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Dysphagia and its treatment in patients with brain injury are multifactorial. Treatment provided should address each deficit area relevant to dysphagia and should be consistent with current trends and knowledge. This article describes the subskills that compose the ability to swallow and their treatment in patients with brain injury. The available literature describing treatment and its efficacy relevant to each subskill area is reviewed. Specific areas for documenting efficacy of occupational therapy interventions are described.
The results of swallowing therapy in 28 patients with neurological disorders causing cricopharyngeal (CP) dysfunction are reported. Variables described include the type of swallowing disorder, type and degree of aspiration, and therapeutic strategies. Patients were monitored by cineradiography before, during, and after therapy. Success of therapy was defined by progress in type, ease and safety of feeding, and range of diet. As an example, a case of an unusually severe disorder of a CP opening subsequent to brainstem meningoencephalitis is described. The bedside clinical evaluation, otolaryngologic findings, and radiographic studies helped determine an individualized program of swallowing therapy. Therapy goals, direct and indirect therapeutic strategies, and the treatment outcome are presented. Ninety percent of patients with CP dysfunction improved with swallowing therapy, 65% by objective and 25% by subjective criteria. We conclude that in neurological patients with CP, dysfunction can effectively be treated with swallowing therapy and that surgical approaches to CP dysfunction should be deferred pending the outcome of conservative management.
Electromyography and biofeedback techniques are well established in the disciplines of physical medicine for the retraining of muscle groups to approximate functional performance. This report documents the application of biofeedback techniques to the treatment of swallowing dysfunction in a selected dysphagic patient.
Little objective documentation is available regarding the efficacy of therapies for oropharyngeal dysphagia. Information specifying efficacy of treatment for chronic dysphagic conditions is almost nonexistent. This report describes a direct therapy program for chronic neurogenic dysphagia resulting from brainstem stroke, and provides information on immediate and long-term clinical outcome. Changes in swallowing physiology reflect goals of therapy. Long-term follow-up shows that functional benefits are long lasting without related health complications.
Swallowing was found to be substantially improved with the prosthesis. Less aspiration, less time necessary to complete the swallow, and greater variation in food consistency tolerated were all positive results of the prosthesis. In addition, videofluoroscopic studies of tongue movements during speech revealed that tip-alveolar /t-d/ and back-velar /k-g/ productions were more normal with the prosthesis. With the prosthesis, the understandibility of /t/ and /d/ was improved 20% and that of /k/ and /g/, 33%. It is clear that compromises must be effected in prosthesis design to facilitate improvement in both speech and swallowing. A large prosthetic mass in the oral cavity can also negatively change speech resonance. These issues are being investigated, as are acoustic and perceptual studies of speech articulation. Future research should address whether a combination of maxillary and mandibular prostheses would result in better speech and swallowing function. A mandibular prosthesis could replace missing teeth and alveolar contour that might influence speech and swallowing. A mandibular prosthesis might also allow construction of a smaller maxillary glossectomy prosthesis to interact with the mandibular prosthesis.
The purpose of this study was to determine the efficacy of oral sensorimotor treatment in moderately eating-impaired children with cerebral palsy and to examine the effects of treatment on measures of growth. Six domains of feeding were examined in 35 children 4.3-13.3 years of age. Weight and skinfold measures were taken. Children were observed at lunch time, and spoon-feeding, biting, chewing, cup drinking, straw drinking, swallowing, and drooling were examined. Children underwent 20 weeks of sensorimotor treatment, 5-7 min/day, 5 days/week. Limited improvement was observed in the following eating domains: spoon-feeding, biting, and chewing, but not in drinking. Children as a group maintained the pretreatment weight-age percentile. To meet the increasing growth demands of the teenage years, oral-motor therapy may need to be combined with oral caloric supplementation.
Epiphrenic esophageal diverticula represent an unusual cause of dysphagia, pain, and weight loss. Although commonly associated with motility disorders, distal esophageal diverticula also have been associated with reflux strictures or other lesions. To determine the most appropriate diagnostic evaluation and operative approach, we reviewed the recent 15-year experience with epiphrenic esophageal diverticula at our institution. Over the study period, 18 patients were diagnosed with pulsion epiphrenic diverticula. Nine patients (50%) with symptomatic diverticula were referred for surgical management. All referred patients were evaluated with preoperative manometry, endoscopy, and contrast esophagography. Diverticulectomy was performed via posterolateral thoracotomy in all patients, combined with myotomy in the 6 patients (67%) with abnormal manometric results and in 2 patients with normal manometric results. The third patient with normal manometric results underwent simple diverticulectomy. There was no operative mortality. One complication, a small esophageal leak, was managed successfully by early reoperation. All patients were free of dysphagia at discharge. Follow-up was obtained for 17 patients (94%) ranging from 3 months to 12 years. Good to excellent results (measured by relief of symptoms, weight gain, and absence of clinical recurrence) were seen in all 9 surgical patients; 6 of 9 nonsurgical patients remained or became symptomatic. This experience demonstrates the efficacy of surgical management of symptomatic epiphrenic esophageal diverticula. Diverticulectomy combined with selective myotomy permits excellent operative results and resolution of associated symptoms.
