Earticle

본 연구는 증례를 통해 먹기와 삼킴장애를 동반한 누난증후군 아동에게 삼킴재활치료가 효과적인지 알아보고자 진행 되었다. 대상 아동은 유전의학 검사를 통해 누난증후군으로 진단 받은 남아였다. 2세5개월(29개월)경 음식 섭취 시 씹지 않고 물고 있는 경향을 보이고 죽 이외에는 섭취 안 하려는 모습을 보여 삼킴재활치료가 의뢰되었다. 당시 시행한 삼킴 기능 평가에서 Behavioral Assessment Scale of Oral Function in Feeding(BASOFF) 24점, American Speech Language and Hearing Association: National outcomes measurements system(ASHA NOMS) 5단계로 평가되었다. 아동의 주 증상은 볼, 입술, 혀의 기능 저하, 음식 섭취 거부, 씹기 기능 저하로 이에 대한 치료 목표를 볼, 입술, 혀의 기능, 씹기 기능 향상 및 음식 섭취 거부 감소를 통한 일반식 섭취로 설정하였고, 주 1회 30분씩 삼킴재활치료를 시행하였다. 삼킴재활 치료로 감각운동 자극, 볼, 입술, 혀 운동, 씹기 운동, 음식 섭취 거부 감소를 위한 훈련, 음식 섭취 훈련을 받았다. 2세9개월 (33개월)에 재시행한 평가에서 BASOFF 38점, ASHA NOMS 6단계로 향상된 모습을 보였다. 3세1개월(37개월)에 재시 행한 평가에서는 BASOFF 44점, ASHA NOMS 7단계로 향상된 모습을 보였고 삼킴재활치료 목표였던 일반식 섭취에 도 달하여 삼킴재활치료를 종결하였다. 종결 당시 아동은 과자, 오징어채, 쥐포 등 다양한 재질의 음식 제공 시 음식덩이 형성 에 어려움 보이지 않았고 흘림이나 기침 없이 삼킴이 가능하였다. 컵으로 물을 마실 때도 흘림이나 기침, 음식에 대한 거부 반응 없이 삼킴이 가능하였다. 본 증례를 통해 삼킴장애를 보이는 누난증후군 아동에게 감각운동 자극, 볼, 입술, 혀 운동, 씹기 운동, 음식 섭취 거부 감소를 위한 훈련, 음식 섭취 훈련과 같은 삼킴재활치료가 효과적인 중재임을 시사하는 바이다.

The purpose of this report is to identify the effect of swallowing therapy on the child who was diagnosed with Noonan syndrome. At the initial examination (29 months old), the patient could not chew the food and hold in the mouth. He ate only the type of the puree and refused solid food. He was evaluated 24 scores on the Behavioral Assessment Scale of Oral Function in Feeding(BASOFF), and 5 levels on the American Speech Language and Hearing Association: National outcomes measurements system(ASHA NOMS). His main problem was decrease of the function of cheek, lips, tongue, and chewing, and refusal the food. So, he was participated in the swallowing therapy during 30 minutes, once a week. His goal was to eat regular diet through improved the swallowing function. The swallowing therapy consisted of oral sensory motor facilitation, exercise of the cheek, lips and tongue, chewing training, training for reduction of rejected food, and feeding training. At 33 months old, he was evaluated 38 scores on the BASOFF, and 6 levels on the ASHA NOMS. And at 37 months old, he was evaluated 44 scores on the BASOFF, and 7 levels on the ASHA NOMS. He could eat various type of the food without drooling, coughing, holding in the mouth, and refusal. He has reached the goal, so the swallowing therapy was finished. This report suggests that the swallowing therapy for children with Noonan syndrome who are difficult in feeding and swallowing has positive effects on swallowing function.

치매는 스스로 먹는 능력이나 음식을 입에 넣고 삼키는 과정에서 문제점을 나타낼 수 있으며, 식사량의 감소와 체중 감소를 야기하게 되고, 영양실조 및 탈수 등을 초래하게 되고, 이러한 상태는 치매 환자들의 주 사망 원인을 차지하게 된다. 이에 본 연구는 치매 종류별 연하장애의 특성과 중재 방법에 대해 알아보고자 하였다. 알츠하이머 치매는 감각 자극의 수용 문제로 인하여 정상 노인에 비해 많은 양의 감각 자극이 필요한 것으로 조사되었으며, 혈관성 치매의 경우 삼킴과 관련된 구조물들의 움직임이 현저히 저하되는 것을 확인할 수 있었다. 루이소체 치매는 파킨슨병과의 관련성으로 있는 것으로 섭식 장애와 연하장애가 일반적으로 나타나는 것으로 여겨지고 있었고, 전두측두엽치매의 경우 삼킴과 관련된 문제보다 행동적 인 측면에서 더 많은 문제점이 나타나는 것을 알 수 있었다. 치매 환자의 경우 인지적인 문제로 정상적인 의사소통이 어려워 평가와 중재가 어려운 점을 감안해 환자가 충분히 따라할 수 있는 단순한 방법들을 선택하여 시행하는 것이 중요할 것으로 판단된다. 또한 연하장애 뿐만 아니라 행동적인 측면의 문제점을 주의 깊게 관찰할 필요성이 요구되며, 각 단계에 맞는 적절 한 훈련을 실시해야 할 것으로 사료된다.

