柴田 斉子

BACKGROUND: The association between oral food intake and oral function during the subacute stage of stroke is not well known. OBJECTIVE: To investigate (1) oral function changes in subacute stroke patients and (2) association between oral function and oral intake status at several time points. METHODS: In a prospective study involving 324 stroke patients at a convalescent rehabilitation unit, four oral function parameters (maximum tongue pressure, MTP; lip-tongue motor function, LTMF; maximum occlusal force, MOF and oral health assessment tool, OHAT) were quantitatively measured upon admission (T0), at 1 month (T1) and 2 months (T2). Oral feeding status was assessed using the Functional Oral Intake Scale (FOIS) and divided based on the FOIS score into the dysphagic and regular diet groups. The changes in oral functions at the three time points were tested using generalized estimating equation analysis. The association between FOIS groups and oral functions at T1 and T2 was analysed by means of logistic regression analysis. RESULTS: All oral function parameters improved significantly over time during the hospital stay (mean differences: 4.9 for MTP, 0.6 for LTMF, 1.1 for MOF and -1.8 for OHAT). The FOIS groups were significantly associated with MTP (p < .05) and OHAT (p < .05) at both T1 and T2. CONCLUSION: Our findings suggest that oral function significantly improves in patients during subacute stroke rehabilitation and better oral health can be associated with better oral intake. Improved oral function through dental intervention and oral rehabilitation may contribute to gains in oral food intake.

BACKGROUND: Upper oesophageal sphincter (UES) serves as an important anatomical and functional landmark during swallowing. However, the precise UES location before and during swallowing has not been well established. OBJECTIVE: This study aimed to determine upper oesophageal sphincter (UES) location and displacement during swallowing accounting for sex, age, and height in healthy adults using 320-row area detector computed tomography (320-ADCT). METHODS: Ninety-four healthy adults (43 males; 22-90 years) underwent 320-ADCT scanning while swallowing one trial of 10 mL honey thick barium. UES location at bolus hold and at maximum displacement and vertical displacement during swallowing were identified using the coordinates and the section classification of vertebrae (VERT scale). The differences and correlations of UES location and distance in terms of sex, age, and height were analysed using Mann-Whitney U test and Spearman's correlation coefficient. RESULTS: UES locations at bolus hold and at maximum displacement were significantly lower and UES vertical displacement was significantly larger in males than in females (p < .001). UES location at bolus hold became lower with increasing age (r = -.312, p = .002), but the negative correlation was low at maximum displacement (r = -.230, p = .026), resulting in larger vertical distance with ageing. UES locations showed high negative correlation at bolus hold with height (r = -.715, p < .001), and showed moderate negative correlation at maximum displacement with height (r = -.555, p < .001), although this effect was unclear when analysed by sex. CONCLUSION: Males showed lower UES location and larger displacement than females. The impact of age was evident with lower location before swallowing and larger displacement during swallowing. Differences observed by sex were not completely explained by using the VERT scale to adjust for height.

OBJECTIVES: To examine the functional outcomes of patients with coronavirus disease 2019 (COVID-19) who underwent a new protocol-based rehabilitation program. METHODS: In this retrospective cohort study, we enrolled patients who were hospitalised in a university hospital in Japan because of COVID-19 from 1st September, 2020-5th July, 2021. The primary outcome was the Functional Independence Measure (FIM) subtotal score for motor items at discharge. The secondary outcomes included the FIM cognitive subtotal score, length of hospital stay, rehabilitation period, total rehabilitation time, final rehabilitation protocol level, and discharge destination. RESULTS: Of the 78 enrolled patients (49 men; mean age [standard deviation], 70.3 [13.9] years), 24 died (30.8%) during hospitalisation. Disease severity was classified as mild, moderate I, moderate II, and severe in 1, 6, 41, and 30 patients, respectively. The FIM motor subtotal score differed significantly among groups for all participants (p=0.027). Post hoc analysis revealed that the FIM motor subtotal score in the severe group was significantly lower than that in the moderate II group (p=0.030). CONCLUSIONS: Disease severity significantly affected patients' functional outcome for COVID-19 at discharge. Our protocol-based program provides a benchmark for COVID-19 rehabilitation in an acute care setting.

