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January2005 Vol.42 Issue:      1 Table of Contents
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Is Swallowing Therapeutic Techniques Effective in the Management of Neurogenic Dysphagia?

Hala A Shaheen1, Mohammad Shahin2, Waleed R ElGabry3
Departments of Neurology, Cairo University (Fayoum Branch)1, Radiology, Cairo University2, ENT, Cairo University (Fayoum Branch)3

ABSTRACT

Background and Purpose: The literature provides reasonable evidence of the plausibility of swallowing therapy as treatment for neurogenic dysphagia but evidence of efficacy is almost nonexistent1. This study aimed to assess the effect of swallowing direct, indirect and compensatory techniques as a treatment of patients with neurogenic oropharyngeal dysphagia. Patients and Methods: Thirty patients with neurogenic oropharyngeal dysphagia were prospectively  evaluated using clinical and videofluoroscopic examinations. An individualized treatment plan was designed for each patient. Follow up plan readjustment and assessment for outcome measures; were done through clinical and radiological reevaluation at 2, 4, 8 weeks interval. Results: Results showed that the number of patients had chest infection (13/30 prior to treatment) dropped to1/30 and the number of patients with aspiration dropped from 16 patients (53.3%) to 5 patients (16.7%). The number of patients fed by enteral tube dropped from (10/30 prior to treatment) to1/30 at the end of follow up. From our 30 patients with dysphagia, 17 patients (56.7%) recovered completely to normal swallowing. The swallowing grade of the remaining 13 patients (43.3%) improved. these difference pre and post treatment was highly statistically significant P was 0.000. Conclusions: Swallowing techniques reduce incidence of aspiration and chest infection. It enables patients with enteral feeding to return to the pleasure of oral feeding. It improves dietary status. It improves power of muscles involved in swallowing It eliminates or at least improves dysphagia. Data obtained indicate that swallowing techniques outcomes are promising.

(Egypt J. Neurol. Psychiat. Neurosurg., 2005, 42(1): 23-33).

 





INTRODUCTION

 

Dysphagia is a common problem in patients with neurologic disorders2. It occurs in up to half of patients after an acute stroke3. Dysphagia occurs frequently in Parkinson's disease although patients themselves may be unaware of swallowing difficulties4. Dysphagia had been reported in many patients with neuromuscular diseases, in particular, motor neuron disease and myasthenia5.

Patients with dysphagia are at risk of developing serious complications such as aspiration pneumonia, dehydration and malnutrition. These consequences of dysphagia severely affect the quality of life and result in high morbidity and mortality rates. Measures of severity indicated that even mildly dysphagic patients are at risk for the development of aspiration pneumonia, and even severely dysphagic patients responded to rehabilitative management of their swallowing problems6. Management of disordered oropharyngeal swallowing begins with careful clinical assessment of the patient's oropharyngeal anatomy and physiology and videofluoroscopic studies that is particularly useful for identifying the pathophysiology of a swallowing disorder and for testing treatment techniques7. Treatment for oropharyngeal dysphagia may take the form of compensatory strategies, direct therapy or indirect therapy. Compensatory strategies include postural changes and modification of bolus volume and consistency as well as rate of food presentation. These strategies are designed to eliminate the symptoms of the swallowing problem. Direct therapy techniques are designed to change swallow physiology and consist of swallow manoeuvres, oral sensory stimulation techniques. Indirect therapy procedures are designed to improve the neuromuscular controls necessary for the swallow without actually producing a swallow8. The type of therapy needs to be tailored to each patient depending upon many variables, including severity and mechanics of pharyngeal dysfunction9.

There is a substantial ignorance and controversy surround the management of neurogenic oropharyngeal dysphagia. The major obstacle to confident recommendations is the lack of high-level evidence supporting most available therapies. However there is reasonable evidence supporting current dietary recommendations as aspiration-minimization strategies. There is only low-level evidence, albeit consistent, to support swallow-behavior modification therapies. But to date the effects of such an approach have not been demonstrated quantitatively10.

This study was conducted to evaluate, subjectively and objectively, the therapeutic effects of swallowing therapy techniques in patients with neurogenic oropharyngeal dysphagia.

 

 

 

 


   



PATIENTS AND METHODS

 

Patients

Thirty patients suffering from neurogenic oropharyngeal dysphagia were prospectively evaluated. They recruited from neurology department and stroke unit, kasr El Aini university hospital.

