Factors influencing the decision to introduce alternative nutrition in patients with Duchenne muscular dystrophy.

INTRODUCTION/AIMS: Nutritional management of adults with Duchenne muscular dystrophy (DMD) is an important clinical issue. However, it is not clear which dysphagia-related factors should prompt introduction of alternative nutrition (AN). We aimed to determine which patients with DMD were introduced to AN. METHODS: This retrospective study included 56 patients with DMD (median age, 23.5 years). They were divided into patients able to continue oral feeding (OF) and those introduced to AN. Body weight, frequency of ventilator use, daily meals, history of steroid treatment, results of videofluoroscopic examination of swallowing (VF), and awareness of dysphagia were evaluated. RESULTS: Of 56 patients, 19 were in the AN group. After AN introduction, 93% of the patients continued oral intake. The proportion of patients who consumed chopped and liquid diets was higher, and body weight was lower, in the AN than in the OF group. There were no significant differences in age, upper limb function of feeding, frequency of ventilator use, or history of steroid therapy between the two groups. The frequencies of aspiration and residue in the pyriform sinus in VF were higher in the AN group than in the OF group. Decision-tree analysis showed that food form and subjective difficulty swallowing solid foods were the most important factors affecting the decision-making for AN. DISCUSSION: Patients with DMD who had difficulty eating solid foods were started on AN because they were unable to maintain their weight. These findings provide information for future longitudinal studies to assess the value of AN.

Effects of head flexion posture in patients with dysphagia.

BACKGROUND: The chin-down posture is often used as a compensatory manoeuvre for patients with dysphagia. This posture presumably involves flexion of the head and/or neck, but this is not clearly defined. OBJECTIVE: This study aimed to assess the effects of head flexion posture in a retrospective study of videofluoroscopic examination of swallowing (VF). METHODS: A total of 73 patients who underwent VF both with and without head flexion posture in the lateral projection were included in the analysis. The head and neck angles at the initiation of the swallowing reflex, penetration-aspiration scale (PAS), nasopharyngeal closure time, stage transition duration, duration of laryngeal closure, time from swallowing reflex to laryngeal closure and to the opening of upper oesophageal sphincter (UES), duration of UES opening, location of the bolus leading edge at swallowing reflex, and bolus transition time were evaluated. RESULTS: The head flexion angle increased (p < 0.001), but the neck flexion angle did not change in the head flexion posture. Moreover, PAS improved (p < 0.001), aspiration was reduced (p < 0.001), the time between the swallowing reflex and the onset of laryngeal closure was shortened (p = 0.006), and the leading edge of the bolus at swallowing reflex became shallower (p = 0.004) in the head flexion posture. Other parameters did not significantly change. CONCLUSION: The head flexion posture resulted in earlier laryngeal closure and a shallower position of the leading bolus edge at swallowing reflex, resulting in PAS improvement and decreased aspiration.

The effect of reclining position on swallowing function in stroke patients with dysphagia.

BACKGROUND: Dysphagia is a common problem in patients with a history of stroke. In Japan, a reclined position is commonly used as a compensatory technique to address this problem. OBJECTIVE: To evaluate the effect of reclined position on swallowing function in patients with stroke who had dysphagia. METHODS: A retrospective analysis was carried out on the videofluoroscopic examination of swallowing (VF) of 4ml honey-thick liquid swallows collected over 9 years. Penetration-aspiration scale (PAS) and residue scores were compared for the following: a body position at 90° upright (90°U) and 60° reclining (60°R) groups, as well as 60°R and 45° reclining (45°R) groups. RESULTS: Two hundred and five records from 98 subjects were reviewed. These included patients with ischaemic stroke (62%), haemorrhagic stroke (32%) and subarachnoid haemorrhage (6%). PAS scores were lower when the body was in a more reclined position (P < .001). The amount of residue in the valleculae and pyriform sinus also reduced in the more reclined position (P < .001). The deeper bolus head at swallowing onset was positively correlated with severe PAS (P < .001). CONCLUSIONS: These findings suggest that in patients with stroke who had dysphagia, a reclined position may be useful in reducing the risk of penetration and aspiration, and in decreasing the amount of residue in the pharyngeal area. The depth of the bolus head at the onset of swallowing increases the severity of penetration and aspiration.

Obstruction-related dysphagia in inclusion body myositis: Cricopharyngeal bar on videofluoroscopy indicates risk of aspiration.

