Explanation
Breathing exercises and neck and trunk exercises are part of indirect training of dysphagia. Respiratory function and neck and trunk function are indirectly but highly involved in eating and swallowing, so impairment of these functions also markedly affects eating and swallowing. We must pay attention to these functions as well as the oral and pharyngeal functions, and provide interventions towards these functions on eating and swallowing. In this module, we look at the significance of breathing exercises and neck and trunk exercises and how to perform interventions used in practice.
Explanation
Patients with dysphagia can also have problems with the respiratory function, such as impaired breathing-swallowing coordination or reduced respiratory reserve due to reduced coughing ability. Breathing exercises are interventions designed to address these problems. They primarily reduce respiratory rate and increase tidal volume (deep and deliberate breathing pattern) while changing or adjusting what area of the body is most utilized in breathing movements (eg, abdominal vs thoracic breathing).
The neck and trunk play important roles in eating and swallowing. Impairment of motor function in these areas (eg, restricted range of motion, muscular dysfunction, or instability) markedly impairs the ability to eat and swallow smoothly. Neck and trunk exercises are intended to address restricted range of motion, muscular dysfunction (eg, muscle weakness, abnormal muscle tone, or coordination disorder), or instability in the neck and trunk.
Explanation
Patients with dysphagia sometimes have concurrent respiratory dysfunction characterized by reduced coughing ability. Compared with healthy elderly adults, patients with dysphagia have significantly reduced ability to produce a voluntary cough and significantly less productive coughing (sputum clearance). Consequently, they have been found to have significantly higher rates of airway secretion retention. Patients with a history of aspiration pneumonia or current cerebrovascular disease have also been shown to have a weakened cough reflex. Disuse-related decline in respiratory function can also occur with reduced ADL.
There are no findings from respiratory function evaluation specific to patients with dysphagia, but patients must be screened for whether they can inhale deeply, exhale forcefully, and cough voluntarily (ie, clear their throat).
Explanation
Common breathing exercises for dysphagia consist of pursed lip exhalation, diaphragmatic/deep breathing, and coughing. Let's look at each in turn.
Explanation
Breathing exercises are considered to be indicated for most patients with dysphagia, but they are particularly well suited for patients with impaired breathing-swallowing coordination, reduced coughing function, and hypertonia of muscle groups in the neck and trunk. They are not indicated for patients whose condition is too severe to regulate their breathing, or patients with concurrent ataxic respiration. A general rule when instructing patients in breathing exercises is to first ensure they breathe deeply and deliberately. This is done to improve the efficiency of ventilation by reducing dead space ventilation (ventilation that does not contribute to gas exchange). Next, they should assume a relaxed posture to improve postural tone and help use the breathing muscles, inhale softly to prevent saliva retained in the pharynx from entering with the inhaled breath, and carefully exhale with confidence (maximum expiratory volume) to proportionally increase the inspiratory volume in the next breath.
Explanation
Pursed lip exhalation involves inhaling through the nose and then slowly exhaling through a narrow opening in the pursed lips. It is useful for relaxation and increasing expiratory volume. The ratio of inhalation to exhalation is set at 1:2 or 1:3, and each session lasts about 5 min. This breathing exercise is indicated for almost all patients with dysphagia. It is particularly suitable for patients with velopharyngeal insufficiency, lip incompetence, or bulbar palsy.
Explanation
The effects of pursed lip exhalation have been investigated in large numbers of patients with chronic respiratory disease. It has been found to reduce airway obstruction during exhalation and improve ventilation efficiency (increase tidal volume and decrease respiratory rate and minute ventilation). In patients with dysphagia, it has been found to improve muscle strength in the soft palate, velopharyngeal closure and lip closure, and breathing control.
Explanation
Diaphragmatic breathing (also called abdominal breathing) is a type of breathing that amplifies movement of the diaphragm during inhalation and emphasizes the resulting expansion of the abdomen. Deep breathing does not emphasize breathing movements in any particular area of the body but instead emphasizes full exhalation and slow and deep inhalation. Many patients have difficulty with diaphragmatic breathing, and deep breathing is substituted for such patients. These exercises are indicated for promoting relaxation, expectoration, and coughing, but it's important to practice them regularly as well. As with pursed lip exhalation, each session lasts about 5 min. These exercises are not indicated for patients with severe respiratory disorder or ataxic respiration because they are not feasible in such patients.
To perform diaphragmatic breathing, first ask patients to lay in a supine position and place their dominant hand on their abdomen and their non-dominant hand on their chest. Then place your own hand over theirs to lightly compress the abdomen in synchrony with exhalation and release the pressure during inhalation. We are aiming at making the abdominal movements grow significantly larger while helping patients to pay attention to abdominal expansion.
Explanation
The effects of both diaphragmatic breathing and deep breathing in patients with chronic respiratory disease are well documented in the literature. Their main effects include improving ventilation efficiency (increasing tidal volume and decreasing respiratory rate and minute ventilation) and changing what areas move during breathing (suppressing activity of the accessory respiratory muscles and increasing movement of the diaphragm). However, their effects have not been sufficiently investigated in patients with dysphagia.
Shows closure and opening of the glottis and laryngeal vestibule
Explanation
Coughing occurs through a process composed of (1) deep inhalation, (2) closure of the glottis, (3) increased intrathoracic pressure, and (4) opening of the glottis (see the video shown on the slide). Normally, coughing is a protective reflex that expels foreign bodies or sputum that has entered the airway. However, as discussed earlier in this module, patients with dysphagia often have impaired coughing function and need to cough consciously (ie, voluntarily). It is particularly critical for them to produce an effective cough to expel aspirated material. It is important for patients to maintain awareness of how to cough through regular clearing of the throat during or after eating practice.