All patients met the following eligibility criteria:

1.      Patients had dysphagia due to neurologic disorder

2.             Any age or sex was inclusive,

 

The exclusion criteria were:

1.      Dysphagia prior to the onset of neurologic disease,

2.      Neurologic disease duration less than 3 months to rule out spontaneous recovery as a sole explanation of amelioration,

3.      Oral or pharyngeal anomaly as suspected by history and or documented by ENT examination.

4.      Uncooperative patient [disturbed conscious level, dementia (minimental state<23), global or sensory dysphasia] to guarantee cooperation during examination and understanding of swallowing therapy techniques,

5.      Use of medications that may affect swallowing.

Methods

 

All patients under went :

1.     Detailed neurological history taking and examination

2.     Detailed ENT examination and Fiberoptic laryngoscopic examination when indicated

3.             Clinical swallowing evaluation using 11:

A)     Dysphagia questionnaire

B)     Oromotor examination (lip, tongue plate, larynx and pharynx examination)

C)     Bedside water swallow test: The patient was given 50 ml water and was asked to drink from a cup without interruption. Coughing during or for up to one minute after completion or the presence of a post swallow wet or hoarse voice quality were considered an abnormal water swallow test.

D)     Bedside observation of food swallowing: The patient was given a spoonful of yoghurt and asked to swallow it. Then the patient is given a piece of bread and the patient was asked to chew then swallow it. He was observed during and after swallowing for the presence or absence of collection of food in the vestibules of mouth, slowed oral transit, signs suggestive of aspiration.

4.     Videofluoroscopic (modified barium swallow) examination12

The examination was performed within 48 hours of the clinical examination. The videofluoroscopic examination was done with the use of a digital X-ray machine (Siregraph D2 Siemens of Germany). The video recorder and the videomonitor is a Sony model (Japan). Initially the patient was seated in the lateral position. The fluoroscopy tube was focused on the lips anteriorly, the posterior pharyngeal wall posteriorly, the palate superiorly and the 7th cervical vertebra inferiorly. Each patient was given 3 consistencies of barium sequentially. Starting with 1 teaspoonful of liquid barium. Then 1 teaspoonful of barium paste then a piece of bread with barium paste. The fluoroscopy was kept on until the bolus tail has passed into the upper esophageal sphinter. Pathophysiology of swallowing dysfunction was searched for. The severity of patient swallowing dysfunction was graded according to13 into mild, moderate and severe dysfunction.

Videofluoroscopic assessment of therapy efficiency was tested

The patient was changed to one of these postures (chin down, head rotated to weak side or lying down), or doing specific swallowing maneuvers ;as breath holding maneuver; selected on the basis of the specific swallowing abnormality causing the dysphagia or aspiration.

Plane of management including compensatory postures, changes in consistency and texture of food, direct stimulation of pharyngeal sensitivity, maneuvers and indirect therapy strengthening (exercises for oropharyngeal muscles) was adjusted for each patient according to the pathophysiology of his swallowing dysfunction.

Follow up assessment including

The clinical swallowing evaluation was done for all patient at time of presentation and was repeated after 2, 4, 8 weeks. Plane of swallowing therapy was readjusted according to improvement in patient swallowing condition at 2, 4 weeks reassessment.

After 8 week, Subjective measure of swallowing function after swallowing therapies was obtained with the patients questionnaire.

Objective data were obtained by clinical and videofluoroscopic reevaluation of swallowing.

In data collection and analysis, the following were used as outcome measures: presence of aspiration, chest infection, mode of nutrition delivery (oral, enteral), dietary adjustments (change of dietary consistencies), and use of compensatory head positioning, change in dysphagia grading.

5.     CT or MRI, EMG, NCS and appropriate laboratory tests were done according to the case.

 

Statistical analysis

Numerical data were presented as means ± SD. Categorical data were presented as frequencies and percentages. The data were compared by Pearson's chi2 test and Fisher exact test when indicated. All of the comparisons were two-sided. P<0.05 is considered significant. P<0.001 is considered highly statistically significant. Statistical analysis was carried out using SPSS version 12 software.

 

RESULTS

 

This study included 30 patients with oropharyngeal dysphagia due to neurological disorder. Their ages ranged from 3-80 years with mean age of 49.7+ 18.6 SD. They were 21 (70%) males and 9 (30%) females. Their clinical presentations are shown in table (1). 