Objectives: Hyolaryngeal movement during swallowing is essential to airway protection and bolus clearance. Although palpation is widely used to evaluate hyolaryngeal motion, insufficient accuracy has been reported. The Bando Stretchable Strain Sensor for Swallowing (B4S™) was developed to capture hyolaryngeal elevation and display it as waveforms. This study compared laryngeal movement time detected by the B4S™ with laryngeal movement time measured by videofluoroscopy (VF). Methods: Participants were 20 patients without swallowing difficulty (10 men, 10 women; age 30.6 ± 7.1 years). The B4S™ was attached to the anterior neck and two saliva swallows were measured on VF images to determine the relative and absolute reliability of laryngeal elevation time measured on VF and that measured by the B4S™. Results: The intra-class correlation coefficient of the VF and B4S™ times was very high [ICC (1.1) = 0.980]. A Bland-Altman plot showed a strong positive correlation with a 95% confidence interval of 0.00-3.01 for the mean VF time and mean B4S™ time, with a fixed error detected in the positive direction but with no proportional error detected. Thus, the VF and B4S™ time measurements showed high consistency. Conclusion: The strong relative and absolute reliability suggest that the B4S™ can accurately detect the duration of superior-inferior laryngeal motion during swallowing. Further study is needed to develop a method for measuring the distance of laryngeal elevation. It is also necessary to investigate the usefulness of this device for evaluation and treatment in clinical settings.

Objective: To compare the functional outcomes of patients with lower limb amputations receiving haemodialysis and those not receiving haemodialysis.Design: A retrospective cohort study. Patients: Patients with lower limb amputation who were admitted to a convalescent rehabilitation ward between January 2018 and December 2021.Methods: The primary outcome was the effectiveness of the Functional Independence Measure (FIM) during hospitalisation in the ward. Secondary outcomes included the total and subtotal (motor/cognitive) FIM scores at discharge, gain in the total and subtotal (motor/cognitive) FIM scores, K-level at discharge, length of hospital stay in the ward, rehabilitation time, and discharge destination. Outcomes were compared between the non-haemodialysis and haemodialysis groups.Results: A total of 28 patients (mean [standard deviation] age, 67.0 [11.9] years; men, 20) were enrolled in this study. Among them, 11 patients underwent haemodialysis. The FIM effectiveness was significantly higher in the non-haemodialysis group than in the haemodialysis group (median [interquartile range], 0.78 [0.72 – 0.81] vs 0.65 [0.28 – 0.75], p = 0.038). The amount of rehabilitation and all secondary outcomes were not significantly different between the groups (p &gt; 0.05).Conclusion: Patients with lower limb amputation who were receiving haemodialysis had poorer FIM effectiveness than those not receiving haemodialysis.LAY ABSTRACTChronic kidney disease is a risk factor for foot ulcers and lower limb amputation. Thus, patients with lower limb amputation often require maintenance dialysis. However, there is a lack of knowledge on whether patients with lower limb amputation receiving haemodialysis can achieve functional outcomes comparable to those not receiving haemodialysis. This study aimed to compare functional outcomes between patients with lower limb amputations receiving haemodialysis and those not receiving haemodialysis. This retrospective cohort study enrolled 28 patients who underwent amputation surgery and were admitted to a rehabilitation ward, including 11 patients undergoing haemodialysis (8 with diabetic nephropathy, 1 with chronic glomerulonephritis, 1 with rapidly progressive glomerulonephritis, and 1 with acute kidney injury). Although the amount of rehabilitation did not differ between groups, the improvement in the activities of daily living was significantly better in the non-haemodialysis group than in the haemodialysis group. Thus, even the same amount of rehabilitation for patients with lower limb amputations receiving haemodialysis may not lead to functional outcomes comparable to those without haemodialysis.

