53.Techniques to Facilitate Swallowing in Direct Training

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Explanation

Rehabilitation of dysphagia encompasses many swallowing techniques from the viewpoints of functional recovery and functional compensation. This module covers the purpose, effects, and implementation of swallowing facilitation techniques of swallowing in direct training.

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Explanation

Dysphagia manifests with a diverse range of symptoms, including not being able to chew or swallow food in the oral cavity or an impaired swallowing reflex. With direct training as a rehabilitation approach, we use actual food, which carries a risk of life-threatening conditions such as asphyxia and pneumonia.

Swallowing facilitation techniques can 1) make swallowing activate and make patient voluntarily attempts to swallow to prevent aspiration, which is likely to occur at the start of eating; 2) trigger the swallowing reflex through the effects of physical and sensory stimuli; and 3) trigger smooth swallowing. So, using swallowing facilitation techniques in direct training is linked to improvements in swallowing function, and these techniques are important from the viewpoints of functional compensation and risk reduction.

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Explanation

Here we see 3 representative techniques aimed at helping to facilitate the swallowing reflex and swallowing movements: 1) thermal-tactile stimulation, 2) applying manual stimulation to the front of the neck to facilitate triggering the swallowing reflex, and 3) K-point stimulation.
Thermal-tactile stimulation techniques utilize an indirect laryngoscope and frozen cotton swabs.

Techniques to stimulate the swallowing reflex are effective for the following groups of patients: 1) when the swallowing reflex is difficult to trigger, 2) when the swallowing reflex is delayed, 3) when voluntary swallowing movements are difficult, and 4) when swallowing movements are interrupted due to impairment in the anticipatory stage.

Swallowing stimulation techniques involve direct contact with the oral cavity and movements stimulated using the free hand, so we need to clearly explain the objectives and procedures to patients before training starts, check their understanding of these, and obtain their informed consent.

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Explanation

Thermal-tactile stimulation techniques include the technique reported by Lazzara et el.¹ and Fujishima's technique for ice massage of the throat².
The term "thermal-tactile stimulation" derives from applying something cold at same time as applying pressure. These thermal-tactile stimulation techniques immediately trigger the swallowing reflex but have a transitory effect only. We need to be mindful of the risk of stimulating the bite reflex when using an indirect laryngoscope and cotton swabs.

The thermal-tactile stimulation reported by Lazzara et al.¹ involves stimulating the nerves involved in swallowing by cold stimulation within the oral cavity. The aim is to shorten the time to triggering the swallowing reflex as well as to trigger the reflex itself.

This technique involves stimulating the left and right anterior pillars 4-5 times by applying the reverse side of a cooled indirect laryngoscope, with the aim of shortening the time to swallowing.

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Explanation

The throat ice-massage technique² aims to stimulate the swallowing reflex and swallowing movements by touching areas involved in triggering the reflex-the soft palate, the base of the tongue, and the posterior pharyngeal wall-with frozen cotton swabs (ice sticks) and activating the nerves involved in the reflex.

In this technique, first ask patients to open their mouth and check that the oral cavity is clean. Apply an ice stick along the left and right anterior pillars a few times while gently raising the dorsum of tongue, posterior pharyngeal wall, and soft palate. Next, take the ice stick out of the mouth and instruct the patient to do a dry swallow.

One precaution when using this technique is to check beforehand if the oral cavity shows hypersensitivity. Also, be mindful of the way in which you touch the oral cavity because direct contact is involved-meaning there should be no sudden contact, no contact deep inside the mouth from the start, and no strong contact. Be mindful also of the gag reflex and bite reflex. Other points to pay attention to are not using the ice stick immediately after taking it from the refrigerator in order to prevent cold burn, and not forcing patients who dislike the stimulation from the ice-massage technique.

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Explanation

Manual stimulation of the front of the neck ^{3 4} is a technique that aims to trigger the swallowing reflex and swallowing movements through sensory input to the swallowing muscles. The repeated simultaneous triggering of the swallowing reflex and swallowing movements can be expected to preserve and strengthen mobility of these muscles.

This technique is indicated for patients who have difficulty with voluntary swallowing or markedly delayed swallowing, and it is effective at reducing the time to trigger the swallowing reflex and swallowing movements.

In this technique, first establish a secure position for the patients' body, neck, and head to allow them to assume an appropriate posture for eating. Ask patients to swallow, and at the same time, repeatedly apply stimulation with your fingers to rub up and down along a line between the thyroid cartilage and the underside of the patient's jaw.

Some precautions are needed with this technique. Gently hold the jaw downward throughout the procedure because it is prone to rise when the trainer rubs up and down along the line of the thyroid cartilage. Avoid excessive pressure on the thyroid cartilage with this method because it is not moving up and down. If water or food is being used in the training, be mindful of any aspiration after the stimulation.

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Explanation

The K-point technique⁵ involves stimulating certain points in the oral cavity to trigger mouth opening and chewing movements as well as the swallowing reflex. It aims to improve swallowing function and can be used in indirect and direct training.

This technique is chiefly used in patients with pseudobulbar palsy when 1) they cannot open their mouth due to the biting reflex, 2) they have difficulty with swallowing reflex, and 3) they experience interrupted swallowing movements with food in their mouth. In cases of bulbar paralysis, the reflex is not stimulated.

This technique involves slight pressure stimulation at the K-point (medial surface slightly posterior to the posterior border of the retromolar triangle). Stimulating the reflex requires appropriate contact at the correct location. For details on the location and stimulation method, refer to "Direct Training at Meal Time (Content 56)".

Precautions for this technique are to accurately apply pressure to the target location, avoiding strong pressure.

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Explanation

Here we look at procedures when the K-point technique is used for preparation before starting the training and when eating movements stop while food is in the mouth.

Preparations before starting the training are aimed at chewing-type movements and the swallowing reflex, activating the various functionalities involved in swallowing, preventing aspiration (which is likely to occur at the start of feeding), and achieving smooth oral feeding. Provide oral care and then start using the technique. Use cotton swabs or similar to apply pressure at the K-point location, and then check for trigger of chewing-like movements and the swallowing reflex. These steps are repeated a number of times, and then training starts.

If eating movements cease with food still in the mouth, stimulate the K-point location with an ice stick or sponge to re-start movements.

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Explanation

Here we see the procedure for K-point stimulation in patients without trismus where bolus propulsion and the triggering swallowing reflex is difficult. Prepare the spoon appropriate for the stimulation such as K-Spoon. Have patients open their mouth, place the food on the posterior part of tongue, lightly apply stimulation to the K point with a used spoon, and then withdraw the spoon. The swallowing reflex should then occur automatically after chewing-like movements.

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References

Gisela de Lama Lazzara M.A., Cathy Lazarus, M.A., and Jeri A. Logemann, Ph.D.: Impact of Thermal Stimulation on the Triggering of the Swallowing Reflex, Dysphagia 1,73-77,1986
Seireimikatahara Hospiral Swallowing Team ed.: Pocket manual for dysphagia 4th.ed. Tokyo: Ishiyaku, 2018
Kojima Y & Uemura K:Application of a technique to facilitate swallowing by dysphagic patients, The Japan Society of Logopedics and Phoniatrics 36, 360‐364, 1995
Medical review committee of The Japanese Society of Dysphagia Rehabilitation ed. Summary of swallowing training 2014, Jpn. J. Dysphag. Rehabil. 18(1),55-89,2014
Kojima C, et al: Jaw opening and swallow triggering method for bilateral-brain-damaged patients: K-point stimulation. Dysphagia 17:273-277,2002.

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