The comparison was done between the patient condition at time of presentation and after 8 weeks of swallowing therapy (each patient serve as a control for himself).  

Comparing questionnaire pre and post treatment : The patients complains of dysphagia, the number of patients with chest infection, and those with repeated swallow attempts and coughing choking complaint dropped and this drop was highly statistically significant.  

The number of patients fed through entral route, those with complaint of chewing difficulty and slow eating decreased significantly in post treatment assessment as shown in table (2).

Comparing oromotor examination abnormalities as a whole pre and post treatment; improvement was highly statistically significant.

All parameters improved. The improvement reached significant difference in lip movement, tongue strength,  volitional cough and gag reflex. Improvement was highly statistically significant in tongue elevation and tongue slide on palate, palatal movement, palatal reflex and pharyngeal sensation as shown in table (3).

Comparing bed side swallowing observation pre and post treatment, the number of patients had abnormal water swallow test and those had abnormal food swallow test dropped markedly and this difference was highly statistically significant as shown in table(4) .

Videofluroscopic abnormalities were recorded in all patients pretreatment and in only 13 patients (43.3%) post treatment. This is difference was highly statistically significant. Improvement was observed in all parameters. This improvement reached significant difference in slow oral transit time, absent swallowing reflex and vallecular residue. The drop in number of patients had pyriform residue was highly statistically significant.

The number of aspirators dropped from16 patients (53.3%) pretreatment to 5 patients (16.7%) post treatment and this was highly statistically significant P 0.002**.

From our 30 patients with dysphagia, 17 recovered completely to normal swallowing. The swallowing grade of the remaining 13 patients improved to mild and moderate dysfunction. No patient remained with severe disorder. These differences pre and post treatment was highly statistically significant as shown in table (5).

Comparing use of Compensatory, direct and indirect techniques at the start of swallowing therapy and at end of follow up, the number of patients use diet modification, maneuvers, sensitization and exercise dropped markedly at end of follow up and this drop was highly statistically significant. The drop in number of patients using Compensatory positions was statistically significant as shown in table (6).


 

Table 1. Clinical presentation of the patients

 

Clinical picture of the patients

NO

%

Stroke

17

56.1

Brainstem

7

23.1

Bilateral hemispherical

3

9.9

Unilateral hemispherical

7

23.1

Parkinson's disease

1

3.3

Wilson disease

1

3.3

Cerebellar meningioma

1

3.3

Polyneuritis cranialis

1

3.3

Motor neuron disease

2

6.6

Polyneuropathy (CIDP)

1

3.3

Mysthenia

3

9.9

Myotonia

1

3.3

Malignant otitis externa

1

3.3

Undiagnosed

1

3.3

Total

30

100

 

 

 

 

Table 2. Questionnaire pre and post treatment.

 

Questionnaire

Pre treatment

Post treatment

P

Patients No (%)

Patients No (%)

Dysphagia

30 (100%)

8 (26.7%)

0.000**

To liquid

1 (3.3%)

2 (6.7%)

 

0.000**

To solids

11 (36.6%)

5(16.5%)

To all

18 (60%)

1 (3.3%)

Chest infection

13 (43.3%)

1 (3.3%)

0.000**

Type of feeding

 

 

 

Oral

20 (67.6%)

28 (93.4%)

 

0.03*

Nasogastic

9 (29.7%)

1 (3.3%)

Gastrostomy

1(3.3%)

1 (3.3%)

Chewing difficulty

9 (30%)

2 (6.7%)

0.04*

Collection in sulci

2 (6.7%)

2 (6.7%)

1

Slow eating

19 (63.3%)

10 (33.3%)

0.02*

Repeated swallow attempts

14 (46.7%)

3 (10%)

0.003**

Food does not go down

11 (36.7%)

4 (13.3%)

0.07

Nasal regurgitation

4 (13.3%)

2 (6.7%)

0.3

Coughing choking

(70%)21

4 (13.3%)

0.000**

 

 

 

Table 3. Oromotor examination pre and post treatment.

