Dissertations / Theses on the topic 'Dysphagia training'

Swallowing is a complex oropharyngeal process governed by intricate neuromuscular functions. Dysfunction in swallowing, clinically termed as dysphagia, can significantly reduce the quality of life. Modified barium swallow (MBS) studies are performed to produce vidoefluoroscopy (VF) for visualizing swallowing dynamics to diagnose dysphagia. To train the clinicians learning standardized dysphagia diagnosis, 2D animated videos coupled with VF are used. However, it is hypothesised that the physiologic components of the oral domain may benefit from extension of the training materials, such as inclusion of 3D models. We develop a 3D biomechanical swallowing model of the oropharyngeal complex to extend the clinical dysphagia diagnosis training materials. Our approach incorporates realistic geometries and accurate timing of swallowing events derived from training animations that have been clinically validated. We develop rigid body models for the bony structures and finite element models (FEM) for the deformable soft structures, and drive our coupled biomechanical model kinematically with accurate timing of swallowing events. We implement an airway-skin mesh using a geometric skinning technique that unifies geometric blending for rigid body model with embedded surface for FEMs to incorporate the deformation of upper airway during a swallowing motion. We use smoothed particle hydrodynamics (SPH) technique to simulate a fluid bolus in the airway-skin mesh where the model dynamics drive the bolus to emulate bolus transport during a swallowing motion. We validate this model in two phases. Firstly, we compare the simulated bolus movement with input data and match the swallowing kinematics identified in the standardized animations. Secondly, we extend existing training material for standardized dysphagia diagnosis with our 3D model. To test the usefulness of the extended training set using 3D visualizations, we conduct a pilot user study involving Speech Language Pathologists. The pilot data indicate that clinicians believe the additional 3D views are useful for identifying the salient features for differentiating between different swallowing impairments, such as direction, strength and timing of the tongue motion, and could be a useful addition to the current standardized MBSImP™© training system.
Applied Science, Faculty of
Graduate

The primary aim of this pilot study was to evaluate the effects of a novel dysphagia rehabilitation approach: skill training on swallowing in individuals who have dysphagia secondary to Parkinson’s disease. The secondary objective was to assess skill retention following treatment termination. This within-subject study involved 10 patients with Parkinson’s disease who met the inclusionary criteria. All participants underwent two baseline data collection sessions, conducted two weeks apart. Data collected included the water swallow test, Test of Mastication and Swallowing Solids (TOMASS), ultrasound measurement of hyoid movement and cross-sectional area of submental muscles, surface electromyography (sEMG) of submental muscles, and swallowing-related quality of life questionnaire (SWAL-QOL). Patients then underwent 10 sessions over two weeks of skill training therapy using custom-designed sEMG software. The focus of the treatment was producing swallowing tasks with defined and adjustable temporal and amplitude precision. The skill training treatment phase was followed by an immediate post-intervention assessment session and two weeks later by a retention assessment session. All outcome measures were administered at each data collection point. The study consisted of a total of 14 laboratory sessions, conducted over a six-week period per subject. Results revealed significant improvements in swallowing efficiency for liquids, reduced durational parameters on sEMG, such as pre-motor time (PMT), pre-swallow time (PST), and duration of submental muscle contraction. There was a functional carry-over effect seen from dry swallows, which were the focus of training, to water swallows, which were not directly trained. Additionally, improvements in swallowing-related quality of life were demonstrated. In conclusion, the skill training approach evaluated in this research is able to produce functional, biomechanical, and swallowing-related quality of life improvements in patients with Parkinson’s disease. This indicates the potential effectiveness of this novel approach for dysphagia rehabilitation in this population. However, replication with a larger number of patients with Parkinson’s disease is needed before findings can be generalised to the larger population

The purpose of this study was to determine the amount, type, and content of training acquired by SLPs presently working in dysphagia management, as well as their level of involvement. A questionnaire was sent to 97 Oregon SLPs. Of these, 77 (80%) responded, and 52 met criteria. The resulting data indicated that SLPs involved with dysphagia work in a variety of settings, including hospitals, nursing homes, home health agencies, and private practice. Seventy-two percent of the subjects have been involved with dysphagia management for less than 10 years; 79% treated between 1 and 10 patients for dysphagia the month prior to filling out the questionnaire; and 81% have provided other staff in their settings with in-service on dysphagia.

