I. Goals and Prerequisites of Rehabilitation Treatment for Swallowing Disorders Rehabilitation treatment must always revolve around function to establish goals, and goal setting always requires the participation of the patient and his or her relatives. Therefore, the description of the goals of rehabilitation treatment for swallowing disorders usually begins with the ideal goals of the physician and therapist, and is developed after communication and consultation with the patient and his or her family. The basic swallowing disorder rehabilitation goals are usually: 1) to avoid accidental ingestion of food into the lungs; 2) to achieve transoral feeding, or to minimize nutritional supply by non-oral routes; and 3) to improve the patient’s ability to swallow foods of different properties. Because of the emphasis on the importance of transoral feeding, swallowing rehabilitation does not include transgastric tube or transvenous nutritional measures in a strict sense, and swallowing treatment should be based on the premise that the patient can understand and cooperate with the treatment. The Glasgow Coma Scale and related cognitive rating scales can be used to assist in determining whether a patient can receive swallowing therapy, or whether a patient can undergo swallowing rehabilitation therapy under the guidance of an experienced physician. In the past few decades, treatment options for swallowing disorders have shifted from empirical or theoretical descriptive programs to scientifically designed and validated programs. However, basic swallowing rehabilitation treatment can still be divided into direct and indirect treatments. Direct therapy refers to swallowing training using food. Indirect therapy refers to swallowing training without the use of food. The basic indications include: consciousness, stable medical condition, swallowing reflex can be elicited, and a small amount of aspiration or swallowing can be coughed out by random coughing. (1) Food preparation Food properties selection: Since patients have different abilities to swallow different foods, the consistency and texture of the food need to be adjusted. Viscosity refers to the tolerance of food to shear forces, and its objective test index can be obtained by means of a viscosity tester. Clinical descriptions of consistency are subjective, and texture refers to a set of physical properties related to the structure of the food that can be felt on the tongue. It is customary to use the terms “runny,” “semi-runny,” “pasty,” “thick,” “thin,” “liquid,” and “solid” to describe the consistency and texture of food. For example, foods such as honeydew, lotus root powder made with boiling water, tomato juice and pudding are often considered as liquid foods. Solid foods are usually not easy to chew, and thin liquid foods are easy to choke on. Therefore, the order of food giving is usually: semi-liquid fluid in terms of consistency and finally water, soft food and semi-solid solid in terms of texture. But from another point of view, solid food is good for training the patient to chew and tongue grinding and stirring function, while liquid is good for water intake. Therefore, the nature of the food used should vary with the different therapeutic needs and degree of risk. For most patients with swallowing disorders, the ideal food properties for easy swallowing usually have the following characteristics: ① soft, homogeneous in density and properties; ② appropriately viscous, not easily loosened and easily formed in the mouth as a food mass; ③ easy to chew and easily deformed when passing through the pharynx and esophagus; ④ not easily adhered and retained on the mucosa. Food for patients with swallowing disorders can be classified into 8 levels (table below). The first seven levels all require the food to be homogeneous and monotonous, with different levels of liquid consistency from 1-4. Food trait grading table level 12345678 description thin liquid nectar-like liquid bee syrup-like liquid pudding-like liquid/gelatinous food do not chew repeatedly soft food to be chewed repeatedly glutinous whole soft food to be chewed repeatedly loose chunks of food multiple properties mixed food examples tea, coffee, orange juice. Creamy soup tomato juice. Thick liquid like raw honey syrup, root powder made with boiling water. Banana paste, rice paste, fruit and vegetable puree, minced meat and eggs mixed and steamed to make meat cake glutinous rice steamed cake, wonton skin or dumpling skin, cheese. Rice, muffins, steamed buns and bread? Plain food. (2) Food nutrition: Malnutrition occurs in 49% of stroke inpatients and up to 65% of stroke inpatients with swallowing disorders. Therefore, nutritional status assessment should be performed promptly. Many patients are undernourished due to limited transoral intake, when commercially available finished nutritional preparations are available, or dietary nutrition can be formulated in collaboration with the dietetic department. Careful consideration needs to be given to nutritional intake when abandoning transgastric tube nutritional supplementation and withdrawing non-enteral nutritional routes. Particular attention should be paid to the following points during the rehabilitation process of patients with clinical swallowing disorders: ① Water intake and output