I. Rehabilitation training
The rehabilitation training for swallowing disorders can be divided into indirect training (basic training) and direct training (feeding training).
Indirect training (basic training), which does not use food and only targets swallowing dysfunction, and direct training (ingestion training), which applies food and improves swallowing function by adjusting the eating position and food properties, and instructing the application of auxiliary swallowing movements.
(i) Indirect training
Indirect training starts from the prevention of disuse hypofunction and the improvement of motor and coordination movements of swallowing-related organs to make the necessary functional preparation for oral intake of nutrition. Since indirect training does not use food and is safe, it is suitable for patients with all types of swallowing difficulties, from mild to severe. Indirect training usually precedes direct training, and indirect training can be used even after direct training has begun. The following indirect training methods are commonly used.
(1) Mouth and lip closure exercises: Mouth and lip movement training can improve the leakage of food or water from the mouth. Have the patient face a mirror and independently perform lip closure exercises. Patients who are unable to actively close their lips can be assisted. Once the patient can voluntarily close the lips, the patient can be asked to hold a large button with a ligature inside the mouth, and the therapist pulls the ligature while the patient closes the lips tightly against it, trying not to let the button come out. Other exercises include lip protrusion and side pulling, mouth corner upward (as a smile), resistance to cheek puffing, etc.
(2) Mandibular movement training: It can promote masticatory function, do exercises to open the mouth as much as possible, and then loosen and move the jaw to both sides. For patients with difficulty in opening the mouth, cold stimulation or gentle massage can be applied to the spastic muscles to relax the occlusal muscles; through active and passive exercises, patients can experience the sensation of opening and closing the jaw. In order to strengthen the muscle strength of the bite muscle, the patient can do the practice of biting the tongue depressor with the molars.
(3) Tongue movement training: It can promote the control of food pills and the ability to deliver them to the pharynx. The patient can be asked to try to stretch the tongue forward and to both sides, and when the tongue extension is not sufficient, gauze can be wrapped around the tip of the tongue and gently pulled, and then the patient can retract the tongue to promote the back and forth movement of the tongue; practice tongue flexibility by licking and sucking around the mouth and lips with the tip of the tongue; practice tongue root elevation by resisting the root of the tongue with the tongue depressor, etc.
(4) Cold stimulation (ice-massage): cold stimulation can effectively strengthen the swallowing reflex, and repeated training can make it easy to induce and swallow powerfully. Dip a frozen cotton swab into a little water and gently stimulate the soft palate, palatal arch, tongue root and posterior pharyngeal wall, and then ask the patient to do swallowing action. If the vomiting reflex appears, the stimulation should be terminated; if the patient salivates too much, cold stimulation of the salivary gland on the affected side of the neck can be performed 3 times/day for 10 minutes/time until the skin becomes slightly red.
(5) Diction training: Patients with dysphagia are often accompanied by diction disorder, and diction training can improve the function of swallowing-related organs.
(6) Vocal fold inversion training: Vocal fold inversion training improves the function of vocal fold atresia and helps prevent food from entering the trachea.
(7) Cough training: Patients with dysphagia may become weak in coughing due to decreased muscle strength and stamina and vocal cord paralysis. A strong cough is beneficial to expel inhaled or accidentally swallowed food and promote laryngeal atresia.
(8) Promote swallowing reflex training: rubbing the skin from the thyroid cartilage to the underside of the jaw with the fingers up and down can cause up and down movements of the jaw and back and forth movements of the tongue, which then trigger swallowing. This method can be used for patients who have food in their mouth but cannot produce swallowing movements.
(ii) Direct training
The indications for direct training are: the patient is conscious, in a stable general state, able to produce a swallowing reflex, and can cough up a small amount of aspiration or swallowing by mistake.
(1) Position: Since there are more patients with simultaneous dysfunction in the oral and pharyngeal phases, a position that is both compensatory and safe should be chosen when starting training. At first, try a 30o supine position with the neck tilted forward. This position can use gravity to make food intake and swallowing easy; forward neck tilt can relax the anterior cervical muscles and facilitate swallowing. Patients with hemiplegia should have the back of the affected shoulder padded, and the caregiver should feed on the healthy side.
(2) Food selection: Generally, food that is easy to swallow has the following characteristics.
