Arquivo da categoria: Treatment

Effectiveness of chin-down posture to prevent tracheal aspiration in dysphagia secondary to acquired brain injury. A videofluoroscopy study

Terré R; Mearin F

Neurogastroenterol Motil;24(5):414-9, e206, 2012 May.

BACKGROUND: The chin-down posture is generally recommended in patients with neurogenic dysphagia to prevent tracheal aspiration; however, its effectiveness has not been demonstrated. AIM: To videofluoroscopically (VDF) assess the effectiveness of chin-down posture to prevent aspiration in patients with neurogenic dysphagia secondary to acquired brain injury. METHODS: Randomized, alternating, cross-over study (with and without the chin-down posture) in 47 patients with a VDF diagnosis of aspiration [31 stroke, 16 traumatic brain injury (TBI)] and 25 controls without aspiration (14 stroke, 11 TBI). Key RESULTS: During the chin-down posture, 55% of patients avoided aspiration (40% preswallow aspiration and 60% aspiration during swallow). The percentage was similar in both etiologies (58% stroke and 50% TBI). Fifty-one percent of patients had silent aspiration; of these, 48% persisted with aspiration while in the chin-down posture. A statistically significant relationship was found between the existence of pharyngeal residue, cricopharyngeal dysfunction, pharyngeal delay time and bolus volume with the persistence of aspiration. The chin-down posture did not change swallow biomechanics in patients without aspiration. CONCLUSIONS & INFERENCES: Only half the patients with acquired brain injury avoided aspiration during cervical flexion; 48% of silent aspirators continued to aspire during the maneuver. Several videofluoroscopic parameters were related to inefficiency of the maneuver. Therefore, the indication for chin-down posture should be evaluated by videofluoroscopic examination.

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Evidence-based Dysphagia Exercises

Walt Greenslade, M.S., CCC-SLP

A Beginning List of Dysphagia Exercises that Have Evidence Base:

SUPRAGLOTTIC SWALLOWING MANEUVER

SUPER-SUPRAGLOTTIC SWALLOWING MANEUVER

HARD / EFFORTFUL SWALLOW

TONGUE HOLD EXERCISE

MENDELSOHN MANEUVER

HEAD LIFTING MANEUVER

JAW-OPENING EXERCISE

TONGUE MOVEMENT EXERCISES

TONGUE RESISTANCE EXERCISES

CLOSURE OF THE LARYNX

BASE OF TONGUE EXERCISES

LINK PARA ACESSO A CADA EXERCÍCIO

Tactile, gustatory, and visual biofeedback stimuli modulate neural substrates of deglutition

Humbert IA; Joel S
Neuroimage; 59(2): 1485-90, 2012 Jan 16.
ABSTRACT
It has been well established that swallowing kinematics are modified with different forms of exogenous and endogenous input, however the underlying neural substrates associated with these effects are largely unknown. Our objective was to determine whether the swallowing BOLD response is modulated with heightened sensory modalities (taste, cutaneous electrical stimulation, and visual biofeedback) compared to water ingestion (control) in healthy adults across the age span. Habituation and sensitization were also examined for each sensory condition. Our principal findings are that each sensory swallowing condition activated components of the swallowing cortical network, plus regions associated with the particular sensory modality (i.e. primarily frontal motor planning and integration areas with visual condition). Overall, the insula was most commonly active among the sensory modalities. We also discuss gradual increases and decreases in BOLD signal with repeated exposures for each condition. We conclude that both stimulus- and intention-based inputs have unique cortical swallowing networks relative to their modality. This scientific contribution advances our understanding of the mechanisms of normal swallowing cortical control and has the potential to impact clinical uses of these modalities in treatments for neurogenic dysphagia.