Oropharyngeal dysphagia is usually either a secondarymanifestation of neuromuscular disease or a primary abnormality related to structural aberrations of the oropharynx. In either case, a focused history is essential in defining the malfunction and distinguishing oropharyngeal dysphagia from globus, xerostomia, or oesophageal dysphagia. The functional evaluation of the oropharyngeal swallow is best accomplished by a videofluoroscopic swallowing study which is used to assess efficacy of functional elements within the swallow: nasopharyngeal closure, UOS opening, airway protection, tongue loading, tongue pulsion and pharyngeal clearance. Both diagnosis and therapy of oropharyngeal dysphagia are based on this functional assessment.
This is a review paper examining the pathogenesis of oropharyngeal dysphagia. Pharyngeal anatomy and physiology are discussed along with a detailed description of the neuronal architecture and function of the medullary swallowing center. The oropharyngeal swallow is then examined in biomechanical terms emphasizing that the swallow is comprised of several elements (velopharyngeal closure, upper esophageal sphincter opening, closure of the laryngeal vestibule, tongue loading, tongue pulsion and pharyngeal clearance) each of which can be compromised, causing dysphagia. The key modality for evaluating patients with oropharyngeal dysphagia is the videofluoroscopic swallowing study which is analyzed according to the efficacy with which these functional elements of the swallow are accomplished. Specific therapy can then be addressed toward correcting dysfunctional elements.
In this critique of research in behavioral treatment ofdysphagia, three types of investigations are briefly reviewed: general management guides, specific behavioral treatments applied to single patients or a few patients, and dysphagia programs applied to large numbers of patients. Efficacy of treatment has been demonstrated in some of the single-case or small-group studies where specific techniques have been utilized. Unfortunately, efficacy has not been demonstrated in any of the studies where large groups of patients have been enrolled in dysphagia programs. Some of the critical factors that have been lacking in many of these studies are discussed and the need to include functional outcome measures in efficacy studies is emphasized.
Normal swallowing consists of a set of physiologicbehaviors which result in food, liquid or other substances moving safely and efficiently from the mouth to the stomach. Dysphagic patients may have difficulty with any one or more of the anatomic or physiologic components of the oral, pharyngeal or esophageal stages of the swallow. Evaluation of the dysphagic patient should identify the anatomic or physiologic abnormalities characterizing the patient's swallow and include introduction and assessment of the efficacy of treatment strategies. Treatment may involve compensatory management, such as postural changes or enhancing sensory input, or active muscle exercise with or without the introduction of food. Speech-language pathologists have taken the lead in research on normal swallow and evaluation and treatment strategies for dysphagia.
Multidisciplinary management of dysphagia ensures that the dysphagic patient receives careful, in-depth assessment and treatment/rehabilitation of their swallowing disorders, and of its underlying etiology. Members of the team usually include the speech-language pathologist (swallowing therapist), gastroenterologist, radiologist, otolaryngologist, neurologist, pulmonologist, pharmacist, dietitian, occupational therapist, and physical therapist. Depending upon the setting, a pediatrician, physical medicine physician (physiatrist) or gerontologist may also be on the team. Respiratory medicine and nursing are usually also involved, as is the feeding staff. Respect for each other's expertise and easy communication between members of the team are crucial to success. Team operations should be continuously monitored for their overall efficacy and cost effectiveness.