① softness, density and uniformity of properties.
② Appropriate viscosity, not easy to loosen.
(3) easy to chew and easily deformed when passing through the pharynx and esophagus.
③ Easy to chew, easy to deform when passing through the pharynx and esophagus The choice should be made according to the patient’s specific situation and dietary habits, taking into account the color, aroma and taste of the food.
(3) One bite amount: that is, the most suitable for patients to swallow each feeding amount. If the amount of one bite is too much, food will easily leak out of the mouth or cause retention in the pharynx, increasing the risk of accidental swallowing; if the amount of one bite is too little, it will be difficult to trigger the swallowing reflex. You should start with a small amount (1 – 4 ml) and gradually increase it to master the right amount of bites.
(4) Adjust the speed of eating: instruct patients to eat, chew and swallow at a slower pace than normal. Generally, it is appropriate to control the duration of each meal to about 45 minutes.
(5) Removal of stagnant food in the pharynx: Patients can be trained to remove food residues that remain in the pharynx by the following methods. ① empty swallow: after each swallow, do empty swallow several times to swallow all the food pellets and then eat; ② interactive swallow: let the patient swallow solid food and liquid food alternately, or drink a little water (1 C 2ml) after each swallow, which is conducive to stimulating the swallowing reflex and can achieve the purpose of removing stagnant food in the pharynx; ③ nod-like swallow: when the neck is tilted back, the valley of the epiglottis becomes narrower, so that the stagnant food can be squeezed out (iii) nodding-like swallowing: the epiglottis narrows when the neck is tilted back, which can squeeze out the stagnant food. By nodding and swallowing with the chin pointing to the left and right, the food left in the pear-shaped saphenous fossa on both sides can be removed and swallowed.
II. Precautions for direct training
The measures for direct training include adjusting the feeding position and posture, the shape of food, the entrance position of the food mass, the nature of food, the amount of bites, the speed of feeding, the swallowing aid, the reminder during feeding, the eating environment, etc., and paying attention to the cleaning of the mouth and sputum before and after feeding.
(I) Body position and posture
It is important to develop good eating habits. It is better to eat regularly and quantitatively, sit up instead of lying down, and eat at the dining table instead of at the bedside.
However, since there are more patients with dysfunction in both the oral and pharyngeal stages, the position of eating should vary from person to person depending on the condition. A position that is both compensatory and safe should be chosen at the beginning of training. For patients who cannot sit, generally take at least the trunk 300f Indian position, with the head bent forward and the shoulder on the hemiplegic side padded with a pillow, and the feeder on the patient’s healthy side. At this point of training, food is less likely to leak out of the mouth, which is conducive to transporting the food mass to the root of the tongue, and can also reduce the risk of reflux to the nasal cavity and accidental swallowing. Forward neck flexion is also a way to prevent micturition because the neck tends to be posteriorly flexed when lying on the back, which makes the anterior cervical muscles related to swallowing activities tense and makes it difficult to lift the larynx, thus making it easy for micturition to occur.
For patients with many different types of swallowing disorders, the use of a modified feeding posture can improve or eliminate swallowing due to aspiration symptoms. The principle of changing the feeding position is to allow the patient’s head or body to change position when swallowing the food mass to relieve the symptoms of swallowing disorder.1. Rotation of the head and neck Rotation of the head and neck to the affected side closes the pear-shaped fossa on that side, moves the food mass to the healthy side, and facilitates the closure of the airway on that side. The most effective way to close the airway is to tilt the head forward and rotate it to the affected side. It is indicated for patients with unilateral pharyngeal paralysis (residual unilateral pharynx).
Lateral swallowing The head is tilted laterally toward the healthy side so that the food mass moves toward the healthy side due to gravity, and at the same time, the pear-shaped fossa on that side narrows, extruding the residue, and the contralateral pear-shaped fossa becomes shallow, producing an efficient peristaltic movement of the pharynx, which removes the residue. Lateral tilting of the head to the affected side narrows the pear fossa on the affected side and extrudes the residue. For patients with paralysis of the lingual and pharyngeal muscles on one side (residues in the oral cavity and pharynx on the same side).