Aims

The aims of the thesis were to validate investigation instruments for stroke patients with dysphagia, and to improve oropharyngeal dysphagia therapies.

Methods/Results

A Lip Force Meter, LF 100, affirmed excellent intra- and inter-reliability, sensitivity and specificity. Controls had significantly stronger lip force (LF) and swallowing capacity (SC) than stroke patients. A normal lower limit of LF was set to 15 Newton. Dysphagia symptoms improved in 7 stroke patients after a 5-week sensorimotor stimulation therapy comprising manual body and facial regulation in combination with palatal plate application. Impaired LF and impaired SC were parallel phenomena in 22 acute stroke patients and did not differ regardless of presence or absence of facial palsy. LF and SC improved and were parallel phenomena in 30 stroke patients and did not differ regardless of presence or absence of facial palsy, time lag between stroke attack and start of treatment, or age. SC was normalized in 19 of 30 dysphagia patients after a 5-8-week daily lip muscle self-training with an oral screen.

Conclusions

LF100 is an appropriate and reliable instrument for measuring lip force. Dysphagia improvement, by body and facial sensorimotor stimulation in combination with palatal plate application, or by training with an oral screen is excellent examples of brain plasticity and cortical reorganisation. . Swallowing capacity and lip force in stroke patients are parallel phenomena. A sub clinical facial paresis seems to be present in most stroke patients. Training with an oral screen can improve LF and SC in stroke patients with oropharyngeal dysphagia.

The use of neuromuscular electrical stimulation (NMES) for the treatment of swallowing disorders has become increasingly popular, yet little is known about its long-term effects on muscle physiology. This study indirectly assessed suprahyoid muscle physiology using electromyography (EMG) during a jaw-opening task that was completed before training, immediately after training, and two-weeks after training. Comparisons were made in muscle performance between control participants who engaged in effortful swallowing training and participants who received conjunctive NMES during effortful swallow training. All participants completed four weeks of swallowing exercises conducted five days a week (20 sessions) and consisting of 120 swallows each session. Results revealed that participants collectively improved their peak force production following training, but peak force and EMG median frequency did not vary as a function of training method. The observed high variability in median frequency between trials in addition to the documented improvement in function without a measured change in physiology suggests the need to consider alternate electrode placements during EMG or other tools of assessment. These findings suggests that both effortful swallow training and long-term conjunctive NMES with effortful swallowing improves jaw-opening strength of healthy adults, though adding NMES to the treatment was no more effective than training without it. Further research is necessary to determine the effects of long-term NMES training on swallowing physiology in vivo using other indirect measurements, or direct measurements such as muscle biopsy if possible.

