I. What is the significance of swallowing disorder rehabilitation assessment? Screening: whether the patient has risk factors for aspiration or swallowing; 2. Diagnosis: whether swallowing disorder exists; 3. 5. Treatment: guide the development of rehabilitation program. Second, the content of swallowing rehabilitation assessment? 1. General assessment The following aspects are mentioned in the previous section and can be broadly summarized into four areas. ① Danger signals: Under what circumstances should we be alert to the possible existence of swallowing disorders ② Underlying diseases: What is the primary disease of swallowing disorders? ⑤ Higher brain function assessment: speech, cognition, emotion, intelligence, attention, memory. The Brief Mental State Examination (MMSE) is often used clinically. For screening of mild cognitive impairment, the Chinese version of the Montreal Cognitive Assessment Scale (MoCA), which is more sensitive than the MMSE, can be used. (1) Oral, lip, dental, soft palate and pharyngeal examinations Observe lip and cheek closing ability, tongue motor ability and strength, chewing ability, salivation ability, taste and oral sensation. Observe the condition of oral mucosa and teeth to detect mucosal breakage or ulcers, dental caries and dental alignment problems in time. Soft palate uplift: observe the degree of symmetry and uplift of soft palate bilaterally during articulation. Laryngeal elevation: Place two fingers on the larynx in front of the neck and feel the ability of laryngeal elevation during the swallowing action. Nausea reflex: usually induced by pressing the tongue base with a tongue depressor. It is important to note that there is not a one-to-one relationship between the nausea reflex and swallowing disorder. The nausea reflex can be absent in a person with absent nausea reflex and can be induced in a person with swallowing disorder. However, when a lateral deviation of the soft palate is observed when the nausea reflex occurs, it often indicates weakness of the contralateral soft palate and should be considered as a possible unilateral medullary lesion. Swallowing observation: A bedside visual screening test may be used. (2) Bedside visual screening tests Some designed and validated tests are simple and easy to perform, especially in elderly patients for whom imaging or other instrumentation is not available or convenient, and can also be used to predict the likelihood of aspiration pneumonia in patients. ① Repeated saliva swallowing test : It is mainly used for screening of swallowing disorders. The procedure is performed with the examinee in a relaxed position. The examiner places his or her finger on the laryngeal node and hyoid bone and asks the subject to swallow as quickly and repeatedly as possible. The number of times the laryngeal node and hyoid bone are moved forward and upward with the swallowing motion, and then reset, is observed. Count the number of times this is done in 30 seconds. Healthy adults can complete at least 5-8 times. If it is less than 3 times/30 seconds, then it indicates the need for further examination. ②Drinking and swallowing test : The sensitivity of diagnosing swallowing disorder with reference to aspiration pneumonia is 77.8% and the specificity is 68.1%. Operational conditions: Patients with a Glasgow Coma Scale score of less than 13 or who cannot maintain a sitting position even with assistance are not suitable for swallowing assessment by this method. If the patient chokes significantly at this stage, there is no need to proceed to the next stage and the patient is judged to have an abnormal swallowing test. The patient was graded according to the following criteria: Level I: the patient could finish the drink in one sip without choking, and finishing the drink within 5 seconds was considered normal. Level II: Finish the drink in two or more times without choking. Swallowing disorder is suspected. Level III: Can finish the drink in one go, but choking. Swallowing disorder is confirmed. Grade IV: Finish the drink in two or more times and choke. Swallowing disorder is confirmed. Grade V: Often chokes and has difficulty finishing the entire drink. Swallowing disorder is identified. ③ Simple swallowing provocation test: With reference to aspiration pneumonia, the sensitivity (94.4%) and specificity (86.4%) of the diagnostic swallowing disorder are higher than that of the drinking test, which can be used to screen for aspiration pneumonia, especially for bedridden people. The procedure is as follows: 0.4 ml of distilled water is injected into the upper part of the patient’s pharynx, and the patient’s swallowing reflex and the time difference between the injection and the onset of the reflex are observed. If the gag reflex can be induced within 3 seconds after the injection, the patient is judged