Low head swallowing Swallowing in a position with the neck flexed as far forward as possible pushes the anterior pharyngeal wall backward and is a better choice for patients with delayed initiation of pharyngeal phase swallowing, inadequate tongue root retraction, and inadequate airway population closure. The effects of swallowing in this position are: (1) to enlarge the space of the epiglottis valley and to allow the epiglottis to shift backward, so as to avoid food spillage into the vestibule of the larynx and to better protect the airway; (2) to narrow the tracheal population; and (3) to move the posterior pharyngeal wall backward so that food leaves the tracheal population as far as possible. It is suitable for patients with delayed swallow initiation in the pharyngeal phase (the food mass has passed the lower jaw and pharyngeal swallowing has not yet been initiated). (Chen Chang’an, a patient with true bulbar palsy with marked swallowing disorder)
From head tilting to nodding swallowing The epiglottic valley becomes narrow when the neck is flexed back, and residual food can be squeezed out. Then, the neck is flexed forward as much as possible in the shape of a nodding head while making empty swallowing movements, which can improve the lack of tongue motor ability as well as the residual epiglottic valley. It is suitable for patients with inadequate backward pushing movement of the tongue root (residual epiglottis).
Head tilting back When the head is tilted back, food is easily passed through the mouth to the root of the tongue due to the effect of gravity. It is suitable for patients with slow intraoral delivery of food mass (poor posterior thrust of the tongue). During the training, the patient is instructed to chew and mix the food into a food mass, then immediately tilt the head back and swallow. Forward and backward head and neck tilting can resolve the retention and movement of the food mass in the oral cavity. If the food mass cannot be transferred to the pharynx to trigger swallowing, the patient should be taught to close the airway at will.
Empty swallowing and cross-swallowing When there is already food residue in the pharynx, the accumulation of residue increases if feeding is continued, which can easily cause misophagy. Therefore, after each feeding and swallowing, several empty swallows should be made repeatedly so that the food mass is swallowed completely before eating. It is suitable for patients with weak pharyngeal contraction (residuals are distributed all over the pharynx). It is also possible to drink a very small amount of water (1-2ml) after swallowing each meal, which is conducive to stimulating the swallowing reflex and removing residual food from the pharynx, called “cross-swallowing”.
(B) Food properties and viscosity
According to the nature of food, food is generally divided into three categories, namely, liquid such as water, juice, etc.; semi-fluid such as rice soup, soup, etc., paste such as rice paste, sesame paste, etc.; semi-solid such as soft rice, solid such as cookies, nuts, etc. Food traits should be selected according to the degree and stage of swallowing disorder, based on the principle of easy first and then difficult. Foods that are easy to swallow are characterized by uniform density, appropriate viscosity, not easily loosened, easily deformed when passing through the pharynx and esophagus and rarely remaining on the mucosa. In clinical practice, paste-like food should be preferred because it can stimulate tactile and pressure sensation and salivary secretion more satisfactorily and make swallowing easy. In addition, the color, aroma, taste and temperature of the food should be taken into account. According to the parts of the swallowing organ affected by swallowing disorder, appropriate food should be selected according to local conditions and reasonably prepared, and food thickening agents can be used to adjust the nature of food.
If the food is loose or the liquid consistency is not enough, medical food “thickeners” (such as Ottosunopharyngeal) can be used to make different degrees of paste, so that the food will be smoothly formed into a mass and not easily loose and remain. The medical food “thickener” – Otto’s throat, colorless and tasteless, does not add too much sugar, salt and other ingredients, more suitable for diabetes, hypertension, hyperlipidemia and other middle-aged and elderly patients with chronic diseases, not only to achieve the reconciliation of food in line with the improvement of swallowing disorders to eat, but also does not affect the primary disease.
(iii) Position of food mass in the mouth
When eating, the food should be placed in the position of the mouth where the food can be felt most, and it is most suitable to promote food retention and delivery in the mouth. It is best to place the food on the back of the healthy side of the tongue or the healthy side of the cheek, so as to facilitate the swallowing of food. This practice is not only suitable for patients with sensory impairment in part or all of the tongue, cheek, mouth and face, but also for all patients with weak facial and tongue muscles.