Swallowing is a complex sensorimotor behaviour that includes precisely-timed bilateral activation and relaxation of muscles of the face, lips, tongue, cheeks, palate, larynx, pharynx and oesophagus. These events of activation and inhibition are controlled by many structures of the brain and are executed by cranial nerves that carry motor and sensory information to and from the swallowing muscles. Swallowing disorders are common sequelae of many neurological and structural disorders, including stroke, Parkinson’s disease, and head and neck cancer. Changes to swallowing physiology are also prevalent in older individuals, but these changes do not necessarily translate to dysphagia. Decreased muscle strength, changes to motor unit properties, and hypotrophic changes in skeletal muscles can result in age-related changes in swallowing physiology. In addition to muscular changes, neural changes might also change swallowing function in older subjects. The motor-learning literature presents a clear distinction between the differential applications and effects of skill- and strength-training approaches for rehabilitation of limb movement. In contrast to limb-movement rehabilitation, swallowing rehabilitation approaches consist mainly of strength training, although the pathophysiological basis for dysphagia is not always weakness. Therefore, this Phase I clinical-trial critically evaluated a unique swallowing skill training protocol in which the goal of intervention is to increase precision of motor control during swallowing. A Phase I clinical-trial was necessary to identify the appropriate protocol for inducing neurophysiological, biomechanical, and structural adaptations, to estimate effect sizes, and to identify adverse effects. The first and primary question addressed in this thesis was whether swallowing skill training would produce greater physiological effects in healthy subjects than a traditional swallowing strength training approach. In order to answer this question, three levels of assessment were included. Neurophysiological assessment consisted of delivering single-pulse transcranial magnetic stimulation (TMS) over the M1 area that sends efferent projections to the submental muscle group during a functional task of volitional saliva swallowing, and during a non-functional task of submental muscle group contraction. Biomechanical assessments consisted of pharyngeal and upper esophageal sphincter (UES) pressure measurements using pharyngeal manometry during effortful and non-effortful swallowing tasks, submental muscle activation measurements using surface electromyography (sEMG) during effortful and non-effortful swallowing tasks, and hyoid displacement using ultrasonography. Structural assessment consisted of measuring the cross sectional area of the submental muscle group. Finally, motor performance during training, and subjective ratings of the training protocols were assessed. Two skill training protocols were developed to assess the use of immediate versus delayed visual feedback in swallowing skill training. In addition, a pilot study aimed at examining the effects of increased dosage of training sessions was conducted. Forty healthy subjects (20 young, and 20 old; 20 females and 20 males) were allocated to skill and strength training groups in a counterbalanced manner. Strength training consisted of execution of the effortful swallowing technique targeting increased demand for strength. Skill training targeted precise timing and force execution during swallowing execution. Several motor-learning principles were considered in devising the training protocols, including the principles of task specificity and high intensity of training. Biofeedback was included to promote motor learning. Since the submental muscle group plays an important role in hyolaryngeal excursion, the current study utilized submental sEMG biofeedback using custom-made training software. The training protocols consisted of 1000 repetition of swallowing over a 2-week period. Subjects trained for an hour, five days a week, for 2 weeks (i.e., 10 training sessions). The extended dosage protocol included 10 subjects and comprised an additional eight sessions. The results indicated that there was a significant difference in submental activation following training, with strength training having an increase in sEMG peak amplitude in comparison to skill training. There were no other differences between groups at the 5% error level. Patterns of change were revealed when marginally significant results (0.05 < p ≤ 0.10) were investigated as well. Strength training resulted in a trend towards increased neural drive for volitional effortful-type tasks (i.e., effortful saliva swallowing, effortful water swallowing, and submental muscle contraction) as indicated by increased MEP magnitude (p = 0.07) which was consistent with significantly increased peak amplitude of submental activity measures (p < 0.001). This finding supports the task specificity principle of motor learning. Skill training resulted in no changes in MEP magnitude. There was a trend (p = 0.06) towards increased submental muscles activity during functional swallowing tasks (i.e., non-effortful swallowing) in young subjects,. Males in skill training had decreased duration of UES opening in 10 mL water effortful swallowing task (p = 0.02), a trend towards increased UES pressure in non-effortful saliva swallowing task (p = 0.07), and reduced hyoid displacement following training (p < 0.001). Changes in pharyngeal pressures were detected for skill training with delayed visual feedback that resulted in decreased pressure at mid-pharynx in effortful and non-effortful tasks (p < 0.05). No difference in submental CSA changes was detected in either training group. Both groups improved motor performance measured by data collected during the session (target hit-rate and muscle activity). The results of the pilot study that examined the effects of an extended dosage of training were difficult to interpret due to the small sample size. However, there were significant and marginally significant effects of skill training on mid-pharyngeal and UES pressure duration events. Dysphagia is common in patients with Parkinson’s disease, but no specific training programme exists for these patients, leading to the second question addressed through this research. Since movement planning is compromised due to dysfunction of the basal ganglia, providing external information for planning and executing swallowing was hypothesized to alleviate dysphagic symptoms. Ten subjects were recruited. Swallowing skill training with immediate feedback was administered for one hour every day, five days a week, for 2 weeks, similar to the training dosage and frequency in the healthy group. Biomechanical and structural changes were assessed. Swallowing skill training with immediate feedback led to an increase in submental activity in effortful swallowing tasks but not non-effortful tasks. In addition, it was found that individuals with dysphagia secondary to Parkinson’s disease have deceased submental muscle reserve relative to healthy subjects. Preliminary analysis of MEP data led to exploration of submental MEP measures between younger and older subjects. This ‘discovery’ research shed light on the third topic addressed in this thesis. There are contradicting results in the literature regarding age-related brain activity during swallowing. Since submental MEPs were included as an outcome measure in the main study, it was important to evaluate them at baseline in order to understand and interpret changes in this measure. Unlike other measures, such as pharyngeal pressure and hyoid displacement that have been documented in the literature to change with age, no similar study has been conducted to assess for differences in swallowing-related MEPs. Baseline data from the main study were analysed. Older subjects produced larger MEP magnitude in comparison to young in volitional saliva swallowing and volitional submental contraction. This finding raised some questions regarding the use of MEPs as an outcome measure, since it is not clear what constitutes a ‘positive’ change. This study documented, for the first time, the application of skill training in swallowing in a healthy and dysphagic population. Positive effects of treatment were found in the dysphagic group; an indication of negative effects was identified in the healthy group. In addition, this is the first study to compare skill to strength training in swallowing. The only significant difference between the two was significantly greater submental activation in effortful swallowing tasks following strength training in comparison to skill training; although there were some significant interactions between age and training type and gender and training type. This project represents the first Phase I clinical-trial of an innovative approach for addressing swallowing impairments. Achieving the ultimate aim of finding the most appropriate training protocol for treating individuals with a specific pathophysiological basis of dysphagia, requires the implementation of a long-term on-going research programme characterized by a staged process. This research programme sets an initial reference framework from which further projects can estimate the sample size required to answer specific questions, control for effects of age and gender and their interaction with training, increase precision in choosing assessment tools, and test new specific questions.