to have normal swallowing. If it takes more than 3 seconds, it is abnormal. Since this test does not require any active cooperation or subjective effort from the patient, it is particularly suitable for bedridden patients. ④Cough reflex test: 2 ml of 20% saline tartaric acid solution is placed in a nasal spray and the patient inhales the spray causing stimulation of the cough receptors in the larynx and triggering the cough reflex. The presence of the cough reflex indicates that the patient is able to prevent food from entering the deep airway through this reflex. A weakened or absent cough reflex means that the possibility of accidental aspiration or swallowing is greatly increased. (3) Scales The experimentally designed and validated scales have two main uses: (1) to screen for swallowing disorders and assess swallowing ability, and (2) to guide the development of swallowing training goals and the evaluation of their effectiveness. For the first use, various assessment scales have been developed internationally for swallowing ability in recent years, among which the screening scale for swallowing disorders with Level 1 (highest level) evidence-based medical evidence is the Toronto Bedside Swallowing Screening Test. Swallowing muscles: The staging of oropharyngeal and esophageal swallowing disorders has been previously described. Common presentations of oropharyngeal swallowing disorders in the oral and pharyngeal phases are as follows: Oral phase (including oral preparation and transit): Inability to retain food in the front of the mouth, commonly due to poor lip closure. Inability to form a food mass or to keep the food mass in the center of the tongue, usually due to poor or uncoordinated tongue movement. Inability to bite properly, usually due to temporomandibular joint dysfunction. Food embedded in the buccal interdental space, usually due to lip or buccal hypotonia or tongue dysmotility. Inability to grind food adequately or adhere to the hard palate, commonly due to tongue weakness tongue against the palate. Repeated incessant rolling of the tongue in the mouth, commonly seen in Parkinson’s disease, resembles resting tremor. Prolonged backward transport of food to initiate swallowing, common in disuse or oral sensory disorders. Pharyngeal phase: Delayed gag reflex. Reflux of food into the nasal cavity. Misaspiration and choking during inspiration after swallowing due to residual food in the airway opening, epiglottis valley or pear-shaped fossa. Misaspiration and choking during swallowing. A variety of laboratory tests, such as barium esophagograms, can be useful in the evaluation of swallowing disorders, but they are not the preferred means of rehabilitation. The assessment of aspiration and aspiration is usually associated with small amounts of food aspiration into the airway in normal subjects. Aspiration of food into the airway is a significant risk factor for death in patients with swallowing disorders. Therefore, a specific rehabilitation assessment is necessary. The term “intrusion” may be used. The main factors affecting airway invasion are: the nature of the invasive material, the depth of invasion, the ability to breathe, and the ability to remove the foreign body from the airway. Large and deep foreign body intrusion into the airway is clearly more dangerous than a small and superficial intrusion. Large solid foreign bodies can cause airway obstruction, and acidic materials (including vomited gastric contents) can be extremely irritating to the airway. There are two main means of airway clearance of foreign bodies: ciliary activity and coughing. When the airway is re-stimulated by acid or infection, its ability to perceive stimuli that induce coughing is reduced, and a more dangerous silent aspiration may occur. When a more precise description is needed, a distinction needs to be made between misopharyngeal and misaspiration. The difference between the two forms of action has already been described in the previous section on the differential diagnosis of medullary paralysis: a mispharyngeal swallow is the active fall of food into the airway, driven by the tongue root, during swallowing when the airflow has stopped, whereas aspiration is the passive entry of food into the airway, driven by the airflow, during inspiration after swallowing. In addition, there is a difference in the depth of food intrusion into the airway: a micturition is usually a shallow intrusion that does not cross the vocal cords, whereas aspiration is a deeper intrusion that crosses below the vocal cords. Misopharynx itself may also cause further misaspiration, so the two are closely related. A more practical scale is the Misopharyngeal Misaspiration Scale, which is divided into eight levels. If necessary, imaging or endoscopy can be used to assist in the rehabilitation assessment.