 

Oromotor examination

Pre treatment

Post treatment

P

Patients No (%)

Patients No (%)

Oromotor abnormalities

30(100%)

14 (46.7%)

0.000**

Reduced lip movement

5 (16.5%)

0 (0%)

0.05*

Reduced lip closure 

4 (13.3%)

0 (0%)

0.11

Reduced Tongue strength

7 (23.3%)

0 (0%)

0.01*

Inability to extend tongue forward

3 (10%)

1 (3.3%)

0.6

Inability to retract it backward

3 (10%)

1 (3.3%)

0.6

Reduced lateral tongue movement

4 (13.3%)

1 (3.3%)

0.3

Reduced tongue elevation

18 (60%)

2 (6.7%)

0.000**

Reduced tongue depression         

1 (3.3%)

0 (0%)

1

Inability to slide tongue on palatal

11 (36.7%)

1 (3.3%)

0.002**

Inability to elevate its back  

2 (6.7%)

0 (0%)

0.4

Reduced palatal movement

5 (16.7%)

0 (0%)

0.05*

Reduced palatal reflex

12 (40%)

4 (13.3%)

0.03*

Reduced volational cough

20 (66.7%)

3 (10%)

0.000**

Abnormal vocal quality

5 (16.7%)

1 (3.3%)

0.3

Reduced gag reflex

20 (66.7%)

9 (30%)

0.004**

Reduced pharyngeal sensation

14 (46.7%)

6 (20%)

0.02*

 

Table 4. Bed side clinical observation of swallowing pre and post treatment.

  

Bed Side Observation of Swallow

Pre treatment

Post treatment

P

Patients No (%)

Patients No (%)

Bed Side Water Swallow

16 (53.3%)

5 (16.5%)

0.003**

Bed side food swallowing

26 (86.7%)

9 (30%)

0.002**

Collection in lateral sulcus

3 (10%)

1 (3.3%)

0.6

Collection of food on palate

3 (10%)

0 (0%)

0.2

Collection on mouth floor

5 (16.7%)

1 (3.3%)

0.19

Slowed oral transit time

24 (80%)

10 (33.3%)

0.001**

Coughing or choking

7 (23.3%)

2 (6.7%)

0.02*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table 5. Videofluoroscopic abnormalities pre and post treatment.

 

Oral and Pharyngeal phase abnormalities

Pre treatment

Post treatment

P

Patients No (%)

Patients No (%)

can not form a bolus

4 (13.3%)

2 (6.7%)

0.6

can not hold a bolus

6 (20%)

2 (6.7%)

0.2

Hesitancy initiate swallow

1 (3.3%)

0 (0%)

1

Stasis  in lateral sulcus

1 (3.3%)

0 (0%)

1

Stasis  on mouth floor

1 (3.3%)

0 (0%)

1

Stasis on hard palate

5 (16.7%)

1 (3.3%)

0.19

Incomplete tongue to palate

3 (10%)

2 (6.7%)

1

Abnormal tongue peristalsis

1 (3.3%)

1 (3.3%)

1

Reduced lingual movement

4 (13.3%)

2 (6.7%)

0.6

Piecemeal deglutition

3 (10%)

2 (6.7%)

1

Slow oral transit time

12 (40%)

5 (16.7%)

0.04*

late swallowing reflex

4 (13.3%)

2 (6.7%)

0.6

absent swallowing reflex

6 (20%)

1 (3.3%)

0.02*

Reduced laryngeal elevation

1 (3.3%)

0 (0%)

1

vallecular  residue

13 (43.3%)

4 (13.3%)

0.01*

Pyriform residue

15 (50%)

4 (13.3%)

0.002**

Aspiration

16 (53.3%)

5 (16.7%)

0.002**

Grading of swallowing

 

 

 

Normal swallowing

0 (0%)

17 (56.7%)

 

0.002**

Mild swallowing disorder

9 (30%)

8 (26.7%)

Moderate swallowing disorder

14 (46.7%)

5 (16.7%)

Severe  swallowing disorder

7 (23.3%)

0 (0%)

 

Table 6. Management plan at the start of swallowing therapy and at the end of the follow up.