should be balanced, as reduced salivation and oral dryness due to dehydration is one of the risk factors for pneumonia; ② Pay attention to electrolyte balance, as many patients have low potassium and sodium due to chronic underfeeding, which should be detected and supplemented; ③ Adequate caloric supply; ③ Protein nutritional status is easily neglected, especially when the patient is immunocompromised (2) When patients have recurrent infections or complications such as pressure sores, attention should be paid to timely checking the patient’s albumin and total protein levels; ⑤ Do not forget the nutritional problems of vitamins and minerals. (3) Feeding position and feeding After choosing the appropriate food, therapists need to ask themselves the following three questions: In what position should the patient eat how many bites? How quickly and frequently should the feeding position be chosen so that the patient can eat safely and in a position that facilitates a protective reflex and compensatory swallowing action. The initial positions are: 30 supine, neck forward, back of the shoulder padded, and healthy side feeding. This position facilitates food intake and swallowing by gravity; it also relaxes the anterior cervical muscles and facilitates swallowing; the healthy side feeding facilitates food delivery from the healthy side and reduces residual food or accidental entry into the airway on the affected side. A mouthful is the amount of food that is most suitable for the patient to swallow at each feeding. If a mouthful is too much, food will easily spill out of the mouth or remain in the pharynx, increasing the risk of mis-swallowing and aspiration; if a mouthful is too little, it will be difficult to trigger the swallowing reflex, which will easily cause mis-swallowing. You should start with a small amount (1-5ml) and gradually increase it to master the right amount of bites. The speed of eating should be slower than normal for ingestion, chewing and swallowing. Usually, it is appropriate to control the time of each meal to about 45 minutes. However, many patients are unable to adhere to 45 minutes, so they can be trained in a small number of times, gradually extending the duration of each meal and reducing the number of meals. In order to prevent residual food in the oropharynx or reflux after eating causing aspiration, the oropharynx should be checked after eating and the feeding position should be continued for 15-30 minutes. (4) Compensatory actions to assist swallowing and reduce food residue? ① Empty swallowing: after each swallow of food, do empty swallowing several times again and again to make all the stagnant food swallowed, and then eat again; ② Alternate swallowing: let the patient swallow solid food and liquid food alternately, or drink a little water (1-2ml) after each swallow, which is not only good for stimulating the swallowing reflex, but also can achieve the purpose of removing the stagnant food in the pharynx; ③ Nod-like swallowing: when the neck is tilted back, the epiglottis valley becomes narrower, which can squeeze out The stagnant food can be squeezed out, then the head is lowered and swallowing action is performed several times repeatedly to clear and swallow the stagnant food. Lateral swallowing: Also known as head turning swallowing, it is mainly used to remove the residual food in the pear-shaped crypt. The direction of head rotation is taken as the direction of chin pointing. When unilateral damage causes residual food in the unilateral pear-shaped saphenous fossa, when the head is turned to the damaged side and nodding-like swallowing is performed, the ipsilateral pear-shaped saphenous fossa is squeezed while the contralateral laryngeal space becomes relatively larger, which facilitates the passage of food from the contralateral side; at the same time, the damaged vocal cords on the same side are also pressured and move toward the midline, which facilitates airway closure. In case of bilateral damage, lateral swallowing by repeatedly turning the head from side to side can remove and swallow the food retained in the pear-shaped crypt on both sides. ⑤ Tilt swallowing: It is mainly a movement of tilting the head to the healthy side and swallowing, which facilitates the entry of food mass into the healthy side of the mouth and pharynx by gravity, and is suitable for unilateral tongue dysfunction and unilateral pharyngeal dysfunction. (6) Flexion of the neck and retraction of the jaw for swallowing: The patient is asked to do a flexion of the neck and retraction of the head at the same time, i.e., the usual action of squeezing out the double chin. This maneuver shortens the distance between the tongue root and the posterior pharyngeal wall, which also increases the force of pushing food downward in the pharyngeal period. Also, this maneuver makes the airway narrower and increases the space in the epiglottis so that food can stay in the epiglottis for a longer period of time favoring patients with delayed swallowing reflexes to produce adequate swallowing, thus reducing the possibility of food intrusion into the airway. (7) Supraglottic swallowing: Also known as breath-hold swallowing, i.e., taking a deep breath from the nasal cavity and then, coughing immediately after swallowing. The principle is that the breath-holding Valsalva maneuver can make the vocal chambers closed and the air pressure at the vocal chambers increase, so that the food mass does not easily enter the trachea when swallowing; coughing after swallowing can remove the food residue that remains in the throat. This maneuver is used for actual swallowing of food provided that the patient has only pharyngeal phase disorders, while the oral preparatory and transit phases are mildly impaired, so that he or she can swallow food through the mouth in a breath-holding state after inhalation through the nose. If the patient is unable to meet the above requirements, then an empty swallow after breath-hold can be used as training without actually eating, thus called supraglottic swallowing training. 