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 previous studies reported that different volumes of thick liquid had an impact on spatiotemporal characteristics and pharyngeal response of swallowing. However, the bolus flow and swallowing motion pattern were different between thick and thin liquids. The effects of thin bolus volume on pharyngeal swallowing, especially true vocal cord (TVC) closure is still unclear. This study assessed the temporal characteristics when swallowing different volumes of thin liquid to determine the mechanical adaptation using 320-row area detector computed tomography (320-ADCT) and investigated a change of swallowing physiology including laryngeal closure, particularly TVC closure. Fourteen healthy women (28-45 years) underwent 320-ADCT while swallowing of 3, 10, and 20 ml of thin liquid barium in 45° semi-reclining position. Kinematic analysis was performed for each swallow including temporal characteristic, structural movements while swallowing, and maximal cross-sectional area of the upper esophageal sphincter (UES) opening. Bolus head reached to pharynx and esophagus earlier in larger volume significantly, indicating faster bolus transport as volume increased. There were significant effects on swallowing mechanism revealing earlier TVC closure and UES opening with increasing volume. Maximum cross-sectional area of the UES opening was increased to accommodate a larger bolus. Differences in mechanical adaptation through bolus transit and motion of swallowing structures were detected across increasing volumes. These volume-dependent adaptations potentially reduce the risk of aspiration. Understanding the swallowing physiological changes as volume increased is helpful for diagnosis and treatment of dysphagia patients as well as outcomes of swallowing rehabilitation in clinical practice.

OBJECTIVES: To examine the relationship between patients' transfer ability and fall risk in stroke patients during hospitalization. MATERIALS AND METHODS: We retrospectively enrolled 237 stroke patients who were transferred to a convalescent rehabilitation ward from acute wards in the same hospital. Using incident reports, we investigated their fall rates and activity status at the falls according to their transfer abilities, which were assessed with Functional Independence Measure (FIM) transfer scores. The bi-weekly time trend of fall rates in all patients and in three subgroups based on FIM transfer scores of 1-3, 4-5, and 6-7, and activity status at the falls, were investigated. In addition, changes of patients' transfer ability on admission, at the first fall, and at discharge were investigated among falling patients. RESULTS: The fall rate was the greatest in patients with a FIM transfer score of 4 (14.3 times/1000 person-days). The majority of falls for patients with a FIM transfer score of 1 occurred at the activity status of "on the bed" and "sitting", while three quarters of patients with a FIM score of 7 had falls during "standing" and "walking". No longitudinal trend in fall rates was found overall; however, the fall rate trends differed depending on the FIM transfer score. The majority of the patients who fell required full assistance for transfers upon admission but required no assistance at discharge. CONCLUSIONS: Fall risk differed among patients with various transfer abilities; the greatest risk was in those who needed minimal assistance for transfers.