Eating problems and nutritional status were studied in a consecutive series of 104 stroke patients admitted to emergency hospital care. During their stay in hospital eating problems were observed in 46 patients. Certain common types of eating problems were identified: aberrant eating behaviour as regards chewing,lokalization or swallowing, eating small amounts, hoarding of food in the mouth, leakage of food from the mouth and unawareness of eating problems. Poor nutritional status occurred in 16 % of the patients on admission and in 22 % on discharge from the stroke unit. A subgroup of 32 patients hospitalized for 21 days or longer was studied for three weeks. On at least one occasion during these three weeks a poor nutritional status was observed in 18 patients, of whom 17 had eating problems. All subjects who had eating problems during their hospital stay, plus those patients without eating problems but with neurological deficits and those living in a nursing home one year after the stroke (n=36) were selected for a longitudinal study 18 months after the onset of stroke. Eating problems were identified in 23 of these patients during their hospital stay while 21 had such problems when they were followed up. Two patients who could not eat due to severe dysphagia (after a stroke) for three years and 18 months respectively, were successfully trained to eat normally. One patient exhibited impaired oral and hypopharyngeal function and the other impaired hypo- pharyngeal function and a spastic crico-pharyngeal muscle. In both patients training in swallowing was the main remedical measure and one of them also had a myotomy of the spastic muscle.