2. Indirect swallowing training Since indirect training does not use food and is safe, it is suitable for all types of swallowing difficulties from mild to severe. Its main purpose is to prevent the decline of swallowing function due to disuse, and also to improve the strength and coordination of swallowing-related muscles, so as to prepare for transoral feeding. Indirect training usually precedes direct training, and indirect training can be combined with direct training after the start of direct training. (1) What is the training for the oral phase? (1) Mouth-lip closure training: Mouth-lip closure training can improve the spillage of food or water from the mouth, and is also one of the important conditions for triggering further swallowing movements. Patients can be asked to face a mirror to train pursed mouth movements, which can be assisted for patients who cannot actively complete the movements. Patients can also be asked to do cheek puffing exercises and use appropriate resistance to squeeze both cheeks while puffing. There are also ways to train such as whistling, making faces or exaggerated expressions. It should be noted that patients with pseudomyelitis may have a sucking reflex and palmar reflex released from the frontal page, and may induce strong crying and laughing movements due to the training of lip and mouth area movements, at this time the lip closure training should be careful to avoid over-strengthening the spastic pattern of the local muscles. ②Mandibular motor training: There are three main roles. On the one hand, it is to train the movement of the temporomandibular joint to avoid ROM disorder of the temporomandibular joint caused by prolonged non-transoral feeding. You can practice mouth-opening movements, followed by relaxation and jaw movement exercises to both sides. For patients with difficulty in opening the mouth, ice stick stimulation or gentle massage can be applied to the spastic muscles, and warm physical therapy can also be applied locally to relax the occlusal muscles and improve the soft tissue extension. On the other hand, the prolonged absence of masticatory activities in patients can lead to hypoesthesia of the proprioception of the jaw movements and a loss of coordination of lip, tongue and jaw movements. Therefore, active or passive exercises can be used to allow the patient to experience the sensation of opening and closing the jaw during mastication. The third aspect is to maintain and strengthen the strength of the occlusal muscles. The patient can be asked to do the exercise of biting the tongue depressor with the molars. It should be noted that some patients with temporomandibular joint dysfunction will have pain during jaw movement, so excessive pain training should be avoided and local ultrashort wave physiotherapy or injection therapy can be given if necessary. ③Tongue body movement training: can tongue promote the ability to form, control and deliver to the pharynx of food blocks. It can refer to the tongue training exercises in dysarthria training, including the back and forth tongue stretching training, tongue licking and sucking around the mouth and cheek gap training and tongue root elevation resistance tongue depressor training. It is important to note that many patients have atrophied tongue bodies at the start of swallowing therapy. Moderate tongue traction under gauze protection may be used if necessary, but the importance of the patient’s own active activity is always emphasized. (2) Training for the pharyngeal phase? ①Ice stimulation: Ice stimulation can effectively strengthen the swallowing reflex, and repeated training can make it easy to induce, and also strengthen the power of swallowing action. The specific operation can be done by first wrapping gauze around one end with 1-2 chopsticks, presenting it about 1 cm in diameter, moistening it and then freezing it to make a popsicle. Dip a little cool boiling water first to make the ice prism on the surface of the popsicle dissolve and avoid scratching the oral mucosa or frostbite. The stimulation area is the soft palate, palatal arch, tongue root and posterior pharyngeal wall, and then the patient is instructed to do swallowing action. The skin between the cheeks and the thyroid cartilage and mandible can also be stimulated while swallowing to promote the swallowing action. If the vomiting reflex appears, the stimulation should be terminated. If the patient is salivating excessively, cold stimulation of the salivary glands on the affected side of the neck can be performed 3 