PURPOSE: The purpose of this study was to elucidate the effects of the tongue-hold swallow (THS) on the pharyngeal wall by quantifying posterior pharyngeal wall (PPW) anterior bulge during the THS. In addition, the effect of tongue protrusion length on the extent of pharyngeal wall anterior bulge was analysed. METHODS: Thirteen healthy subjects (6 males and 7 females, 23-43 years) underwent 320-row area detector CT during saliva swallow (SS) and THS at two tongue protrusion lengths (THS1 protrude the tongue as much as 1/3 of premeasured maximum tongue protrusion length (MTP-L) and THS2 protrude the tongue as much as 2/3 of MTP-L). To acquire images of the pharynx at rest, single-phase volume scanning was performed three times during usual breathing with no tongue protrusion (rest), protrusion of the tongue at 1/3 of MTP-L (rTHS1) and protrusion of the tongue at 2/3 of MTP-L (rTHS2). Length from cervical spine to PPW (PPW-AP) and the volume of pharyngeal cavity was measured and was compared between rest, rTHS1 and rTHS2 and between SS, THS1 and THS2. Correlation between MTP-L and PPW-AP was calculated in three conditions, SS, THS1 and THS2. RESULTS: PPW-AP at rest, rTHS1 and rTHS2 was 2.9 ± 0.6 mm, 3.0 ± 0.5 mm and 3.0 ± 0.5 mm, respectively, showing no significant differences across swallows. PPW-AP at the maximum pharyngeal constriction was 8.1 ± 2.0 mm, 9.1 ± 2.4 mm and 8.7 ± 2.0 mm in SS, THS1 and THS2, respectively. Compared to SS, PPW-AP in THS1 was significantly larger (p = 0.04) and PPW-AP in THS2 was not significantly different (p = 0.09). Pharyngeal volume at rest, rTHS1 and rTHS2 was 16.4 ± 5.2 mm3 , 18.4 ± 4.5 mm3 and 21.3 ± 6.2 mm3 , respectively. It was significantly larger during rTHS2 compared with rest or rTHS1 (rTHS2-rest p = 0.007, rTHS2-rTHS1 p = 0.007). Pharyngeal volume was completely obliterated (zero volume) at maximum pharyngeal contraction in all except one subject. There was no correlation between MTP-L and PPW-AP in any of the three conditions (SS, THS1 and THS2). DISCUSSION: This study demonstrated that the expanded pharyngeal cavity due to the tongue protrusion was completely obliterated by the increase in anterior motion of pharyngeal wall during THS. It also became clear that the degree of tongue protrusion did not linearly correlate with the movement of PPW during THS. There was no relationship between PPW motion and the MTP-L, suggesting that the effect of tongue protrusion is better determined in each subject by analysing the motion of PPW using imaging tools.

BACKGROUND: Electrical stimulation therapy is effective for patients with dysphagia. However, because of the pain, strong stimulation cannot be applied. Although magnetic stimulation induces less pain, there are no reports on magnetic stimulation being synchronised with a swallowing reflex. OBJECTIVE: This study aimed to determine whether it is possible to induce magnetic stimulation during a voluntary swallowing using electromyography (EMG)-triggered peripheral magnetic stimulation and to evaluate its effect on healthy individuals. METHODS: A total of 20 healthy adults in seated position were instructed to swallow saliva and 10 ml of barium under videofluoroscopy. For concomitant use of magnetic stimulation, a magnetic stimulus for suprahyoid muscles at 30 Hz frequency was applied for 2 s when the EMG level in the sternohyoid muscle exceeded the threshold. During the voluntary swallowing, the movement of the hyoid bone and opening width of the upper oesophageal sphincter (UES) were measured. Furthermore, pressure topography was evaluated in 6 subjects using high-resolution manometry. RESULTS: The magnetic stimulation significantly extended the movement time of the hyoid bone (p < 0.001). During liquid deglutition, significant increases were observed in the anterior maximum movement distance of the hyoid bone (p < 0.05), opening width of the UES (p < 0.001) and anterior movement distance of the hyoid bone at the maximum UES opening (p < 0.01). In the pressure topography, the maximum pressure immediately after UES closure significantly decreased with magnetic stimulation (p < 0.05). CONCLUSION: EMG-triggered peripheral magnetic stimulation made it possible to apply magnetic stimulation during a voluntary swallowing.

BACKGROUND: Stroke patients often suffer from dysphagia during their recovery. We hypothesised that subacute stroke patients with dysphagia had more deteriorated oral health status including muscle strength and motor function. OBJECTIVE: Quantitatively investigate oral health status and identify associations with oral feeding status in stroke patients admitted to a convalescent rehabilitation unit. METHODS: We prospectively recruited 187 stroke patients admitted to a convalescent rehabilitation unit. Oral feeding status was examined using the Functional Oral Intake Scale (FOIS), and the cohort was divided into three groups based on FOIS score as non-oral feeding (FOIS-123; 22 patients), dysphagic diet (FOIS-45; 74 patients), and regular diet (FOIS-67; 91 patients) groups. Activities of daily living (ADL) were assessed with the Functional Independence Measure (FIM). Oral health status was measured quantitatively in six oral function parameters and Oral Health Assessment Tool (OHAT), and differences according to the FOIS, age and FIM were statistically tested. RESULTS: In bivariate analysis, two parameters, tongue pressure and tongue-lip motor functions were significantly higher in the regular diet group than in the other groups (P < .01). Gross OHAT score was also significantly better in the regular diet group than in the other groups (P < .01). These significant associations mostly remained in the multiple model after adjusting for age and FIM. CONCLUSION: This study suggests that, amongst oral health status, tongue strength and motor function, as well as OHAT score, may have strong associations with oral feeding status in subacute stroke patients at convalescent rehabilitation units regardless of ADL levels.