In all of these case reports, the patient's swallow function and the effect of therapy procedures on this function could be observed and measured from the videofluoroscopic assessment. In some cases, effects could be measured using other imaging procedures. The effects of each swallow therapy procedure can be measured by examining specific physiologic elements of the swallow. Table 3 presents the various therapy procedures and appropriate efficacy measures for each. In some cases, introduction of therapy procedures into the diagnostic evaluation can immediately enable the patient to begin eating. In other cases, evaluation of the effectiveness of the therapy procedure can validate its appropriateness for use with a patient in building the neuromuscular control necessary to return to oral intake. Not all therapy procedures can be introduced into the diagnostic setting, however, since they do not all result in immediate effects. For example, range of motion exercises for the lips, tongue, and/or jaw do not have an immediate effect, but typically show an effect after 2 to 3 wks. However, the clinician can still quantify the effects of range of motion exercises by measuring the patient's structural movement at each therapy session. When a second assessment is completed, change in range of motion of the target structure can be assessed by comparing the first and second studies. Introducing treatment techniques into the diagnostic swallowing assessment requires the clinician to read the results of the radiographic study or other imaging procedure immediately and identify the physiologic dysfunction so that appropriate therapy procedures can be selected and introduced. Because videofluoroscopy involves X-ray exposure to the patient, all possible treatment techniques cannot be attempted while in X-ray. Rather, the clinician must select those techniques believed to be most appropriate for that patient's anatomy and swallow physiology. When effective techniques are identified, the videotape of the diagnostic procedure can be used as an educational tool with the patient and his or her family, nurses, physicians, and others to educate and counsel them regarding the rationale for use of particular procedures with the patient, including introduction of particular posture, diets, etc. This type of visual evidence often improves patient and family compliance with therapy recommendations.
A case of deglutition syncope of 20 years' duration in a patient without cardiac or esophageal disease is presented. The therapeutic efficacy of beta-blockade is documented by symptomatic improvement, repeat esophageal balloon inflation and tilt-table testing. This suggests the Bezold-Jarisch reflex or sympathetic nervous system may be involved in the pathogenesis of deglutition syncope.
Over the last 10 years, the literature in the area of oropharyngeal dysphagia has focused on treatment techniques for specific medical conditions and the documentation of treatment efficacy. Increasingly, there has been multidisciplinary involvement in the study of swallowing physiology and dysphagia. Investigators have used a wide range of technologies in quantifying changes in swallowing physiology as a result of imposed therapeutic adjustments and maneuvers. Group studies and single case design investigations have attempted to address the question of treatment efficacy. This article addresses the status of clinical treatment and the future needs for research.
Increasing international recognition of the high incidence of oropharyngeal dysphagia has incited Speech and Language Therapists to establish a service for the management of this life-threatening disorder. This study evaluates the first such Irish service instigated in St. James's Hospital four years ago. Retrospective analysis of Speech and Language Therapy departmental records for a twelve month period examined incidence of referral for dysphagia, subsequent clinical and objective assessment findings and management recommendations. A referral rate of 52% emerged with a mean of 74 years. CVA was found to be the commonest etiology. Therapeutic intervention was implemented with 68% of dysphagic subjects considered suitable candidates and improvement evidenced in 78% of treated cases. These results highlight the prevalence of oropharyngeal dysphagia in a neurologically impaired Irish adult population and the efficacy of a dysphagia service in its management, while categorically stating the need for such service provision nationwide.
Data demonstrating the efficacy of behavioral methods fortreating dysphagia are in short supply. This paper defines efficacy and distinguishes it from efficiency. It highlights the attitudes, measures, decisions, and data essential to the design of clinical trials. The need for additional outcome measures and for establishing appropriate treatment intensities are emphasized.
BACKGROUND: The aim of this prospective study was to evaluate the results of laparoscopic treatment of gastroesophageal reflux using a posterior fundoplasty. STUDY DESIGN: Fifty-one patients with gastroesophageal reflux or paraesophageal hernia, or both, documented by fibroscopy, acid reflux monitoring, and manometry were evaluated. The operative technique consisted of abdominal esophagus mobilization, approximation of the crura, and construction of a 270 degree posterior gastric valve, 5 to 7 cm in height. A clinical examination was performed after two weeks, four months, one year, and two years, and fibroscopy, acid reflux monitoring, and manometry were done at four months. RESULTS: One patient required a conversion to laparotomy. One opening of the gastric valve was repaired laparoscopically. There was no perioperative death. Morbidity was limited to one case of pulmonary aspiration of gastric juice. All patients but one who were operated on laparoscopically have been clinically evaluated between four and six months after surgery. There was no dysphagia, diarrhea, or gas bloating reported after two months. Four patients without clinical symptoms refused to go through postoperative explorations. Among the 45 remaining patients, one had a reflux recurrence and another only an abnormality on acid reflux monitoring. There was no degradation of the clinical result among the 26 and 12 patients seen at one and two years, respectively. CONCLUSIONS: A 270 degree posterior fundoplasty can be performed laparoscopically without major morbidity. A short follow-up examination confirms the efficacy of the procedure and the absence of specific morbidity. If these results are confirmed, they could be an argument to broaden the indications of the antireflux procedure as compared to prolonged medical treatment.