(D) One-bite volume and eating speed
A mouthful, that is, the most suitable for swallowing the amount of each ingestion entrance. Generally, the amount per bite for normal people: 1 – 20 ml of fluid, 5-7 ml of jelly, 3-5 ml of paste food, and 2 mlo of meat dough on average, if… If a mouthful is too much, food will leak out of the mouth or cause pharyngeal residue leading to misaspiration; if it is too little, it will be difficult to induce swallowing reflex due to insufficient stimulation intensity. Generally, a small amount is tried first (1-4 ml of liquid), and then increased as appropriate. To prevent accidental aspiration of food into the trachea during swallowing, training can be combined with supraglottic swallowing to make the vocal cords close better before swallowing, and coughing immediately after swallowing can remove the food residue left in the throat. In order to reduce the risk of accidental aspiration, the appropriate eating speed should be adjusted, the first bite of swallowing is completed before eating the next bite to avoid the phenomenon of two overlapping food populations. In addition, attention should be paid to the choice of tableware, which should have a blunt and thick edge, long spoon and spoon with a capacity of about 5 to l0 ml, so that it is easy to place food accurately and control the amount of food per spoon.
The size of the food mass and the speed of eating have some influence on whether some patients can swallow smoothly. Some patients with delayed initiation of pharyngeal swallowing or pharyngeal contraction muscle weakness often need 2 to 3 swallows to swallow the food mass. If the food mass is too large and the eating speed is too fast, the food will be easily retained in the pharynx and aspiration will occur. In addition, according to the patient’s swallowing function, instruct the patient to change and adapt to the eating habits, and remind to slow down if the speed is too fast to prevent mis-swallowing.
(V) Reminder at feeding
Remind during eating to promote the patient’s swallowing and help the patient reduce the risk of aspiration. There are five main methods as follows.
Verbal gestures, such as the caregiver saying “swallow” while the patient is eating to remind the patient.
Gestures such as the caregiver pointing to their lips to remind the patient to keep their lips closed during the swallowing period.
Physical cues such as using chin and head supports to remind the patient to maintain proper body posture.
Textual cues Use text to provide constant reminders to patients and caregivers to prevent complications.
Taste and temperature of food Cold sensations can be stimulated to trigger the gag reflex, while hot liquids can remind the patient to suck the liquid slowly.
(vi) Eating environment
Usually, eating and swallowing is a routine daily activity that does not require much thought. However, patients with swallowing problems require attention in order to facilitate swallowing and prevent aspiration. Therefore, it is important for patients with dysphagia to eat in a quiet environment to avoid distractions. Talking during meals can cause the patient to forget the swallowing action and thus interfere with swallowing.
(vii) Clean the mouth and expel sputum before and after eating
Normal people will naturally produce swallowing once every two minutes or so, swallowing oral and pharyngeal secretions into the esophagus to deal with them, and after eating, if there are residues in the oral cavity and pharynx, they will have a foreign body sensation and can reflexively cough up and remove them, while patients with swallowing disorders have poor sensation and reflexes in the oral cavity and pharynx, and saliva cannot enter the esophagus in patients with cricopharyngeal muscle dysfunction, and usually flows into the respiratory tract easily; food left in the oral cavity and pharynx after eating can easily enter the respiratory tract with The food left in the mouth and pharynx after eating can easily enter the respiratory tract with breathing, leading to potential lung infection after eating. Therefore, cleaning of the mouth and pharynx before and after eating is an important measure to prevent pulmonary infections in patients with swallowing disorders.
Patients with oral and pharyngeal cancer suffer from dry mouth, mouth ulcers and tooth decay due to insufficient saliva secretion as a result of salivary glands destroyed by radiation treatment. Therefore, patients rinse their mouth with water or mouthwash to keep their mouth moist and clean to improve the above symptoms. During the process of eating, applying interactive swallowing can clean up the residue.
For patients with abnormally increased secretions, the secretions need to be cleared before eating before eating, and if the secretions affect swallowing during eating, they also need to be cleared to keep the eating process smooth.
III. Comparison of the effect of indirect training and direct training
When the condition of patients with swallowing disorder is serious, they usually receive only indirect training, and only when they meet the indications for direct training (the patient is conscious, in a stable general state, can produce swallowing reflex, and can cough up a small amount of inhalation or swallowing by mistake), they can start to receive direct training and then remove the nasogastric tube.