ABSTRACT: Dysphagia is the difficulty in swallowing because of the presence of certain diseases; it particularly compromises the oral and/or pharyngeal stages. In severe acute respiratory syndrome coronavirus 2 infection, neuromuscular complications, prolonged bed rest, and endotracheal intubation target different levels of the swallowing network. Thus, critically ill patients are prone to dysphagia and aspiration pneumonia. In this review, we first discuss the possible cause and pathophysiology underlying dysphagia associated with coronavirus disease 2019, including cerebrovascular events, such as stroke, encephalomyelitis, encephalopathy, peripheral neuropathy, and myositis, that may lead to the dysphagia reported as a complication associated with the coronavirus disease 2019. Next, we present some recommendations for dysphagia evaluation with modifications that would allow a safe and comprehensive assessment based on available evidence to date, including critical considerations of the appropriate use of personal protective equipment and optimization individual's noninstrumental swallowing tasks evaluation, while preserving instrumental assessments for urgent cases only. Finally, we discuss a practical managing strategy for dysphagia rehabilitation to ensure safe and efficient practice in the risks of severe acute respiratory syndrome coronavirus 2 exposure, in which swallowing therapy using newer technology, such as telerehabilitation system or wearable device, would be considered as a useful option.

【目的】兵頭スコアを用いて摂食嚥下障害の重症度や推奨食形態,水分形態が予測可能かどうかを後方視的観察研究により明らかにすること.【方法】当院で摂食嚥下障害が疑われた741例を対象とした.年齢は中央値77歳,主病名は呼吸器疾患,脳血管疾患が多かった.嚥下内視鏡検査の結果から,兵頭スコア,嚥下障害の重症度,推奨飲食形態を決定した.嚥下障害の重症度はDysphagia Severity Scale(DSS)で評価した.推奨食形態は主食は7通り,副食は8通り,推奨水分は6通りからの選択とした.【結果】DSS,兵頭スコアともに中央値は4であった.順序ロジスティック解析の結果,兵頭スコアは安静時,トータルスコアともに,DSS,推奨された主食,副食,水分に有意に関連する因子であった(p<0.001).【結論】摂食嚥下障害の重症度や推奨食形態,水分形態の予測に兵頭スコアは有用であった.(著者抄録)

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.

Swallowing disorder or dysphagia is quite common in hospitalised patients. Using fibre-optic endoscopic evaluation of swallowing (FEES) is one of the clinical standards for evaluating swallowing disorder to prevent serious consequences such as aspiration pneumonia. This study aimed to determine the prevalence and the associated risk of dysphagia in hospitalised patients by using FEES finding. We retrospectively analysed the FEES records from the patients who were screened and suspected of swallowing problems by a certified nurse of dysphagia nursing (CNDN). The FEES findings were compared between dysphagia and without dysphagia to evaluate the associated risk of dysphagia. Six-hundred and nine FEES records were analysed. We found dysphagia 76% in patients who suspected swallowing problems by CNDN. FEES was assessed after the subjects had been admitted for 22 days on average. There was no difference in age between dysphagia and without dysphagia participants. However, the advanced age (age > 85 years old) increased the odd of dysphagia 1.18, P = .03. The primary disease of the subjects was mainly cerebrovascular disease (24%) and pneumonia (22%). Abnormal FEES findings including soft palate elevation, velopharyngeal contraction, whiteout, volitional cough, glottis closure during breath holding, cough reflex and presence of secretion in pharynx were found in hospitalised patients with dysphagia. The prevalence of dysphagia was high in hospitalised patients. Hence, screening the swallowing problem by nurse and FEES evaluation is essential to detect and prevent the complication in the patient who has dysphagia.