Effects of Mendelsohn maneuver on measures of swallowing duration post stroke

McCullough GH; Kamarunas E; Mann GC; Schmidley JW; Robbins JA; Crary MA
Top Stroke Rehabil; 19(3): 234-43, 2012 May-Jun.
PURPOSE: The purpose of this pilot study was to determine whether intensive use of the Mendelsohn maneuver in patients post stroke could alter swallow physiology when used as a rehabilitative exercise. METHOD: Eighteen outpatients between 6 weeks and 22 months post stroke were enrolled in this prospective study using a crossover design to compare 2 weeks of treatment with 2 weeks of no treatment. Each participant received an initial videofluoroscopic swallow study (VFSS) and an additional VFSS at the end of each week for 1 month for a total of 5 studies. During treatment weeks, participants received 2 treatment sessions per day performing Mendelsohn maneuvers with surface electromyography for biofeedback. Measures of swallowing duration, penetration/aspiration, residue, and dysphagia severity were analyzed from VFSS to compare treatment and no-treatment weeks. RESULTS: Significant changes occurred for measures of the duration of superior and anterior hyoid movement after 2 weeks of treatment. Improvements were observed for duration of opening of the upper esophageal sphincter (UES), but results were not statistically significant. Measures of penetration/aspiration, residue, and dysphagia severity improved throughout the study, but no differences were observed between treatment and no-treatment weeks. CONCLUSIONS: Intensive use of the Mendselsohn maneuver in isolation altered duration of hyoid movement and UES opening in this exploratory study. Results can guide future research toward improved selection criteria and exploration of outcomes. Larger numbers of participants and variations in treatment duration and intensity will be necessary to determine the true clinical value of this treatment.

Deglutição e envelhecimento: enfoque nas manobras facilitadoras e posturais utilizadas na reabilitação do paciente disfágico

Steenhagen, Claudia Helena Vigné Alvarez de; Motta, Luciana Branco da.

Rev. bras. geriatr. gerontol; 9(3): 89-100, jan. 2006.

Resumo

O propósito deste artigo é apresentar uma revisão de literatura sobre as manobras utilizadas na reabilitação das disfagias. O aumento da população idosa acarreta maior prevalência de doenças neurológicas que cursam com quadro de disfagia o que reforça a necessidade de estudos tema. Este fato vem despertando atenção de por parte de profissionais que atuam na reabilitação, em especial a fonoaudiologia. Dentro da reabilitação encontramos manobras facilitadoras e posturais que podem proporcionar maior segurança alimentar. Baseados na literatura, observamos que as manobras facilitadoras supraglótica, supersupraglótica e de esforço ajudam na proteção da via aérea através da técnica do controle da apnéia confortável, e afirmam ter como propósito à segurança alimentar do paciente disfágico. As manobras posturais de cabeça para baixo, cabeça para trás, rotação de cabeça para o lado comprometido e cabeça inclinada para o lado bom mostraram ter como propósito o fechamento do vestíbulo laríngeo, reduzirem a distância hio-laríngea e a drenagem gravitacional do alimento em direção à faringe. Assim sendo, o estudo da dinâmica da deglutição através do método videofluoroscópico e o conhecimento por parte dos profissionais das diferentes manobras e suas complicações clínicas mostraram ser importantes para a reabilitação do paciente idoso disfágico

Indicadores da evolução do paciente com paralisia cerebral e disfagia orofaríngea após intervenção terapêutica

Carolina Castelli Silvério; Cristiane Soares Henrique

Rev. soc. bras. fonoaudiol. vol.14 no.3 São Paulo  2009

RESUMO

OBJETIVO: Verificar a evolução na função de alimentação e estabilidade clínica de crianças com paralisia cerebral tetraparética espástica após intervenção terapêutica.
MÉTODOS: Foram levantados em prontuário médico, antes e após a terapia, os dados de classificação da funcionalidade da alimentação (escala FOIS) e grau de disfagia, consistências alimentares e sinais sugestivos de penetração e/ou aspiração laringotraqueal de 36 crianças com paralisia cerebral espástica.
RESULTADOS: A maioria dos sujeitos alimentava-se com preparo especial, antes e após a intervenção, ocorrendo restrição de sólidos e líquidos no segundo momento. Houve diminuição da severidade da disfagia, redução de broncopneumonias e hipersecretividade pulmonar, aumento do peso e diminuição dos sinais sugestivos de penetração e/ou aspiração laringotraqueal, exceto recusa alimentar e cianose.
CONCLUSÃO: A intervenção fonoaudiológica, em conjunto com a equipe multidisciplinar em disfagia, promove maior funcionalidade da deglutição e diminuição dos sinais sugestivos de penetração e/ou aspiração traqueal, além de maior estabilidade clínica.