[2] s., s. 1-45: sammanfattning, s. 49-130: Härtill 6 uppsatser

digitalisering@umu

碩士
國立臺北護理健康大學
聽語障礙科學研究所
102
Swallow maneuver is a common technique in traditional dysphagia rehabilitation. It can facilitate the neuromuscular recovery directly and thus regain the normal pharyngeal swallowing mechanism in dysphagia individuals. However, the training effect of swallow maneuver in dysphagia rehabilitation is unsatisfactory since the dysphagic patients might have difficult in performing the expected pharyngeal muscle contraction due to impaired pharyngeal sensation or inadequate learning ability. Previous researches depicted that biofeedback can assist the stroke patients to identify the internal covert physiologic activities of swallowing when applied in swallowing maneuver. This study attempted to recognize the influence of laryngeal elevation exercise, including effortful swallow and Mendelsohn’s maneuver, combined with innovated game-based swallowing biofeedback on swallow physiology, swallow function, and life quality in the stroke dysphagic patients. Twenty stroke patients with dysphagia were randomized into the study group (n=10) and control group (n=10). There were no differences in age, onset time, lesion sites and swallow function between the two groups. Every participant underwent 16 sessions treatment in which one hour for each session and two to three sessions per week. Every section included thirty-minute traditional swallowing treatment and thirty-minute laryngeal elevation exercise. The participants in study group received game-based swallowing biofeedback during the laryngeal elevation exercise. Submental ultrasonography, Functional Oral Intake Scale, and SWAL-QOL were measured before and after 16 sections’ treatment. There was significant improvement in swallow function of both groups after treatment. The study group had greatly significant improvements in the hyoid bone displacement distance, the score of Functional Oral Intake Scale, and actual diet intake in SWAL-QOL than those of control group. The nasogastric tube removal rate of the study group (80%) was higher than the control group (20%). In conclusion, both laryngeal elevation exercise and laryngeal elevation exercise combined with game-based biofeedback group improved the the swallowing function in stroke patients with dysphagia. Moreover, the laryngeal elevation exercise combined with game-based swallowing biofeedback had better effect in swallow function, hyoid bone displacement distance, and SWAL-QOL of the stroke patients with dysphagia than those of laryngeal elevation exercise only.

博士
國立陽明大學
護理學系
101
Background and Importance: Dysphagia is a commonly seen symptom in patients who have an impaired cranial nerve, a degenerative disease, or senility. Dysphagia is often occurs as a result of stroke. Nearly half of stroke patients recover their swallowing function within seven days after the stroke; however, 11 to 13% continue to suffer from dysphagia after six months. Dysphagia problems that persist in stroke patients may include inability to swallow, choking and coughing, and delayed swallowing reflex, among others. The ideal rehabilitation period for treating dysphagia is within six months of the stroke. Aims: To explore if either increased thermal stimulation or the supraglottic swallow maneuver, in addition to exercise training, results in improved swallowing function in dysphagia patients over exercise training alon. Methods: A total of 52 subjects completed training. Stroke patients with dysphagia from the neurology clinic and wards in two local and regional medical institutions in northern Taiwan were recruited as the participant sample for this study. A repeated measure experimental design was adopted and each of the different swallowing training programs was executed five times a week for eight weeks, meaning that each subject underwent swallowing training forty times. Both the experimental and control groups began with swallowing exercise training as the training base. An increase in thermal stimulation was added for experimental group 1, while experimental group 2 added the supraglottic swallow maneuver. Then, pre-test, mid-test, post-test, and follow-up test data for the subjects were collected for comparative analysis. The subjects were randomly chosen on a weekly basis from the neurology clinic and wards and then divided into the three groups. Research tools that were used included the National Institutes of Health Stroke Scale (NIHSS), the Short Portable Mental Status Questionnaire (SPMSQ), a swallowing checkup questionnaire, a 90-ml water swallowing test, a peripheral arterial blood oxygen saturation analysis, laryngeal electromyography, spirometry (to measure peak expiratory flow rate, (PEFR)), the swallowing training programs, and a self-assessment of the swallowing training programs. Results: The generalized estimating equation (GEE) model was used to test the effects of the swallowing training. No statistical differences were found with regard to the main effects among the groups. The frequency of choking and coughing, daily record of choking and coughing, swallowing speed, residual water after swallowing, dysphagia scores, and other terms tested at different times did reach statistical differences with increased training time. In terms of interaction effect analysis for training time and group, an interaction effect was found in the choking and coughing indicator in the inter-test and post-test for experimental group 1 (ß=1.865，p=0.026；ß=1.792，p=0.048); swallowing speed in experiment group 1 had an interaction effect in the 1M and 3M post-tests (ß=-2.348, p=0.017; ß=-2.221, p=0.048); and the time span between the maximum value of laryngeal surface electromyography (S-EMG) in experimental group 1 (ß=0.213, p=0.012) and (ß=0.126, p=0.040) in experimental group 2 also saw an interaction effect. In terms of the basic properties of stroke, pathological data analysis indicated that the amount of residual water after swallowing had an interaction effect on the National Institutes of Health Stroke Scale (NIHSS) scores of experimental group 2 (ß=3.813, p=0.000). The maximum value of laryngeal surface electromyography (S-EMG) and the stroke type in experimental group 1 saw an interaction effect as well (cerebral embolism ß=-0.332, p=0.016; cerebral thrombosis ß=-0.367, p=0.010). In addition, the peripheral arterial blood oxygen concentration and the stroke type of experimental group 2 had an interaction effect (experimental group 2: thrombosis ß=-3.311, p=0.045). Lastly, peripheral arterial blood oxygen concentrations and the National Institutes of Health Stroke Scale (NIHSS) scores for stroke severity also had an interaction effect (ß=0.875, p=0.015). Self-assessments of the swallowing training programs indicated that 49 patients (94.2%) said their dysphagia had been relieved. Discussion and Conclusion: The results showed that neither increased thermal stimulation or the supraglottic swallow maneuver led to significant additional improvements in swallowing function, indicating that swallowing exercise-based training alone is sufficient for improving swallowing disorders. Thus, it is suggested that future clinical care can choose swallowing exercise training as the main method of intervention. This can improve the neuromuscular dysfunction of dysphagia caused by impaired cranial nerves to achieve optimal recovery, providing a means to enhance the effects of swallowing nursing programs offered to patients with dysphagia. It is advised that future research efforts should include more medical institutions from which to select patients to increase the number of samples. Also, to reduce any possible deviations, a third party can be added to the swallowing training program to help collect subjective data after a week of training. Furthermore, swallowing training programs should cover swallowing exercise-based training, along with self-practice manuals and multimedia teaching methods, to assist patients in practicing swallowing movements to speed the recovery of swallowing function.

