2.Overview of Dysphagia Rehabilitation

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Explanation

We can use the Japanese term "摂食" (sesshoku) to apply to the entire eating process, from taking food into the mouth (food capture), chewing it (mastication), and transporting it to the stomach (swallowing). Swallowing consists of the swallowing reflex and subsequent esophageal peristalsis. For a clear definition, from April 2014 the Japanese Society of Dysphagia Rehabilitation decided to call the entire eating process "摂食嚥下" (sesshokuenge), rather than the more traditional Japanese expression "摂食・嚥下" (sesshoku・enge). Impairments of mastication, swallowing, or other eating capabilities (dysphagia) are termed "摂食嚥下障害" (sesshokuengeshougai) in Japanese. The term "摂食障害" (sesshokushougai) is not used, because this term is applied to eating disorders in psychological conditions such as anorexia and bulimia nervosa. Also, although the term "摂食嚥下障害" (sesshokuengeshougai) for dysphagia is sometimes simplified to "嚥下障害" (engeshougai), we must be careful using this simplified term because it does not represent an impairment of swallowing only-it also includes disorders of food capture and mastication. So, "摂食嚥下障害" (sesshokuengeshougai) and to a lesser degree "嚥下障害" (engeshougai) correspond to the term "dysphagia" in English.

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Explanation

With aging, even healthy people can experience choking when eating or drinking. However, if this doesn't interfere with daily life, dysphagia will not be diagnosed. Swallowing fluorography studies in healthy individuals have found momentary penetration of liquid food containing a contrast agent into the laryngeal vestibule in 1 in 3 people under 50 years of age and in 2 of 3 people over 50. So, we are talking about a continuum rather than a clearly defined borderline between dysphagia and normal swallowing. What is important clinically is not dividing people into 2 groups-those with and without dysphagia-but rather investigating the need for treatment based on the degree of disablement and selecting a treatment approach that matches the disablement. When patients are being classified as having or no having dysphagia in epidemiological studies, a clear definition of dysphagia should be given. Generally, the Dysphagia Severity Scale is used to distinguish dysphagia that interferes with daily living from milder dysphagia.

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Explanation

The aim of dysphagia rehabilitation is to help patients with dysphagia regain the ability to enjoy food. For patients who can't eat orally, we should consider how to make eating even just a small amount possible for them. For patients who can eat only a small amount of food orally, we should consider how to increase the amount that can be eaten. For patients who experience choking or complicating aspiration pneumonia, we should consider how to offer relief and techniques to enable them to eat orally. In every case, the process is important. The aim of treatment is not to achieve a complete cure of the dysphagia; in other words, patients are not divided into 2 groups of the cured and not cured. Another mistake is to automatically regard patients who cannot eat a full meal as disabled people incapable of eating orally. For example, we must recognize that some capacity for oral feeding remains-so a therapeutic approach should be taken-even in patients with severe dysphagia after gastrostomy. Conversely, we must not forget the risk of aspiration for patients with dysphagia. It is essential that we conduct a suitable assessment to help us decide a safe technique that allows some oral feeding, and it is the responsibility of medical professionals to avoid any risk to the patient's life as far as possible.

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Explanation

Dysphagia rehabilitation is normally started in the acute stage of underlying diseases and injuries, similar to general rehabilitation for physically handicapped patients. Starting rehabilitation as early as possible can prevent disuse syndrome and shorten the convalescent phase.

Acute phase rehabilitation includes:

  1. prevention of aspiration pneumonia through frequent oral care and by avoiding careless long-term placement of an indwelling nasogastric feeding tube;
  2. early assessments to determine whether or not oral feeding is possible and which foods can be safely eaten;
  3. indirect training to prevent dysphagia-related organ disuse;
  4. promotion of early ambulation and prevention of decline in physical endurance; and
  5. consideration of posture to prevent aspiration.
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Explanation

Dysphagia rehabilitation in the convalescent phase involves comprehensive therapy that includes the following basic elements: improving oral care and physical endurance and regulating nutritional status and water intake. Dysphagia rehabilitation has more than a single focus on direct training for oral feeding; it is a comprehensive therapy that also includes functional assessments and indirect training.

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Explanation

Some people hold the common misconception that dysphagia rehabilitation facilitates feeding with a dysphagia diet as soon as possible. In reality, dysphagia rehabilitation consists of multiple processes. Vital and indispensable elements in the dysphagia rehabilitation process are improving oral care and physical endurance and regulating nutritional status and water intake. When we start dysphagia training, it is crucial to make a detailed assessment of feeding and swallowing function, and then to select an appropriate training method and safe foods based on that evaluation. Until safety is confirmed, we apply indirect training without using food. Then, once safety is confirmed using selected foods and adjusting posture, we can start direct training using food using an appropriate dysphagia diet.