OBJECTIVE: This study investigated the effects of bolus consistency on pharyngeal volume during swallowing using three-dimensional kinematic analysis. METHODS: Eight subjects (2 males and 6 females, mean ± SD 44 ± 10 years old) underwent a 320-row area detector scan during swallows of 10 mL of honey-thick liquid and thin liquid. Critical event timing (hyoid, soft palate, UES) and volume of pharyngeal cavity and bolus were measured and compared between two swallows. RESULTS: The pharynx is almost completely obliterated by pharyngeal constriction against the tongue base for both consistencies. There were no significant differences in maximum volume, minimum volume and pharyngeal volume constriction ratio values between thick and thin liquids. However, the pattern of pharyngeal volume change (decrease) was different. For thick liquids, the air volume started to decrease before the onset of hyoid anterosuperior movement and decreased rapidly after onset of hyoid anterosuperior movement. During thin liquid swallowing, air volume remained relatively large throughout the swallow and started to decrease later when compared to swallowing thick liquids. At onset of UES opening, the bolus volume was not significantly different between thin and thick liquids; however, air volume was significantly larger when swallowing thin liquids, which made the total volume of the pharyngeal cavity larger. CONCLUSION: This difference between the two consistencies is associated with differences in tongue motion to propel the bolus and clear the pharynx from possible residue.

OBJECTIVES: Surgical procedure is considered in patients with severe dysphagia when conservative treatment fails. This study aimed to evaluate laryngeal suspension (LS) and upper esophageal sphincter (UES) myotomy for treating severe dysphagia due to brain disease. METHODS: Fourteen patients underwent LS and UES myotomy, with a median follow-up of 5 years and 6 months when conservative treatment failed. The penetration-aspiration scale (PAS), the Dysphagia Severity Scale (DSS), the Eating Status Scale (ESS), and diet contents were evaluated just before surgery, at discharge, and at the last follow-up. RESULTS: Preoperative intake was tube feeding in all patients. The patients learned the extended head and flexed neck posture to open the esophageal inlet. PAS, DSS and ESS scores, and diet contents were significantly improved at discharge compared with before surgery, and were maintained until the last follow-up. Eight patients had pneumonia during their hospital stay, and five had pneumonia between discharge and at the last follow-up. Age was significantly, negatively correlated with DSS and ESS at the last follow-up. CONCLUSION: Although LS and UES myotomy require a long inpatient rehabilitation and the risk of pneumonia after surgery is high, the outcome is favorable and the effects last for a long time.

【目的】摂食嚥下機能評価に用いる嚥下造影検査(VF)ではおもにバリウムを使用するが,VF後の下剤使用についてのコンセンサスは得られていない.本研究の目的はVF後の消化管内バリウム残留を評価し,下剤使用の有用性を検討することである.【方法】Study 1ではVF,および3日後に腹部X線撮影を施行した88例を対象に投与バリウム量と残留位置,残留部位数,消化管症状を評価した.Study 2ではVFで10g以上のバリウムを使用しかつ下剤投与を行った51例とStudy 1で10g以上のバリウムを使用した63例を比較した.【結果】Study 1では60例にバリウム残留を認め10g以上バリウムを使用した症例で残留と残留部位数が多かった(p<0.001).Study 2では下剤を投与した症例ではもっとも口側のバリウムがより肛門側に移動し(p=0.043),バリウム残留部位数が少なかった(p=0.017).【結論】VF中にバリウムを10g以上使用するとバリウム残留が多くなる.また,下剤投与はバリウムの排泄を促進する.(著者抄録)