Explanation
Neck and trunk exercises for dysphagia consist of exercises to adjust the muscle tone of the neck and trunk (relaxation), improve laryngeal movement, improve mobility and muscle function in the neck, and improve stability of the trunk (including ability to maintain a sitting position). Let's look at each of these in detail.
Explanation
It is important to evaluate the motor function in the head and neck, with particular focus on laryngeal movement. Yoshida et al. developed indices for relative laryngeal position and suprahyoid muscle function as factors influencing laryngeal movement during swallowing that can be easily evaluated externally. To determine relative laryngeal position, place patients in the supine position with maximum neck flexion and use a tape measure to measure the distance between the chin (genio: G) and the superior end of the thyroid cartilage (thyroid: T) (GT) and the distance from the superior tip of the thyroid cartilage and the superior end of the sternum (sternum: S) (TS). To determine suprahyoid muscle function, evaluate muscle strength using the 4-point scale shown here.
Explanation
Smooth swallowing movements are impaired when the neck and trunk muscle tone increases to maintain a sitting position during eating. To facilitate eating and swallowing movements, patients need to reduce muscle tone by relaxing their neck and trunk muscle groups. Relaxation is achieved by deliberate and gentle breathing or passive/active exercise of the neck and shoulder girdle. These exercises should be included in regular exercises to improve sitting posture and also as a warm-up for training with food.
Explanation
Laryngeal elevation is a particularly important swallowing movement. The suprahyoid muscles are the agonists in this movement, and they also work together to open the esophageal orifice. Impaired laryngeal movement is often associated with limited neck mobility due to bedrest or old age. So, interventions to improve laryngeal mobility need to be combined with methods aimed at improving motor function in the neck. Laryngeal mobility is improved by methods such as mobilization of the hyoid bone and larynx through joint play exercises that involve manipulation and stretching of the suprahyoid muscles by neck extension with the hyoid bone manually held in place. The head raising exercise is one method of strengthening the suprahyoid muscles, but it can rarely be used as was intended in the original article, due to the stress it puts on the neck. It can be substituted with maintaining the head in the raised position or applying resistance against lowering of the mandible while passively supporting the head.
Explanation
Limited neck mobility, particularly limited anteflexion, greatly restricts swallowing movements. Patients likely to be lying in bed for a long period of time due to needing acute or general care, as well as elderly patients who have limited spinal mobility, require interventions to improve neck mobility and neck muscle function. These should include correcting poor asymmetrical posture while the patient is lying in bed, selecting an appropriate pillow and adjusting alignment to avoid overextension of the neck, massaging the neck muscles, stretching the suboccipital muscles by passive extension and anteflexion of the head, and performing passive range of motion exercises involving anteflexion, lateral flexion, and rotation while holding the head.
Explanation
Trunk stability is an important factor in stable eating posture. Other important targets are alignment of the neck and trunk, bilateral symmetry, positioning to reduce postural muscle tone (techniques to support a good sitting posture), mobility of the trunk, activation and strengthening of the trunk muscles, and tolerance towards sitting up.
Explanation
In summary, breathing exercises are indicated for patients with impaired breathing-swallowing coordination, reduced coughing function, and hypertonia of muscle groups in the neck and trunk. They play a supportive role in safe eating training because they help with expelling aspirated material and clearing retained airway secretions.
Neck and trunk exercises also improve the effectiveness of eating training by (1) facilitating, adjusting, and strengthening swallowing movements by improving the function of muscles involved in swallowing, and (2) reducing and eliminating factors that impede swallowing movements by adjusting posture as well as the mobility, muscle tone, and alignment of the neck.
References
- Ryo Kozu , Ichiro Fujishima , et al.: Clinical characteristics and outcome of dysphagia rehabilitation in patients with aspiration pneumonia. (in Japanese)Journal of Japan Society for Respiratory Care.9(3): 293-298, 2000.
- Takashi Oshima , Takako Tanaka , et al.: What you want to do next , if you are interested in eating and swallowing care(in Japanese), Expert Nurse, 24(3): 70-73, 2008.
- Ryo Kozu , Ichiro Fujishima .:Respiratory physiotherapy for eating and swallowing disorders (in Japanese),Modern Physician, 26(1): 50-52, 2006.
- Tsuyoshi Yoshida :Physical therapy for dysphagia in patients with stroke hemiplegia , Journal of physical therapy (in Japanese),23(8): 1130-1136, 2006.
- Shaker R, Kern M, et al.: Augmentation of deglutitive upper esophageal sphincter opening in the elderly by exercise, Am J Physiol, 272: G1518-G1522, 1997.
- Tsuyoshi Yoshida , Yasushi Uchiyama , Mayuko Kumagai ,The reliability and clinical application of the new indexes for thyroid cartilage position and muscle strength of suprahyoid muscle group(in Japanese) , Dysphagia , 7(2): 143-150, 2003
- Tsuyoshi Yoshida : Relationships of Swallowing Disorder to the Sitting Posture for the Stroke Patients (in Japanese),Physical Therapy Research 33(4): 226-230, 2006.
Recommended readings
- Swallowing team in Seirei Mikatahara General Hospital :Pocket Manual of Dysphagia , Ishiyaku Publisher
- Ichiro Fujishima :Clinical Text Book of Dysphagia , Revised 2nd edition , NAGAI SHOTEN
- Eiichi Saito , Yoshiharu Mukai:Dysphagia Rehabilitation , Revised 2nd edition , Ishiyaku Publisher