 

Management plane

treatment start

Post treatment

P

Patients No (%)

Patients No (%)

Compensatory techniques

 

 

 

Diet modification

19 (63.3%)

5 (16.7%)

0.000**

Position

11 (36.7%)

3 (10%)

0.07*

Chin down

3 (10%)

0 (0%)

Head elevation

1 (3.3%)

0 (0%)

Head turn

7 (23.3%)

3 (10%)

Direct techniques

 

 

 

Maneuvers

16 (53.3%)

3 (10%)

0.000**

Sensitization

16 (53.3%)

2 (6.7%)

0.000**

Indirect techniques

 

 

 

Exercise

21 (70%)

1 (3.3%)

 

 

0.000**

Tongue

18 (60%)

1 (3.3%)

Larynx

1 (3.3%)

0 (0%)

Tongue and larynx

2 (6.7%)

0 (0%)

 

 

 


DISCUSSION

 

Neurogenic oropharyngeal dysphagia is a prevalent problem. It causes significant morbidity that lowers quality of life and even mortality. These patients benefit from swallowing therapy performed 14. A wide variety of compensatory, direct and indirect techniques are available to therapists who must be specially trained in such methods. Swallowing therapy cannot be thought of as a series of "lessons" for a patient, but rather a management strategy that aim to improve swallowing and reduce the risk of choking, aspiration and chest infections 15.

In this study, 17 patients out of 30 patients (56.7%) recovered completely to normal swallowing. The swallowing grade of the remaining 13 patients (43.3%) improved. This was in accordance to Schindler etal 16 who reported that swallowing therapy can in many cases eliminate, and in nearly all cases, improve swallowing difficulty. But differ from Deane et al.4 who said that there is currently no high evidence to support or refute the efficacy of non pharmacological swallowing therapy for dysphagia.

In this study the number of aspirators dropped from16 patients (53.3%) pretreatment to 5 patients (16.7%) post swallowing therapy treatment. The number of patients with chest infection dropped from 13 patients (43.3%) to 1 patient (3.3%) after swallowing therapy. This was similar to Shanahan etal 17 who found that the number of patients with aspiration dropped from 55 patients to 24.

The mechanism by which swallowing therapy can prevent aspiration and reduce chest infection was postulated in various compensatory and direct techniques. For example use of the chin-down posture during swallowing has been reported to reduce the occurrence of aspiration in patients who aspirated because of delay in triggering the swallowing reflex 18. As chin down posture widens the vallecula to prevent bolus entering the airway, push epiglottis posteriorly, push tongue base backwards towards the pharyngeal wall, increases vocal fold closure by applying extrinsic pressure These changes improve airway protection19. Supraglottic maneuver is a voluntary breath hold designed to close the two vocal cords before and during swallow that improves airway protection in certain patients as those with defective laryngeal closure. The patient takes a breath, hold it before and during the swallowing and cough at the end of the swallow. This cough clears any residual around the airway entrance 20. Modification of bolus volume and consistency as well as rate of food presentation, teaspoon delivery of liquids significantly reduced aspiration compared with natural cup drinking21.  Logemann et al. 22 found a significant reduction in frequency of aspiration with the sour as compared to the non-sour boluses in neurogenic dysphagia patients. The mechanisms may be due to increased gustatory and trigeminal stimulation of acid to the brainstem23. 

Success of swallowing therapy to patients suffering from neurological disorders was defined by progress in type, ease, and safety of feeding24. This study showed that the number of patients fed through entral route (unable to take anything by mouth) dropped from 10 patients (33.3%)  pre treatment to 1 patient (3.3%) post swallowing therapy treatment. This was similar to the results obtained by Neumann et al.25 who reported that 67% of their patients who received tube feeding at admission achieved exclusive oral feeding, over a median treatment interval of 15 weeks and to Poertner and Coleman 15 whose results showed that the number of patients fed by enteral tube dropped from 50/81 (61.7%) prior to treatment to 36/81 (44.4%) upon discharge from hospital, and to Prosiegel et al.26  who reported that 55% of the patients initially dependent on tube feeding were all oral feeders after swallowing therapy. The difference in percentage of improved patients from this study could be explained by different patients selection and median treatment interval. But differ from Oppermann27 who reported that the aim, to make a complete and safe oral nutrition possible again, is not reached in every case treated with swallowing therapy. 

How swallowing therapy help to improve progress in type, ease, and safety of feeding? The mechanism was postulated in various compensatory and direct techniques. For example head rotation position not only alters the bolus pathway causes the bolus to lateralize away from the weak side, but also has a useful effect on both pharyngeal clearance and upper esophageal sphincter (UES) dynamics28. Indirect therapy such as exercises improves muscle tone, that improves voluntary function of the orofacial, lingual, and laryngeal musculature. Combined thermal and chemical modification of water consistent alters swallowing behaviour through reducing the delay in swallowing reflex29.