OBJECTIVE: To show the predictive risk factors for aspiration pneumonia and prognostic importance of a cricopharyngeal bar (CPB) on videofluoroscopic examination of swallowing (VFS) in inclusion body myositis (IBM). METHODS: In this retrospective study, we examined a consecutive series of 37 patients with clinico-pathologically defined IBM based on the European Neuromuscular Center diagnostic criteria for IBM from 2013. The Swallowing Disturbance Questionnaire was used for the evaluation of dysphagia. A standard VFS was performed at diagnosis. The primary outcome was aspiration pneumonia. Secondary outcomes included IBM Functional Rating Scale score, forced vital capacity (FVC), and body mass index. RESULTS: Aspiration pneumonia occurred in 10 of 37 IBM patients (27%). Based on univariate analysis, 4 factors increased aspiration pneumonia risk: BMI < 18.5 (n = 5; hazard ratio [HR], 10.7; 95% CI, 2.50-46.0; p = .001); aspiration (n = 7; HR, 7.57; 95% CI, 1.82-31.6; p = .005); insufficient opening of the upper esophageal sphincter (n = 11; HR, 4.53; 95% CI, 1.12-18.3; p = .03); and CPB presence (n = 15; HR, 11.6; 95% CI, 1.46-91.8; p = .02). Clinical features of IBM-CPB(+) were elderly onset, obstruction-related dysphagia, and mild decreases in FVC, resulting in aspiration pneumonia in 1.3 years (interquartile range, 0.9-5.2); 67% of IBM-CPB(+) patients underwent interventional procedures for dysphagia. IBM-CPB(+) patients had a lower FVC than IBM-CPB(-). CONCLUSIONS: A CPB in IBM largely contributes to obstruction-related dysphagia and is a risk factor that predicts aspiration pneumonia and refractory dysphagia requiring aggressive therapy.

Laterality of bolus passage through the pharynx in patients with unilateral medullary infarction.

Laterality of bolus passage in the pharynx is often seen in patients with medullary infarction. We evaluated the dominant side of bolus passage in the pharynx and investigated the factors that cause the passage to dominantly occur on the affected side. Forty-one patients (35 men and 6 women, 64 ± 9 years) with unilateral medullary infarction participated in this study. Bolus passage of 4 mL of thick liquid was evaluated in 3 regions (oropharyngeal, thyropharyngeal, and cricopharyngeal) and classified into 4 patterns (dominantly on the unaffected side [UAS], on both sides without clear laterality [BS], dominantly on the affected side [AS], and nonpassage of the bolus [NP]) by videofluoroscopic examination of swallowing. The bolus passages were as follows: UAS, BS, and AS occurred in 2, 32, and 7 patients in the oropharyngeal region; UAS, BS, and AS occurred in 5, 20, and 16 patients in the thyropharyngeal region; and UAS, BS, AS, and NP occurred in 11, 9, 10, and 11 patients in the cricopharyngeal region, respectively. In the thyropharyngeal region, the proportion of patients in whom the swallowing reflex occurred when the bolus was in the oropharynx and the proportion of patients with unilateral pharyngeal constrictor paralysis were greater in patients whose bolus passage was AS than in patients whose passage was BS. This suggests that the bolus predominantly passed through the affected side of the thyropharyngeal portion because of the asymmetry of pharyngeal contraction during swallowing in the early period after onset.

Dysphagia Testing with VF and VE : Understanding the Clinical Condition / The Japanese Journal of Rehabilitation Medicine

It is difficult to make dysphagia assessments in actual meal settings. Therefore, instrument-based evaluations are necessary, and videofluoroscopic examinations (VF) and video-endoscopic examinations (VE) of swallowing are typically performed for this purpose. Much information can be obtained by understanding the respective advantages and disadvantages of VF and VE and combining them for evaluations, making them useful for both assessment and treatment. Essentially, VF is contrast radiography using a fluoroscope. It uses test food containing a contrast agent that allows the flow of the food from the mouth to the pharynx and esophagus accompanying swallowing movements to be observed in real time to determine whether there is aspiration or food remaining in the pharynx. The images are taken mainly from the frontal and lateral views under fluoroscopy. VE is a test that involves direct fiberscopic observation of things such as glottal closure, saliva and secretions, and food boluses or other substances remaining in the pharynx. Assessment includes evaluation of vocal cord paralysis, redness and swelling of the arytenoid region, and whether there is saliva aspiration into the larynx. Next, the swallowing function is assessed using actual food. The body posture used in the test is the individual's regular posture when eating and a safe, proper posture with a low risk of aspiration. Today, VF and VE are essential tools for assessing and treating dysphagia. It is hoped that many practitioners will acquire the skills to administer and make use of these tests in the rehabilitation of patients with eating and swallowing disorders.