OBJECTIVE: To compare laparoscopic (LNF) with open Nissenfundoplication (ONF) in terms of hospital charges, efficacy, and patient satisfaction. DESIGN: A prospective, nonrandomized study with a median follow-up of 370 days. SETTING: Two tertiary care university hospitals. PATIENTS: Eighty-six patients with complications of gastroesophageal reflux who had not had previous antireflux surgery were studied. Patients chose ONF or LNF following discussion with the surgeon; 12 underwent ONF and 74 underwent LNF, of whom eight required conversion to laparotomy. MAIN OUTCOME MEASURES:Hospital charges, disability, satisfaction, and side effects of fundoplication. RESULTS: Patients were demographically similar. Total charges (mean +/- SD) for LNF ($11,673 +/- $4723) were significantly less than for ONF ($18,394 +/- $17,264). Patients who underwent LNF returned to work sooner (10 +/- 3 days) than those who underwent ONF (28 +/- 1 days). Bloating, dysphagia, and recurrent heartburn occurred with equal frequency in both groups. Recurrent reflex occurred in four of 74 LNF patients and one of 12 ONF patients. Overall satisfaction scores were similar, irrespective of operative technique (LNF, 3.35 +/- 0.87; ONF, 3.50 +/- 0.94. CONCLUSIONS:Laparoscopic Nissen fundoplication is as effective as ONF in the treatment of complications of gastroesophageal reflux disease and appears to cost less and lead to faster recovery from surgery, but does not result in higher patient satisfaction than ONF. The most important factor in patient satisfaction is the abolition of preoperative symptoms rather than the type of operation.
We prospectively compared the efficacy of polyvinyl bougies (Savary type) passed over a guide wire and through-the-scope balloons for the dilation of peptic esophageal strictures in a randomized study. Thirty-four patients, 17 in each treatment arm, were studied. At entry, dysphagia was assessed according to a six-point scale (0, unable to swallow; 5, normal). The end-point for dilation was to size 45F or 15 mm. Discomfort during the procedure was graded on a four-point scale (0, no discomfort; 1, mild; 2, moderate; 3, severe discomfort). Follow-up visits were at 1 week, 1 month, 3 months, and every 3 months thereafter for 2 years. At the 1-week visit, the size of esophageal lumen was measured by 8-, 10-, and 12-mm pills. Both devices effectively relieved dysphagia. By life-table analysis, stricture recurrence during the first year of follow-up was similar in both groups, but during the second year, the risk of recurrence was significantly lower in patients whose strictures were dilated with balloons. Other advantages of balloons included the need for fewer treatment sessions to achieve the defined end-diameter for dilation (1.1 + 0.1 versus 1.7 + 0.2, p < .05), and less procedural discomfort (p < .05). The differences in luminal size after dilation, measured by the barium pill test, were not significant. Ability to pass the 12-mm pill and absence of dysphagia were correlated. Our results indicate that both devices are effective in relieving dysphagia, but balloons may have a long-term advantage.
Freed, M., Christian, M., Beytas, E., Tucker, H., Kotton, B.(1996). Electrical stimulation of the neck: A new effective treatment for dysphagia. Dysphagia, 159.
Mittal, Ravinder K. et al.: Influence of breathing pattern on the esophagogastric junction pressure and esophageal transit. Influence of breathing pattern on the esophagogastric junction pressure and esophageal transit.
Kuppersmith, R.B. (1996) A guide to otolaryngology resources on the internet. Otolaryngology - Head and Neck Surg., 115, 335-341.
Page, Megan et al. : Mechanisms of airway protection after pharyngeal fluid infusion in healthy, sleeping piglets.
Wesson, Rebecca: A Survey of Speech-Language Pathologists' Application of Structured Breath Control Technique in Clinical Practice.
1. Utley, D.S. (1996). Stop the heartburn. California, Lagado Publishing.
This 96 page soft covered book was written by an otolaryngologist and serves as a resource for patients with gastroesophageal reflux. Using lay terminology, the author describes the anatomy and physiology involved in gastroesophageal reflux as well as associated medical problems. The author also discusses various medical treatments for gastroesophageal reflux. Much of the book is devoted to lifestyle changes that the patient can implement to reduce the risk and effects of gastroesophageal reflux. Recipes for healthy meals that can reduce heartburn are included.
This book can be purchased for $9.95 + $2.00 shipping and handling. Call 415-562-3800 or send a check, money order or credit card information to:
Stop the Heartburn
Californians please add 7.75% sales tax.
2. PASTICCIO THE GOURMET PATE by Herb Rubkin
This is a soft covered spiral reference approximately 30 pages in length. This book provides recipes for people with swallowing disorders. In addition to the recipes, the author also provides caloric information for each recipe.
This book can be ordered from the Puree Kitchen Company by calling 1-800-838-8684.
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