In this study exercise training as indirect techniques was effective, Comparing oromotor examination pre and post treatment with swallowing therapy; improvement in tongue, palate, laryngeal and pharyngeal sensation was highly statistically significant. The improvement in lip movement, lip closure, volitional cough and gag reflex was statistically significant.

Comparing use of Compensatory, direct techniques and indirect techniques pre and post treatment with swallowing therapy, the number of patients uses diet modification, maneuvers, sensitization dropped markedly at end of follow up and this drop was highly statistically significant. The drop in number of patients using Compensatory positions was statistically significant. This was similar to Pelletier et al.19 who reported their patients showed significant improvement after 2 months of swallowing therapy.


Conclusion

Data obtained indicated that swallowing techniques could effectively reduce aspiration and chest infection, enable patient to return to the pleasure of oral feeding instead of enteral feeding and change consistency of diet toward normal. It improves the power of muscles involved in swallowing. Thus oropharyngeal dysphagia rehabilitation is promising.

 

Recommendations

Large randomized controlled study is required to assess the effectiveness of swallowing therapy for dysphagia. The patients should be followed for at least 6 months to determine the duration of any improvement.

 

REEFRENCES

 

1.      Crary MA: A direct intervention program for chronic neurogenic dysphagia secondary to brainstem stroke. 105. Dysphagia. 1995 winter; 10(1):6-18.

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3.      Kedlaya D, Brandstater ME. Swallowing, nutrition, and hydration during acute stroke care. Top Stroke Rehabil. 2002 summer; 9(2):23-38.

4.      Deane KH, Whurr R, Clarke CE, Playford ED, Ben-Shlomo Y. Non-pharmacological therapies for dysphagia in Parkinson's disease. Cochrane Database Syst Rev. 2001 ;( 1):CD002816.

5.      Cumhur Ertekin, Nur Yüceyar, brahim Aydodu: Clinical and electrophysiological evaluation of dysphagia in myasthenia gravis J Neurol Neurosurg Psychiatry 1998; 65:848-856 (December)

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7.      Kasprisin AT, Clumeck H, Nino-Murcia M. Efficacy of rehabilitative management of dysphagia. Dysphagia. 1989; 4(1):48-52.

8.      Logemann JA. Approaches to management of disordered swallowing. Baillieres Clin Gastroenterol. 1991 Jun; 5(2):269-80.

9.      Ohmae Y, Ogura M, Kitahara S, Karaho T, Inouye T. Effects of head rotation on pharyngeal function during normal swallow. Ann Otol Rhinol Laryngol. 1998 Apr; 107(4):344-8.

10.    Martens L, Cameron T, Simonsen M. Effects of a multidisciplinary management program on neurologically impaired patients with dysphagia.  Dysphagia. 1990; 5(3):147-51.

11.    Oropharyngeal dysphagia in stroke patients clinical and videofluoroscopic study 2000 MD Thesis by Hala A. Shaheen supervised by Prof Dr Farouk M. Koura, Prof Dr Azza A. Helmi, Prof Dr Yahia A. Ali

12.    Logemann JA. Evaluation and treatment of swallowing disorders. San Diego: College Hill, 1983.

13.    Chen M.Y., Ott D. J., Peel V. N., Gelfand D. W. (1990): Clinical correlate of dysphagia in stroke patients. Arch. Phys. Med. Rehabil. 70:56-59

14.    Paterson WG. Dysphagia in the elderly. Can Fam Physician. 1996 May; 42:925-32.

15.    Poertner LC, Coleman RF. Swallowing therapy in adults. Otolaryngol Clin North Am. 1998 Jun; 31(3):561-79.

16.    Schindler A, Grosso E, Tiddia C, Cavalot AL, Ricca G, Ottaviani F, Schindler O. Swallowing disorders: management data. Acta Otorhinolaryngol Ital. 2003 Jun; 23(3):180-4.

17.    Shanahan TK, Logemann JA, Rademaker AW, Pauloski BR, Kahrilas PJ. Chin-down posture effect on aspiration in dysphagic patients. Arch Phys Med Rehabil. 1993 Jul; 74(7):736-9.

18.    Welch MV, Logemann JA, Rademaker AW, Kahrilas PJ Changes in pharyngeal dimensions affected by chin tuck: Arch Phys Med Rehabil. 1993 Feb; 74(2):178-81.

19.    Pelletier CA, Lawless HT: Effect of citric acid and citric acid-sucrose mixtures on swallowing in neurogenic oropharyngeal dysphagia. Dysphagia. 2003 Fall; 18(4):231-41.