The primary objective of the current study was to attempt to establish whether there is a need for a dysphagia training programme for nurses and speech-language therapists working with acute tracheostomised patients in critical care units in South Africa. The research design that was adopted for this project was within a mixed methods approach framework. An exploratory descriptive survey design using semi-structured face-to-face interviews was used. The final sample consisted of interviews with 20 speech-language therapists from eight different hospitals with critical care facilities and 12 nurses from four different hospitals with such facilities. Data from the close ended questions were analysed using descriptive statistics, while remaining data from open ended questions were thematically analysed and the constant comparison method was applied. The data demonstrated that all speech-language therapists and 10 out of the 12 nurses were in agreement that there was a need for a dysphagia training programme for nurses in critical care for tracheostomised patients presenting with dysphagia. An important and unexpected result of this study was that speech-language therapists themselves required additional training in this area. The data demonstrated that the majority of speech-language therapists and nurses were of the view that they had received minimal theoretical and practical hours on tracheostomy screening, assessment and management at an undergraduate level. Overall, the results of the current study suggested varied practices in the screening, assessment and management of tracheostomy and dysphagia, particularly with regard to blue dye testing, suctioning protocols and cuff inflation and deflation protocols. The research significance and implications of the study included the need to improve undergraduate training for speech-language therapists and nurses in the area of dysphagia and tracheostomy, to alert professional training bodies regarding institution of additional licensing and qualifications for speech-language therapists and nurses in the area of dysphagia and tracheostomy, and to thereby improve the situation of clinicians practising in dysphagia and tracheostomy management through the development of guidelines, protocols and position papers. An important implication of this research is that it established the need for a dysphagia training programme for both speech-language therapists and nurses in critical care in dysphagia and tracheostomy, and thereby monitoring the efficacy of this programme and measuring/monitoring the outcomes of multidisciplinary teamwork in the assessment and management of dysphagia and tracheostomy in critical care.