Descritores: Paralisia cerebral; Transtornos de deglutição; Fonoterapia; Pneumonia; Alimentação

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Eficácia da fonoterapia em disfagia neurogênica usando a escala funcional de ingestão por via oral (FOIS) como marcador

FURKIM, Ana Maria  e  SACCO, Andréa Baldi de Freitas

Rev. CEFAC [online]. 2008, vol.10, n.4, pp. 503-512.

OBJETIVO: avaliar a eficácia da fonoterapia e a interferência dos fatores de risco para disfagia no atendimento de pacientes adultos internados com doença neurológica e sintoma de disfagia, tendo a escala funcional de ingestão por via oral como marcador da progressão segura da dieta por via oral. MÉTODOS: foi realizado estudo retrospectivo de 49 prontuários de pacientes com disfagia neurogênica, atendidos em fonoterapia no leito hospitalar e comparada a escala de ingestão de alimentação por via oral antes e depois da terapia – FOIS, (mede a quantidade e tipo de alimento que o paciente consegue ingerir por via oral de forma segura). Foram estudados também possíveis fatores de interferência na melhora via ingestão oral na fonoterapia como: doença de base, idade, condições respiratórias, condições clínicas, estado de consciência, tempo de terapia e número de sessões. RESULTADOS: dos 49 pacientes, 36 apresentaram melhora na FOIS após a fonoterapia. Quanto aos possíveis fatores de interferência nessa melhora, foram constatados: a piora clínica do doente, as intercorrências clínicas e o rebaixamento do nível de consciência, como estatisticamente significantes para a não evolução em fonoterapia visando à ingestão de alimentos por via oral. Os outros fatores analisados como: doença de base, idade, condições respiratórias, tempo e numero de sessões não demonstraram significância estatística, sugerindo não interferir na melhora ou piora do paciente. CONCLUSÃO: observa-se melhora efetiva da ingestão de alimentos por via oral nos pacientes com disfagia neurogênica atendidos em ambiente hospitalar em fonoterapia, salvo se apresentarem intercorrências clínicas e rebaixamento do nível de consciência durante o processo.

Palavras-chave : Transtornos de Deglutição; Alimentação; Fonoterapia.

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Recovery of Swallowing After Dysphagic Stroke: An Analysis of Prognostic Factors

Kumar S, Doughty C, Doros G, Selim M, Lahoti S, Gokhale S, Schlaug G.

J Stroke Cerebrovasc Dis. 2012 Oct 23. doi:pii: S1052-3057(12)00314-X. 10.1016/j.jstrokecerebrovasdis.2012.09.005.

 

Abstract

BACKGROUND:

Dysphagia is a major complication of stroke, but factors influencing its recovery are incompletely understood. The goal of this study was to identify important prognostic variables affecting swallowing recovery after acute ischemic stroke.

METHODS:

We retrospectively reviewed our patient database to identify acute ischemic stroke patients who developed dysphagia after stroke but were free of other confounding conditions affecting swallowing. Of the 1774 patients screened, 323 met the study criteria. We assessed the effect of age, sex, baseline National Institutes of Health Stroke Scale (NIHSS) score, level of consciousness (LOC), facial weakness, dysarthria, neglect, bihemispheric infarcts, right hemispheric infarcts, brainstem infarcts, intubation, aspiration, acute stroke therapies, occurrence of symptomatic hemorrhagic transformation, seizures, pneumonia, and length of hospitalization (LOH) on persistence of dysphagia at hospital discharge in a logistic regression analysis.