times/day for 10 minutes/time, and can be trained before eating. Each session should be performed until the local skin is slightly red. Particular attention should be paid to the fact that unskilled or violent manipulation can easily cause damage to the orofacial area or oral mucosa, and may also lead to damage to the patient’s incisors. A detailed oral examination should be performed before the operation. ② Supraglottic swallowing training: The training method has been described as before. ③ Modified supraglottic swallowing training: For some patients who also have oral transit phase disorder, modified supraglottic swallowing training can be used. The specific operation is: first inhale and then hold the breath to put 5-10 ml of liquid into the mouth è continue to hold the breath while tilting the head back so that the liquid flows into the pharynx continue to hold the breath while swallowing 2-3 or more times to swallow all the liquid as much as possible to release the airway and cough several times to clear the residual liquid. ④ Vocal fold inversion training: Vocal fold inversion training is performed to achieve vocal fold atresia during breath holding to prevent food from entering the trachea. Operation method: The patient inhales deeply, presses both hands against the table or palms in front of the chest, pushes hard, closes the lips and holds the breath for 5 seconds. This method and supraglottic swallowing training and modified supraglottic swallowing training need to be used with care that breath holding is not excessive, and for some patients with underlying cardiovascular and cerebrovascular diseases need to be used only when the medical condition is stable under the guidance of an experienced physician or therapist. (3) Swallowing training for esophageal phase ① Mendelssohn swallowing training method: The patient does the laryngeal upward movement during swallowing and maintains it at the highest point for 2-3 seconds. This action can pull the upper esophageal sphincter and improve its relaxation ability, thus allowing food to enter the esophageal stage smoothly during swallowing. The therapist or the patient may also apply some external force to the thyroid cartilage or cricoid cartilage to assist in lifting while doing this maneuver. However, this external force may also induce the patient’s cough reflex. ②Shack training method: Its main purpose is to make the anterior cervical muscles isotonic/isometric contraction, thus improving the strength of the muscles that pull the larynx up and making it easier for the upper esophageal sphincter to relax during the laryngeal lift. Procedure: The patient lies flat with the pillow removed and uses the neck force to lift the head off the bed until it is just high enough to see his or her toes, while making sure that the shoulders do not leave the bed. This isometric contraction of the neck muscles lasts about 1 minute each time, 3 times per group; 3 groups per day; a course of treatment for six weeks. For patients who are initially unable to perform this movement, booster exercises can be given. (3) Heimlich maneuver: It is a first-aid technique used for patients who cannot cough up food after it falls into the airway, and is also known as diaphragmatic lower abdominal thrust. (4) Other indirect methods? (1) Diction training: Patients with dysphagia often have diction disorders, and diction training can improve the function of swallowing-related organs. ②Cough training: Patients with dysphagia will have weak cough due to decreased physical strength, decreased respiratory muscle strength and vocal cord paralysis. Respiratory muscle training and vocal fold closure training can be used, and coughing movements can be practiced. The coughing action can be done with the therapist placing both palms in a butterfly shape on the patient’s abdomen to try to drive external force to increase abdominal pressure. ③ Tool making: Patients with ingestion disorders can make small tools (such as long-handled spoons with auxiliary functions) to assist in eating. 3.Physiotherapy and traditional treatment Low-frequency electrotherapy, medium-frequency electrotherapy, modulated medium-frequency electrotherapy, electromyography biofeedback therapy, etc. can be applied. The purpose is to enhance the muscle strength of swallowing-related muscles and promote the coordination of swallowing action, so as to improve swallowing function. There are also modulated IF electrotherapy devices that can be controlled by the patient while eating and swallowing, triggering an electrical stimulation while food is in the mouth to complete the swallowing action. Acupuncture therapy may be effective for patients with delayed swallowing reflexes and swallowing muscle weakness. It is important to note that the use of electrotherapy and acupuncture needs to be carefully selected when there is impaired coordination of the swallowing muscles, spasticity, or other obvious manifestations of upper motor neuron injury to prevent worsening of spasticity and detrimental recovery from swallowing disorders. 