20.    Hamdy S, Jilani S, Price V, Parker C, Hall N, Power M. Modulation of human swallowing behaviour by thermal and chemical stimulation in health and after brain injury. Neurogastroenterol Motil. 2003 Feb; 15(1):69-77.

21.    Bulow M, Olsson R, Ekberg O. Videomanometric analysis of supraglottic swallow, effortful swallow, and chin tuck in patients with pharyngeal dysfunction. Dysphagia. 2001 Summer; 16(3):190-5

22.    Logemann JA, Pauloski BR, Colangelo L, Lazarus C, Fujiu M, Kahrilas PJ: Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia. J Speech Hear Res. 1995 Jun; 38(3):556-63.

23.    Pelletier CA, Lawless HT. Effect of citric acid and citric acid-sucrose mixtures on swallowing in neurogenic oropharyngeal dysphagia. Dysphagia. 2003 Fall; 18(4):231-41.

24.    Neumann S. Swallowing therapy with neurologic patients: results of direct and indirect therapy methods in 66 patients suffering from neurological disorders. Dysphagia. 1993; 8(2):150-3.

25.    Neumann S, Bartolome G, Buchholz D, Prosiegel M. Swallowing therapy of neurologic patients: correlation of outcome with pretreatment variables and therapeutic methods. Dysphagia. 1995 Winter; 10(1):1-5.

26.    Prosiegel M, Heintze M, Wagner-Sonntag E, Hannig C, Wuttge-Hannig A, Yassouridis A. Deglutition disorders in neurological patients. A prospective study of diagnosis, pattern of impairment, therapy and outcome Nervenarzt. 2002 Apr; 73(4):364-70.

27.    Oppermann P. Oral and pharyngeal dysphagia There Umsch. 2004 May; 61(5):335-40.

28.    Ekberg O. Posture of the head and pharyngeal swallowing. Acta Radiol Diagn (Stockh). 1986 Nov-Dec; 27(6):691-6.

29.    Cook IJ. Treatment of Oropharyngeal Dysphagia. Curr Treat Options Gastroenterol. 2003 Aug; 6(4):273-281.


 

 

الملخص العربى

 

هل تنجح تدريبات البلع  فى علاج صعوبة البلع الفمية البلعومية

 

تعد تدريبات البلع من الطرق المنطقية فى علاج صعوبة البلع الفمية البلعومية ولكن الادلة لكفاءة هذه الطرق مازالت تحتاج لابحاث.

يهدف هذا البحث لتقييم تأثير تدريبات البلع المباشرة والغير مباشرة والتعويضية فى علاج صعوبة البلع الفمية البلعومية الناتجه عن مرض بالمخ والأعصاب.

تم دراسة ثلاثون حالة من مرضى صعوبة البلع الفمية البلعومية نتيجة أمراض الجهاز العصبى بالفحص الاكلينكي، وبجهاز تصوير الاشعة المنظورة بالفيديو ، ثم وضعت خطة علاجية لكل مريض حسب حالتة، وتم اعـادة التقييم الاكلينيكى  بعـد أسـبوعين، وبعد أربعة أسابيع لتعديل خطة العلاج حسب تقدم حالة المريض ثم اعـادة التقييم الاكلينيكى ، وبالاشعة بعـد ثمانية أسابيع لمقارنة حالة المريض قبل وبعد العلاج.

وكانت نتيجة البحث وجود فروق ذات دلالة احصائية بين عدد المرضى الذين كانوا يعانون من مرض الالتهاب الرئوى والرشف الرئوى وعدد المرضى الذين يعتمدون على الغذاء عن طريق أنبوبة من الانف للمعدة قبل و بعد العلاج.

وتحسن درجة صعوبة البلع حيث وصلت الى الحالة الطبيعية فى 17 مريض (56.7%)، والى درجة أقل فى باقى المرضى 13 مريض (43.3%) وكان الفرق ذو دلالة احصائية.

ومن هذا البحث نستنتج أن تدريبات البلع قللت نسبة الالتهاب الرئوى والرشف الرئوى ومكنت المرضى من التغذية عن طريق الفم وقضت على أو على الاقل قللت درجة صعوبة البلع. وبهذا تكون نتائج تدريبات البلع مبشرة فى مرضى صعوبة البلع الفمية البلعومية.



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