Explanation
Learning objectives
- To understand the posture adjustment techniques used in direct training and their purpose
- To understand the methods and effects of common posture adjustment
- To lean the necessary precautions when adjusting posture
Explanation
When food passes through the oral cavity to the pharynx, it is constantly subject to a strong gravitational effect. Where there is some type of gradient, the food moves to a lower position, and transit is smooth if the angle between the oral cavity and the pharynx is suitable. By exploiting this effect and controlling the speed at which food moves to the pharynx, we can try to prevent aspiration and avoid food from becoming lodged in the pharynx. Postural adjustment manipulates how wide and narrow spaces are. and these manipulations can be used to stimulate proper functionality in the oral cavity and pharynx to deal with food and prevent aspiration and food from becoming lodged in the pharynx. These postural adjustment techniques have some advantages: they involve little pain, they don't require complicating procedures, and they are relatively easy to carry out even for patients with cognitive impairment. They are also highly effective.
Nevertheless, we must thoroughly evaluate patients in order to use the most suitable technique for them because applying a technique incorrectly or applying an inappropriate technique risks worsening the swallowing status.
Explanation
Common posture adjustments
Various techniques for postural and craniocervical position adjustment have been introduced, and here we see shows some representative techniques.
Explanation
Reclining posture
Significance: This technique is indicated for many patients, and it is worth trying once in patients with aspiration. Generally, a small angle of around 30º reduces the likelihood of aspiration in people with dyshagia2, 3. However, the appropriate angle varies between patients due to structural differences and the presence of any abnormalities of the pharynx or back or of other factors, so this angle should be set after comprehensive evaluation of each patient.
Method: In this technique, patients initially lie back on a raiseable bed or sit back in a reclining wheelchair. The important points at this stage are: to relax their body and neck with flexion at the hips and knees to prevent change of posture through sliding or falling, to use a pillow to prevent overextension of the head and neck, and to keep their back on the bed or the backrest of the wheelchair and to not lean to the left or right.
Precautions: This technique supports the passage of food through the oral cavity; but there is a risk of aspiration if liquid reaches the pharynx quickly.
Explanation
Advantages and disadvantages of the reclining position and sitting position
Here we see the advantages and disadvantages of the reclining posture and sitting position. We can refer to this table when selecting which posture to use.
Explanation
Lateral leaning and lateral position3
Lateral positioning allows a greater concentration of the food bolus on one side, and is more effective, than Lateral leaning (trunk rotation). The affected side is often upward, however, when patients need to lie with their affected side downward, use of cushions and consideration where to place the hands and feet is necessary to avoid pain and discomfort.
Explanation
Lateral leaning and lateral position
Significance: In many cases, a food bolus can readily pass through the non-paralyzed side of the pharynx, but in some cases it can readily pass through the paralyzed side. Videofluoroscopic examinations are desirable to ascertain the side where a food bolus can pass easier.
Explanation
Head rotation
Significance of head rotation: Rotating the head widens the unrotated side of pharyngeal space, and it reduces the pressure on the opening of the UES4, 5.
Method: When aiming to prevent the residue in the pharynx and to improve bolus transit into the esophageal opening, have patients rotate their head toward the worse functional side of pharynx and swallow. When aiming to decrease the pharyngeal residue, after swallowing, have the patient turn their head to the opposite side of the residue and swallow.
Explanation
Chin-down (head flexion, neck flexion, or head & neck flexion)6
The chin-down technique can involve head flexion, neck flexion, or head & neck flexion. There are general terms of positions with the head and the neck involving head flexion, neck flexion, combined flexion (head flexion + neck flexion), and neck flexion & head extension7. Each of these positions has a different effect. Thus, the appropriate position should be selected after comprehensively assessing the patient's condition. It is desirable to evaluate the effect of the posture with videofluoroscopic examination and then use the appropriate posture.
Explanation
Chin-down rotation (head flexion, neck flexion, or head & neck flexion)
Main scope: head flexion narrows the oropharynx, so this technique is used for patients with poor pharyngeal constriction, who have residue in the pharynx. Conversely, neck flexion and combined flexion tend to widen the pharyngeal space, so these techniques are used for patients with high neck tension or those who aspirate before swallowing. Neck flexion with head extension (anterior bending of the cervical spine with part of the neck projected)3 tends to reduce pressure at the UES opening, so this technique is good for patients with aspiration prior to swallowing and poor bolus transit through the UES opening.
