Learning goals
・Understand the definition of indirect training
・Understand the significance of indirect training
・Know things to keep in mind when conducting indirect training
What is indirect training?
Indirect training is training that targets various organs to improve swallowing function without using food in efforts to help the patient swallow safely. We must conduct a thorough assessment and only start training once a physician or dentist's order has been obtained. Training sessions can include warm-up exercises that can be done before meals, training to improve the function of various organs or the coordination of their movement, speech training, breathing training, and the learning and practice of techniques to be used in direct training.
Eligibility for starting indirect training
- Level of consciousness and cognitive function: Can follow instructions reasonably well.
- Stable general condition: Vital signs should ideally be stable.
- Risk management: The training must be conducted in an environment with thorough risk management.
We can start indirect training if these criteria are met. Indirect training is unique in that it has a low risk of aspiration and choking because it does not use food. This means that it can be performed at any stage of rehabilitation, from the acute to the recovery and maintenance stages. However, we need to tailor the training goals and methods to the stage.
Even though patients can't aspirate food during training, they may still aspirate saliva. This is why vital signs should ideally be stable. However, if vital signs are not stable, we can still provide training with the methods shown in Slide 6.
How to conduct indirect training
After assessment, we should set achievable training goals and devise a training program for meeting those goals. We should determine the specific methods of training, as well as the load to be applied, the amount of training, the duration of training, and how tasks will be allocated across disciplines. The key to conducting training is to understand the characteristics of the various training methods and to select those methods that fit the patient's situation. After training, we need to make additional assessments to determine the effects of training and to revise the training program as necessary.
Indirect training method (1)
If the patient's general condition is stable, the approach to take addresses the following problems that directly contribute to aspiration.
1. Impaired bolus propulsion: Tongue exercises
2. Poor pharyngeal constriction: Tongue base retraction exercises, Masako maneuver
3. Inadequate opening of the upper esophageal sphincter: Shaker exercise, balloon dilatation
Once each exercise produces the desired effect, training should move to the next necessary exercise.
Indirect training method (2)
If the patient's general condition is poor or they have issues such as recurrent pneumonia, we should use the following approach.
1. Airway management exercises: Breathing and coughing exercises
2. Low-intensity exercises: Thermal tactile stimulation
Once the patient's general condition has stabilized, we can start the methods shown in the previous slide ("Indirect training methods (1)").
Things to keep in mind when conducting indirect training
Indirect training is less risky than direct training, but we must always consider the patient's level of fatigue and general condition. It is particularly important to pay attention to excessive muscle fatigue (especially in patients with progressive diseases or muscular diseases). Specifically, we need to give due consideration to the frequency, intensity, load, and duration of training.
Training also tends to get monotonous, we should also consider how to motivate patients to continue training. Make their improvements clear by showing the results of training as numbers or visual representations. Also, help patients to understand the importance of training, and always try creative ways to make training fun or interesting for them. Many patients who need training have communication disorders, so we need to clearly communicate our training instructions, using gestures or written instructions if they have difficulty understanding. Always observe patients so that changes in their condition will be detected.
Interim assessments and revision of the training plan
Perform interim assessments on a regular basis to assess the effects of training (ie, changes in function). Compare changes in outcomes such as the number of actions, duration of actions, sputum volume, and voice with data from before training. When possible, use videofluoroscopy or videoendoscopy for assessment. Training should be continued if the patient improves, and the training plan should be revised if not.
References
- Saitoh E & Mukai Y Ed.: Dysphagia Rehabilitation 2nd.ed.Tokyo: Ishiyaku, 2007
- Saitoh E & Ueda K Ed.: Dysphagia Rehabilitation 3rd.ed.Tokyo: Ishiyaku, 2016
- The Society of Japanese Clinical Dysphagia Research ed: Rehabilitation for Dysphagia - Think and Practice 2nd edition, Ishiyaku Publisher, 2008
- Shimizu M Ed.: Series of Speech Hearing Therapy 15. Dysphagia, Kenpakusha, 2004 (Japanese)