【目的】前舌保持嚥下法(THS)が嚥下時の咽頭腔に与える影響について,320列面検出器型CT(CT)を用いて3次元的に運動学的解析を行った.THSでは咽頭腔体積が唾液嚥下(SS)に比べ減少する,つまり咽頭がより縮小すると仮説を立てた.【方法】言語聴覚士6名(22-29歳)を対象とした.SSとTHSをCTにて撮影し,咽頭腔体積,舌骨喉頭の運動距離,食道入口部(UES)の開大面積を計測し,SSとTHSで比較した.【結果】嚥下中の咽頭腔体積はSSに比しTHSで縮小する例だけでなく,拡大する例も認めた.嚥下開始時の舌骨,および最大上方位の舌骨喉頭はTHSで有意に高かった.UES面積はTHSで有意に大きかった.【考察】THSによる咽頭腔体積への影響は一定の傾向を認めなかった.今後,挺舌長などTHSの方法論について検討する必要が示唆された.また舌骨喉頭挙上およびUES開大にも寄与する可能性が示された.(著者抄録)

【目的】前舌保持嚥下法(THS)が嚥下時の咽頭腔に与える影響について,320列面検出器型CT(CT)を用いて3次元的に運動学的解析を行った.THSでは咽頭腔体積が唾液嚥下(SS)に比べ減少する,つまり咽頭がより縮小すると仮説を立てた.【方法】言語聴覚士6名(22-29歳)を対象とした.SSとTHSをCTにて撮影し,咽頭腔体積,舌骨喉頭の運動距離,食道入口部(UES)の開大面積を計測し,SSとTHSで比較した.【結果】嚥下中の咽頭腔体積はSSに比しTHSで縮小する例だけでなく,拡大する例も認めた.嚥下開始時の舌骨,および最大上方位の舌骨喉頭はTHSで有意に高かった.UES面積はTHSで有意に大きかった.【考察】THSによる咽頭腔体積への影響は一定の傾向を認めなかった.今後,挺舌長などTHSの方法論について検討する必要が示唆された.また舌骨喉頭挙上およびUES開大にも寄与する可能性が示された.(著者抄録)

This study used 320-row area detector computed tomography (320-ADCT) to determine whether kinematic swallowing events and bolus movement through the oropharynx are affected by bolus consistency and angle of recline. Fourteen healthy adults (4 men, 10 women; age, 22-90 years) underwent 320-ADCT assessment during three 10-mL barium swallow tests, with honey-thick liquid at 60° recline (60°thick), thin liquid at 60° recline (60°thin), and thin liquid at 45° recline (45°thin). The times of swallowing events were measured and compared among the different tests. Bolus propulsion, onset time of true vocal cord (TVC) closure, and upper esophageal sphincter opening were significantly earlier for 60°thin than for 60°thick. Onset time did not significantly differ between 60°thin and 45°thin; however, greater variability was noted for onset of TVC closure with 45°thin, as the TVC started to close before onset of swallowing in 30% of participants. Modulation of TVC closure depends on bolus transport in different reclining positions. The 45° reclining position elicited pre-swallow TVC closure in some participants, which suggests that excessive recline can increase perceived risk of airway invasion during swallowing.

【目的】舌骨挙上障害を持つ摂食嚥下障害に対する末梢磁気刺激治療の実現可能性を検討した。【方法】2秒間の磁気刺激を30回で1セットとして1日に2〜3セット、1週間に5日以上の反復末梢磁気刺激治療(repetitive peripheral magnetic stimulation:rPMS)を6週間、舌骨挙上障害を持つ摂食嚥下障害患者2例に対して施行した。【結果】2例ともに、6週間のrPMSを問題なく施行可能であった。82歳の誤嚥性肺炎後の廃用症候群患者ではrPMS後に筋力および舌骨挙上距離の改善を認めた。47歳の皮膚筋炎患者ではrPMS介入後に筋力および筋疲労の改善を認めた。磁気刺激後には頸部のこわばりが軽減し食事中の疲労感が軽減した。【結論】舌骨挙上障害に対するrPMSは新しい治療法となりうる可能性がある。(著者抄録)