Methods
Head flexion: This involves extension of only the cervical vertebrae, to produce a double-chin-like appearance.
Neck flexion: The lower cervical vertebrae are extended so that the patient is looking downward.
Combined flexion: The head and neck are extended at the same time.
Neck flexion with head extension: The head is extended so that the jaw juts out, and the neck is bent.
Explanation
Head and neck extension5
Significance: Head and neck extension is effective in the oral stage but is associated with an increased risk of aspiration in the pharyngeal stage. As such, this technique is indicated for a relatively small number of patients. The target patients are those with severe tongue paralysis and those after surgery for tongue cancer who have no cognitive impairment, are able to hold their breath at intervals between the passage of food, and are able to return their neck to the neutral position when swallowing.
Explanation
Reclining position plus head rotation8
In cases where a reclining position on its own does not sufficiently prevent aspiration, it can be combined with head rotation so that the food bolus is concentrated on the non-paralyzed side for swallowing, which prevents aspiration and food from lodging in the pharynx.
Methods
- When the angle of reclining does not exceed 45º, head rotation serves to lower the side toward which the head is turned (the paralyzed side) and guides the food bolus to the paralyzed side. In some cases, aspiration can be exacerbated.
- When the reclining position and cervical rotation are combined, the body may be rotated instead of the head in line with the reclining position; with rotation of the body to the unaffected side, the head becomes the true center, and the food bolus is prevented from passing to the paralyzed side.
Explanation
Basic posture
Normally, we eat sitting down. This is the basic posture for eating. As swallowing function improves, various postural adjustments can gradually be dropped as we approach patients sitting to eat. Abnormal posture exacerbates aspiration and lodging of food in the pharynx, so we should be mindful of the height of the chair and the angle between the chair and the pelvis in order to achieve stable posture.
Explanation
Important points to remember and chairs for postural adjustment
There are a number of points to remember for postural adjustment. The adjustment should be suitable for each patient based on their condition, an assessment should be made to establish the optimum posture for preventing aspiration, the recommended posture adjustment should be practiced, and checks are needed to ensure the posture is being achieved accurately in direct exercise or in actual eating situations.
The Swallow Chair (Tomebrace Co., Ltd.) has been designed to solve the problems of discomfort, fatigue, and procedural complexity seen in postural adjustment, and it can be used to achieve simple and comfortable postures quickly for the purpose of examinations, training, and actual eating situations9.
References
- Medical review committee of The Japanese Society of Dysphagia Rehabilitation ed. Summary of swallowing training 2014, Jpn. J. Dysphag. Rehabil. 18, 82, 86-89, 2014
- Saitoh E, Kimura K, Yamori S et al.: Application of videofluorographyin dysphagia rehabilitation. Jpn J Rehabil Med 23: 121-124, 1986.
- Fujishima I & Tanguchi H:Rehabilitation for swallowing disorders associated with stroke 3rd.ed.Tokyo: Ishiyaku, 2017, pp 87-135
- Karaho T, Ohmae Y, Tanabe T et al: Effect of head rotation maneuvers on pharyngeal shape and the swallowing function. J. Jpn. Bronchoesophagol. Soc. 48: 242-248, 1997.
- Nakayama E, Kagaya H, Saitoh E et al: Changes in pyriform sinus morphology in the head rotated position as assessed by 320-row area detector CT. Dysphagia 28: 199-204, 2013
- Logemann JA: Evaluation and treatment of swallowing disorders, 2nd ed. Austin, Tex.: PRO-ED, Inc., 1998.
- Okada S, Saitoh E, Palmer JB, et al: What is the "Chin down" posture? - A questionnaire survey of speech language pathologists in Japan and the United States-. Dysphagia 22: 204-209, 2007.
- Ota K, Saitoh E, Matsuo K et al: Clinical consideration about the combinations of positioning for dysphagia -Effect of neck rotation on the pathway of bolus in pharynx at recling postion. Jpn. J. Dysphag. Rehabil. 6: 64-67, 2002.
- Inamoto Y, Saitoh S, Shibata S et al.: Effectiveness and applicability of a specialized evaluation exercise - chair in posture adjustment for swallowing. Jpn J Compr Rehabil Sci 5: 33-39, 2014
