useful for assessing patients when VFSS is not feasible. They may also be useful as screening procedures to determine which dysphagia patients need a VFSS.
Article
機能的嚥下障害スクリーニング法として,「反復唾液嚥下テスト」(the Repetitive Saliva Swallowing Test: RSST)を考案した.30秒間の平均空嚥下回数は若年者(N=30)で7.4回,高齢者(N=30)で5.9回,30秒間の平均人工唾液嚥下回数は若年者で7.7回,高齢者で6.2回であった.空嚥下,人工唾液嚥下ともに高齢者は若年者より有意に嚥下回数が少なかった.一方,若年者,高齢者それぞれの空嚥下と人工唾液嚥下の嚥下回数には有意差を認めなかった.嚥下運動の確認は喉頭挙上の触診で可能であった.高齢者の積算嚥下時間(検査開始から嚥下完了時点までの時間)上限より,RSST 2回/30秒間以下が嚥下障害のスクリーニング値として設定できた.
Article
Aspiration pneumonia is associated with decreases in both swallowing and cough reflexes and is the most common cause of death in the elderly. Basal ganglia strokes might predispose these patients to develop pneumonia owing to reductions of both reflexes, resulting in frequent aspiration during sleep. An impairment of dopamine metabolism in the basal ganglia is observed in these patients and levodopa administration improves the impaired swallowing reflex. Both swallowing and cough reflexes are mediated by endogenous substance P (SP) released from vagal sensory nerves in the pharynx and upper airways. The addition of a low dose of capsaicin to liquid or food, which stimulates the release of SP, may help prevent aspiration pneumonia. Angiotensin-converting enzyme inhibitor decreases SP catabolism resulting in improvements in both reflexes. Oral care and the sitting position after meals may decrease aspiration pneumonia in the elderly.
Article
Stroke mortality in Japan has significantly declined during recent decades. To determine the cause of this decrease, we studied the trends in stroke incidence and case fatality within 28 days after stroke in a rural area in Japan. We used a population-based registry during 1977-1991 in Oyabe, a rural area in the central part of Japan. The average population aged 25 years and older numbered 32 859 persons. Changes in age-standardized stroke incidence rate were calculated and compared between the 3 periods 1977-1981, 1982-1986, and 1987-1991. The 28-day case fatality rate was evaluated and also compared between the 3 periods by onset year. The total number of strokes was 2068. The age-standardized incidence rate of all strokes decreased during the 15-year period, from 605 to 417 per 100 000 in men and from 476 to 329 per 100 000 in women. A marked decline was found during 1977-1986 but was not apparent during 1987-1991. Moreover, there was an increase in the group aged 75 years and older. The 28-day case fatality rates for all strokes improved from 18.0% to 14.2% in men and from 26.8% to 19.1% in women during the observation period. These data indicate that declines in the stroke incidence and the 28- day case fatality have been associated with a marked decrease in stroke-related mortality in Japan.
Article
We evaluated the effect of a novel rehabilitative exercise on restoration of deglutition in a group of patients with deglutitive failure caused by abnormal upper esophageal sphincter (UES) opening manifested by postswallow residue and aspiration necessitating percutaneous tube feeding. We studied a total of 27 patients by videofluoroscopy and functional assessment of swallowing scores before and after 6 weeks of a head-raising exercise program. Seven of 27 patients, assigned randomly, participated in a sham exercise before entering the tested exercise program. Eleven of 27 were randomized to the real exercise program. Although there was no change in swallow function and biomechanics after the sham exercise, following 6 weeks of real exercise, all 11 patients exhibited a significant improvement in their UES opening, anterior laryngeal excursion (P < 0.01), as well as resolution of postdeglutitive aspiration and were able to resume oral feeding. Similar results were found when the 7 patients in the sham group were crossed over to the real exercise group. Comparison of before and after exercise values for anteroposterior UES opening (P < 0.01) and laryngeal anterior excursion (P < 0.05), as well as functional outcome assessment of swallowing (P < 0.05) in the entire group of 27 patients also showed significant improvement. Etiology and duration of dysphagia did not affect the outcome. The proposed suprahyoid muscle strengthening exercise program is effective in restoring oral feeding in some patients with deglutitive failure because of abnormal UES opening.
Article
No large-scale study has ever compared the clinical and radiological features of lateral medullary infarction (LMI) and medial medullary infarction (MMI). The aim of this study was to investigate them through the use of cooperatively collected cases. Medical information on all patients from 1996 to 2000 with medullary infarction (MI) proven by brain MR images at 35 stroke centers in the Tohoku district, Japan, was collected, and their clinical and radiological features were analyzed. A total of 214 cases of MI were registered. They included 167 cases (78%) of LMI, 41 (19%) of MMI, and 6 (3%) of LMI plus MMI. The mean age of onset and the male-to-female ratio were 60.7 years and 2.7:1 in LMI and 65.0 years and 3.6:1 in MMI, respectively. The middle medulla was most frequently affected in LMI, and the upper medulla was most frequently affected in MMI. Dissection of the vertebral artery was observed in 29% of LMI and 21% of MMI. Prognosis, assessed by the Barthel Index, was favorable in both LMI and MMI. Diabetes mellitus was more frequently associated with MMI than with LMI. The present study surveyed a large number of MI cases and revealed that (1) the mean age of onset of MMI is higher than that of LMI, (2) the dissection of the vertebral artery is an important cause not only of LMI but also of MMI, and (3) diabetes mellitus is frequently associated with MMI.
Article
The purpose of this study was to evaluate the effects of functional training on outbreak frequency of pneumonia for the elderly dysphagia patients who were being tube fed. Subjects were divided into two groups; one group (n = 10) received oral care (i.e. non-training group) and the other group (n = 11) received functional training of dysphagia in addition to oral care (i.e. training group). The dental health team treated subjects once a week for 3 years (1999-2001). The frequency of pneumonia outbreaks and changes in activities of daily living scale (ADL) were evaluated for each year. It was recognised that the frequency of pneumonia in the training group decreased year by year (p < 0.05). Cognitive items in ADL improved in two subjects of the training group. No statistical differences were recognised in the non-training group. It was suggested that once-a-week functional training of dysphagia with professional oral care might be effective in preventing pneumonia for elderly people who were being tube fed.
Trends in stroke incidence and acute case fatality in a Japanese rural area. The oyabe study Heart disease and stroke statistics 2007 update
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Balloon catheter treatment methods for cricopharingeal dysphagia
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