4. Issues related to the rehabilitation of swallowing disorders: (1) Trans-tubular gastric feeding Although there is a controversy on the long-term or short-term use of trans-tubular gastric feeding, it is still a convenient and practical clinical treatment for patients with confusion, massive aspiration, silent aspiration, esophageal obstruction, recurrent pulmonary infections, and inability to take in sufficient water and nutrients through swallowing. Among them, nasal feeding tube (gastric tube inserted through the nose), transendoscopic gastrostomy (food enters the stomach directly from the outside through the gastric tube without passing through the esophagus) and oral gastrostomy are commonly used. Esophageal gastrostomy (insertion of a gastrostomy tube through the mouth). In the clinical work of the rehabilitation unit, it is most common for patients to be transferred to the rehabilitation unit with a nasal feeding tube. As a result, rehabilitation physicians encounter a series of pressing questions: should the tube be removed? When to remove the tube? How to remove the tube? When the patient is conscious and able to cooperate with feeding, the nasal feeding tube can be considered for removal. Before removing the nasal feeding tube, assess the amount, rate and tolerance of oral feeding to see if the patient will receive adequate nutrition and hydration after removal of the tube and to assess the patient’s risk of food intrusion into the airway. Swallowing rehabilitation after removal of the nasal cannula. Replacement of the nasal feeding tube may be considered when the patient has poor swallowing ability, and orogastric feeding may also be considered. It has three main advantages: ① No side effects of long-term nasal feeding tube; ② Feeding speed can be faster than nasal feeding, about 50 ml/min; ③ Transoral intubation also helps to stimulate the swallowing reflex in patients with easy swallowing. Specific operation method: insert the 14F silicone catheter from the patient’s mouth through the tongue side, gradually penetrate deeper until the end of the tube is near the lip, and feed when the tube is confirmed to be in the stomach. The limitation of this method is that it requires more skilled operation and 4-6 intubations per day, thus causing some inconvenience to the clinical operation. However, in the short term after removal of the nasal feeding tube, experienced physicians and therapists can try to use this method to address dietary supplementation during the recovery period of swallowing disorders. (2) Medication issues The appropriate medication can be selected for the primary cause of the patient’s swallowing disorder, but more importantly, care should be taken to exclude swallowing problems that are caused or aggravated by medication use. For example, dry mouth caused by taking anticholinergic active drugs is a common cause of drug-related dysphagia in the elderly. (3) Relationship between tracheotomy and dysphagia Patients with tracheotomy are often encountered in clinical practice. In the past, tracheotomy with tube placement was thought to save the patient from inadvertent aspiration. This concept has now been proven to be wrong. Therefore, tracheotomy and placement of a tube is not a means of preventing aspiration in patients, but only as a means of preventing or managing the occurrence of choking in patients. In fact, the incidence of aspiration in tracheotomized patients is over 50%. Effects of tracheotomy on swallowing function: limited effective cough: tracheotomy results in loss of subglottic air pressure, shortened inspiratory time, and reduced lung capacity. Restricted laryngeal elevation: The tracheotomy tube tightens the larynx against the surrounding neck tissue, which leads to restriction of the larynx. Restricted laryngeal inotropic reflex: Impaired sensation in the larynx and lower pharynx, and blunted laryngeal inotropic reflex (vocal cord inotropy). Impaired coordination of muscle groups: changes in airflow patterns lead to pre-existing swallowing? impaired air closure coordination, which leads to misaspiration. Rehabilitative management includes tracheotomy care, swallowing training after blockage, or use of a small-diameter tracheal cannula, or a one-way articulatory valve to increase subglottal air pressure. Corresponding rehabilitation treatment is provided for the effects of tracheotomy. (4) Pediatric swallowing disorders The rehabilitation of swallowing disorders in pediatric patients differs greatly from that in adults. In adults, before swallowing disorders occurred, the cerebral cortex had normal swallowing sensation and cognition, and was able to perform appropriate ingestion and swallowing skills. Therefore, rehabilitation treatment for swallowing disorders in adults is based on past experiences. In pediatric swallowing disorders, the cerebral cortex has not developed normal swallowing sensation and cognition, and normal ingestion? swallowing skills have not been acquired either. Therefore, rehabilitation of pediatric swallowing patients should be guided by developmental processes. For example, pediatric patients with cerebral palsy usually have problems with the control of the relative position of the head and trunk, which in turn is closely related to the acquisition of skills for coordinated limb and mouth movements to obtain food. Therefore, rehabilitation of swallowing disorders in infants and children goes beyond feeding training and includes treatment of a variety of cognitive, developmental, and behavioral problems.