Food and Liquid Swallowing Difficulty in Stroke Patients : A Study based on the Findings of Food Tests, a Modified Water Swallowing Test and Videofluoroscopic Examination of Swallowing / The Japanese Journal of Rehabilitation Medicine

We compared food and water swallowing tests to investigate the reliability of the tests to exclude aspiration following acute stroke. Subjects were 155 patients with cerebral strokes aged between 20.98 years (66.6±12.9 years) and for whom videofluoroscopic examination of swallowing (VF) was performed for swallowing difficulty or suspected swallowing difficulty. Food tests (FTs) using jelly and rice porridge, and a modified water swallowing test (MWST) were evaluated during VF. The results showed fewer occurrences of choking, cough, wet voice and aspiration during the FTs than in the MWST. The sensitivity and specificity of the FTs for aspiration ranged from 80.0% to 83.3% and 25.5% to 41.3%, respectively. The MWST gave a sensitivity of 58.0% and a specificity of 72.4% for aspiration. There were more incidences of silent aspiration in the MWST than in the FTs. However, the validity of the FTs and their positive predictive value were lower than for the MWST. Choking and cough had a significant relation to aspiration in both tests. We recommend that we need to use each of these tests with an understanding of their characteristics and limitations in order to obtain correct findings in stroke patient swallowing assessments.

Gastrointestinal Complications and Intestinal Stasis after Videofluoroscopic Examination of Swallowing / The Japanese Journal of Rehabilitation Medicine

The purpose of this study was to investigate the occurrence of gastrointestinal complications and intestinal stasis after a videofluoroscopic examination of swallowing. Of 121 inpatients who underwent videofluoroscopic examinations from October 2008 to March 2009 and September to October 2009, we analyzed 33 patients who underwent abdominal X-ray four days after their videofluoroscopic examination. Six of 33 patients (18.2%) suffered gastrointestinal symptoms. Three patients had diarrhea, two had vomiting, and one had abdominal distention. The incidence of gastrointestinal complications after videofluoroscopic examination was estimated to be two of 33 patients (6.1%) because we assumed that two of the six patients' condition was related to their videofluoroscopic examination and that the other four were related to other factors. One of two patients with a poor general condition developed pneumonia after vomiting. There was no relationship between the incidence of gastrointestinal complications and the patient's background. Intestinal stasis as detected by X-ray was identified in 25 of 33 patients (75.8%). There was more barium sulfate intake in the patients who had intestinal stasis than the patients who had no intestinal stasis. There was no relationship between intestinal stasis and the incidence of gastrointestinal complications. Our findings suggest that the risk of gastrointestinal complications after videofluoroscopic examination is low except in patients with a poor general condition.

A Case Report of Isolated ACTH Deficiency with Severe Dysphasia / The Japanese Journal of Rehabilitation Medicine

The following report illustrates a rare case of dysphagia caused by secondary adrenal insufficiency in a patient with isolated ACTH deficiency. A 76-year-old man with progressive appetite loss, weight loss and general fatigue was hospitalized due to dehydration, aspiration pneumonia and hypoglycemia. He was unable to stand and walk by himself. His serum cortisol and ACTH levels were both low. An endocrinological examination resulted in a diagnosis of isolated ACTH deficiency. Following the administration of 15mg of glucocorticoids daily, his symptoms diminished without dysphagia. Furthermore, we investigated his swallowing function using a videofluoroscopic examination of swallowing (VF). The VF showed an impaired laryngeal movement as well as an upper esophageal opening and severe aspiration without a delay in his swallowing reflex. Oral intake was judged to be impossible, but his swallowing function gradually improved and he was able to resume eating all of his meals 2 months after treatment. Dysphagia is not a common symptom in ACTH deficient patients but a few similar cases have been reported. The swallowing function of the patients in these cases was not evaluated in detail, so we evaluated this case according to the results of the VF and the patient's process of recovery. Careful monitoring of swallowing function and appropriate treatment for both dysphagia and adrenocortical failure are required for the recovery of such patients. In conclusion, practitioners should be wary of isolated ACTH deficiency in elderly patients with progressive weight loss and dysphagia.

Early Pulmonary Complications after Videofluoroscopic Examination of Swallowing / The Japanese Journal of Rehabilitation Medicine

Videofluoroscopic examination of swallowing (VF) is widely used for evaluating swallowing function. However, pulmonary complications after VF are seldom evaluated. We checked residual barium sulfate on chest X-rays and early pulmonary complication after VF. One hundred and ninety-eight patients underwent VF and chest X-rays. Eighty-six patients who did not aspirate during VF had no residual barium on their chest X-rays. One hundred and twelve patients aspirated during VF, but only 40 of these patients showed residual barium on their chest X-rays. Ten patients had fever after VF, but no significant relationship was observed between fever and residual barium on chest X-rays or aspiration. Aspiration was not correlated with mobility or cognitive status. One case had pneumonia after VF, but VF did not seem to be the cause of the pneumonia. In conclusion, no severe early pulmonary complications after VF were observed. It is difficult to predict early pulmonary complications from chest X-rays.