RESULTS:

The mean age and NIHSS scores (mean ± standard deviation) were 75.9 ± 13.6 years and 13.5 ± 6.9, respectively; 58.5% were women. In a multivariate analysis, aspiration detected on a clinical swallowing evaluation (odds ratio [OR] 21.83; 95% confidence interval [CI] 8.16-58.42; P < .0001), aspiration on videofluoroscopic swallowing study (OR 10.50; 95% CI 3.35-32.96; P < .0001), bihemispheric infarcts (OR 3.72; 95% CI 1.33-10.43; P = .0123), dysarthria (OR 3.4; 95% CI 1.57-7.35; P = .0019), intubation (OR 2.86; 95% CI 1.10-7.39; P = .0301), NIHSS score ≥12 (OR 2.51; 95% CI 1.19-5.23; P = .0157) were significant predictors of persistent dysphagia. The area under the curve and Somer’s D(xy) statistics of the model were 0.8918 and 0.78, respectively, indicating good calibration and discriminative power.

CONCLUSIONS:

Prognostic factors affecting swallowing recovery identified in this study can help advance dysphagia research methodologies and the clinical care of stroke patients.

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Dysphagia treatment post stroke: a systematic review of randomised controlled trials

Foley N, Teasell R, Salter K, Kruger E, Martino R.

Age Ageing. 2008 May;37(3):258-64. Review.

Abstract

BACKGROUND:

dysphagia is common following stroke and is associated with the development of pneumonia. Many dysphagia treatment options are available, some still experimental and others already rooted in common practice. Previous reviews of these treatments were limited due to a dearth of available studies. Recently, more trials have been published warranting a re-examination of the evidence.

OBJECTIVE:

a systematic review of all randomised controlled trials (RCTs), updating previous work and evaluating a broader range of therapeutic interventions intended for use in adults recovering from stroke and dysphagia.

METHODS:

using multiple databases, we identified RCTs published between the years 1966 and August 2007 examining the efficacy of dysphagia therapies following stroke. Across studies, results of similar treatments and outcomes were compared and evaluated.

RESULTS:

fifteen articles were retrieved assessing a broad range of treatments that included texture-modified diets, general dysphagia therapy programmes, non-oral (enteral) feeding, medications, and physical and olfactory stimulation. Across the studies there was heterogeneity of the treatments evaluated and the outcomes assessed that precluded the use of pooled analyses. Descriptively these findings present emerging evidence that nasogastric tube feeding is not associated with a higher risk of death compared to percutaneous feeding tubes; and general dysphagia therapy programmes are associated with a reduced risk of pneumonia in the acute stage of stroke.

CONCLUSIONS:

dysphagia is known to be a common and potentially serious complication of stroke. Despite the recent newly published RCTs, few utilise the same treatment and outcomes thereby limiting the evidence to support the medical effectiveness of common dysphagia treatments used for patients recovering from stroke.

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Sensory stimulation activates both motor and sensory components of the swallowing system

Lowell SY, Poletto CJ, Knorr-Chung BR, Reynolds RC, Simonyan K, Ludlow CL.

Neuroimage. 2008 Aug 1;42(1):285-95. Epub 2008 Apr 26.

Abstract

Volitional swallowing in humans involves the coordination of both brainstem and cerebral swallowing control regions. Peripheral sensory inputs are necessary for safe and efficient swallowing, and their importance to the patterned components of swallowing has been demonstrated. However, the role of sensory inputs to the cerebral system during volitional swallowing is less clear. We used four conditions applied during functional magnetic resonance imaging to differentiate between sensory, motor planning, and motor execution components for cerebral control of swallowing. Oral air pulse stimulation was used to examine the effect of sensory input, covert swallowing was used to engage motor planning for swallowing, and overt swallowing was used to activate the volitional swallowing system. Breath-holding was also included to determine whether its effects could account for the activation seen during overt swallowing. Oral air pulse stimulation, covert swallowing and overt swallowing all produced activation in the primary motor cortex, cingulate cortex, putamen and insula. Additional regions of the swallowing cerebral system that were activated by the oral air pulse stimulation condition included the primary and secondary somatosensory cortex and thalamus. Although air pulse stimulation was on the right side only, bilateral cerebral activation occurred. On the other hand, covert swallowing minimally activated sensory regions, but did activate the supplementary motor area and other motor regions. Breath-holding did not account for the activation during overt swallowing. The effectiveness of oral-sensory stimulation for engaging both sensory and motor components of the cerebral swallowing system demonstrates the importance of sensory input in cerebral swallowing control.

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