&lt;p&gt;Ozeki M, Kagaya H, Shibata S, Onogi K, Sugiyama T, Saitoh E. Transanal irrigation for bowel dysfunction in chronic stage of spinal cord-injured patients. Jpn J Compr Rehabil Sci 2019; 10: 9-13.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Objective&lt;/b&gt;: To investigate the efficacy of transanal irrigation (TAI) for patients with spinal cord injury who experience subjective symptoms, such as abdominal distension, due to constipation that has not been well managed.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Methods&lt;/b&gt;: An irrigation kit was used to perform TAI on 8 patients with spinal cord injury (mean age, 44 years). The patients had the following injury sites: cervical spinal cord (2 patients), thoracic spinal cord (4 patients), lumbar spinal cord (1 patient), and sacral spinal cord (1 patient). Before and after the irrigation procedure, we assessed the time spent on defecation, time interval between defecations, constipation, diarrhea, fecal incontinence, defecation management methods, and defecation status using a visual analogue scale (VAS). At the last follow-up, we examined the usage of irrigation, constipation, diarrhea, fecal incontinence, and defecation management methods.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Results&lt;/b&gt;: Irrigation was possible for all patients included in this study. No changes were observed in the time spent on defecation or the interval between defecations. However, we did observe a significant decrease in constipation and a significant improvement in VAS after the irrigation procedure. Four patients were continuing the use of irrigation at the last followup. Including the 2 patients who discontinued irrigation because their defecation management improved, satisfactory results were observed in 6 patients.&lt;/p&gt;&lt;p&gt;&lt;b&gt;Conclusion&lt;/b&gt;: Irrigation using an irrigation kit was effective for bowel dysfunction in patients with spinal cord injury.&lt;/p&gt;

【目的】一口嚥下,連続嚥下,咀嚼嚥下の喉頭侵入,誤嚥のリスクを比較すること.【方法】2011年1月から2016年5月に嚥下造影検査において液体10mLの一口嚥下(LQ10),液体コップ30gの連続嚥下(CUP30),液体5mLとコンビーフ4gの混合物の咀嚼嚥下(MX)の3試行を座位かつ代償手技なしに行った136例の喉頭侵入,誤嚥の有無を評価した.それぞれの難易度はMcNemar検定で,Penetration-Aspiration Scale(P-A Scale)はSpearmanの順位相関係数を用いて検討した.【結果】喉頭侵入はLQ10で73例,MXで62例,CUP30で97例認め,CUP30ではLQ10よりも(p<0.001),またMXよりも(p<0.001)有意に多く認めた.誤嚥はLQ10で8例,MXで14例,CUP30で20例認め,CUP30ではLQ10よりも有意に多く認めた(p=0.009).P-A Scaleの相関係数はLQ10とCUP30ではρ=0.370(p<0.001)と有意であったがMXとCUP30はρ=0.100(p=0.312),LQ10とMXではρ=-0.202(p=0.055)と有意ではなかった.【結論】喉頭侵入の頻度はCUP30,LQ10,MXの順に高く,誤嚥の頻度はCUP30,MX,LQ10の順に高かった.MXのP-A ScaleはLQ,CUP30のそれとは有意な相関がみられなかった.(著者抄録)

症例は52歳男性で、右ワレンベルグ症候群と診断され、発症2週間後に誤嚥性肺炎を併発した。人工呼吸管理の後、気管切開を施行されたが、経口摂取が困難なため、発症5ヵ月後に胃瘻造設された。その後、本人が経口摂取を強く希望し、発症1年2ヵ月後に当科紹介となった。本症例の摂食嚥下障害は、咽頭への食塊送り込み不良、舌骨挙上不良、食道入口部通過不良が原因と考えられ、さらに高解像度マノメトリーと筋電図検査から食道入口部通過不良は咽頭圧低下と食道入口部の弛緩不全に起因すると推測した。保存加療では経口摂取の実現は困難と判断し、手術療法について検討した。入院71日目に喉頭挙上術(甲状軟骨舌骨下顎骨固定術)および両側輪状咽頭筋切断術を行った。術後1ヵ月で摂食嚥下障害臨床的重症度分類は4(機会誤嚥)となり自宅退院し、常食とnectar thickの経口摂取を継続した。