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Explanation

Smoothly conducting dysphagia rehabilitation requires the participation of professionals from many disciplines. This is called a multidisciplinary approach. The multidisciplinary team members, each from different professions, do not treat the patient independently, but instead they exchange detailed information in, for example, case conferences and provide rehabilitation in line with a common objective. In this way, a medical team approach is indispensable. A therapeutic approach that has a focus on cooperation between different professions is called an interdisciplinary approach. It's important that each health professional follows a predetermined role, but in the case of dysphagia rehabilitation, it's not easy to draw clear boundaries between the roles of all participating health professionals. So, it is crucial that different health professionals take on responsibilities in the "borderline zone". When health professionals take on these complementary roles, a more effective therapeutic approach can be followed, and this is termed the transdisciplinary approach.

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Explanation

As the first step in dysphagia rehabilitation in the convalescent phase, the physician or dentist examine the patient to ascertain all aspects of the problem and then gives directions to each health professional on each relevant aspect. The physician or dentist then carry out further tests or examinations, and the other health professionals make their own assessments. A case conference is then called to review the findings, consider the mechanism of the disablement, establish functional goals, and decide the treatment plan. Therapy then proceeds with dysphagia training, physical training, oral care, and selection of an appropriate dysphagia diet. At any point as therapy progresses, the patient can be reevaluated, and case conferences can be held again as appropriate. Guidance on activities for the patient to do at home after discharge will be then given, and this point is the goal of dysphagia rehabilitation in the convalescent phase. Although the physician or dentist generally assumes the lead role, therapy should be provided as team medicine.

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Explanation

The Japanese Society of Dysphagia Rehabilitation conducted a multicenter study examining the efficacy of dysphagia rehabilitation. Patients with cerebrovascular disease and comorbid dysphagia were divided into those who had undergone dysphagia rehabilitation (the intervention group) and those who had not (the non-intervention group), and changes after rehabilitation were compared between the 2 groups. When the Dysphagia Severity Scale (DDS; proposed by Saitoh et al.) was used for the comparison, there was a marked improvement in DDS score in the intervention group at the end of treatment relative to the start of treatment, whereas there was no significant change in the non-intervention group after 3 months of physical rehabilitation.

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Explanation

Similar findings waeres seen when the Food Intake LEVEL Scale (proposed by Fujishima et al.) was used: there was a marked improvement in the score in the intervention group at the end of treatment relative to the start of treatment, whereas there was no significant change in the non-intervention group after undergoing 3 months of physical rehabilitation. Taken together, dysphagia rehabilitation is considered to be an effective therapy for dysphagia in patients with cerebrovascular disease. The results of these studies correspond to level IIa evidence in evidence-based medicine.

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Explanation

After the convalescent phase, patients enter the maintenance phase, and feeding and swallow function are not always constant. The possibility that feeding and swallow function can be further improved is far from negligible when patients are motivated to live a fulfilling life, eat, and gain physical strength. Conversely, a risk that feeding and swallow function will deteriorate exists for patients with dehydration and malnutrition due to reduced food and water consumption, hyponatremia, loss of physical strength, large amount somnifacient drug consumption, and/or sleep deprivation. It is important in the maintenance phase that the patient's condition is examined by the family doctor and dentist, visiting nurse, dental hygienist, and/or other health professionals to provide appropriate medical guidance. Regular checks on oral care also represent key measures, alongside utilizing the long term care insurance system and guarding against any loss of physical strength or motivation to live.

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References

  1. Baba, M & Saitoh E:Diagnosis and evaluation of dysphagia (Japanese). Japanisch-Deutsche Medizinische Berichte 46: 17-25, 2001
  2. Daggett A, Logemann J, Rademaker A, Pauloski B: Laryngeal penetration during deglutition in normal subjects of various ages. Dysphagia 21(4): 270-274, 2006
  3. Tsubaraha A, Saitoh E, Fujisihima I et al:Effect of dysphagia rehabilitation (Japanese). The Japanese Journal of Dysphagia Rehabilitation 11(3): 403-405, 2007

Recommended readings

  1. Tsubahara A:Principle and practice of dysphagia (Japanese). Nagai Publisher, 2006
  2. Kaneko Y, Chino N:Dysphagia Rehabilitation (Japanese). Ishiyaku publisher, 1998
  3. Fujishima I: Clinical Text Book of Dysphagia. 2nd edition. Nagai publisher, 2005
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