Dementia deteriorates individuals' ability to eat and swallow food. This disorder leads to weight loss, malnutrition, and dehydration. In addition, this neurological condition is a leading cause of death for individuals with dementia. The purpose of this study was to describe the characteristics of dysphagia interventions across types of dementia. Alzheimer's dementia has been found to require a more considerable amount of sensory stimulation than healthy older adults due to problems with sensory stimulation acceptance. In the case of vascular dementia, the movement of structures in the brain related to swallowing is significantly reduced. Lewy body dementia is associated with Parkinson's disease. These brain impairments frequently result in eating and swallowing problems. Behavioral problems are more common than swallowing problems in frontotemporal lobe dementia. Typically, cognitive problems make it difficult to evaluate and establish intervention plans for patients with dementia due to impaired communication skills. Considering this, it is crucial to select and implement simple methods that can be quickly followed by patients. Also, it is necessary to observe swallowing disorders as well as behavioral problems in this patient group and provide appropriate training for each stage to improve residual swallowing function.

Objectives: To examine the improvement of discharge swallowing status between patients with a primary dysphagia diagnosis and those with post-stroke dysphagia discharged from inpatient rehabilitation facilities (IRFs). Methods: A retrospective cohort design used data from the United States Uniform Data System for Medical Rehabilitation (UDSMR) during 2016 and 2017. Ordinal logistic regression model compared the swallowing status at discharge between the two comparison groups, accounting for baseline patient and clinical characteristics. Multiple imputations with the fully conditional specification method was used to deal with the missing observations for the discharge swallowing status variable. Results: The mean age of the sample was 71.4 years (SD = 12.8). A total of 992 patients were retrieved from the study data, including 64 patients with a primary dysphagia diagnosis and 928 patients with post-stroke dysphagia. Adjusted ordinal logistic regression model revealed that patients with primary dysphagia had lower odds of improving their swallowing status (odds ratio [OR] 0.300; 95% Confidence Interval [CI] 0.142, 0.636) than those with post-stroke dysphagia at discharge from IRFs. Similarly, the multiple imputations method revealed that patients with primary dysphagia had lower odds of swallowing status improvement at discharge from IRFs (OR 0.563; 95% CI 0.342, 0.925). Discussion: Patients with a primary dysphagia diagnosis receiving rehabilitation services in IRFs demonstrated substantially worse swallowing status compared to those with post-stroke dysphagia in a large national sample. This finding suggests that healthcare providers should be aware of the differences occurring in swallowing improvement across dysphagia diagnosis groups.

Objectives: To examine the association of stroke-induced dysphagia during an inpatient rehabilitation facility (IRF) stay and depressive symptoms at a 3-month follow-up. Methods: A retrospective cross-sectional design using the Stroke Recovery in Underserved Populations 2005-2006 study database. Hierarchical logistic regression models were utilized to examine if stroke-induced dysphagia is a significant predictor for depressive symptoms at 3-month follow-up across the stepwise introduction of the demographics and clinical characteristics at the IRF discharge and 3-month follow-up. Multiple imputations with Markov-chain Monte Carlo method was used to address the covariates with missing observations. Results: In a total of 1,045 stroke survivors, 335 (32.1%) stroke survivors had dysphagia and 710 (67.9%) stroke survivors did not have dysphagia during the IRF stay. The adjusted logistic regression model and multiple imputation method revealed that stroke survivors with dysphagia are more likely to have depressive symptoms at 3-month follow-up (Odds ratio [OR] 3.169, 95% confidence interval [CI] 1.379-7.283; OR 1.746, 95% CI 1.153-2.642, respectively). A high level of functional and cognitive status, functional support, and community participation at the 3-month follow-up was inversely associated with depressive symptoms (OR 0.973, 95% CI 0.951- 0.995; OR 0.884, 95% CI 0.829-0.942; OR 0.793, 95% CI 0.714-0.882). Discussion: Stroke survivors experiencing dysphagia during the IRF stay had a higher risk of developing depressive symptoms compared to those without dysphagia at 3-month follow-up. Healthcare providers should pay attention to dysphagia care in IRFs which might prevent the development of depressive symptoms when the stroke survivors are discharged and back in their communities.

구인두연하장애를 가지고 있는 뇌졸중 환자들의 경우 삼킴 근육의 약화로 목뿔후두복합체의 움직임에 관여하는 목뿔 위근의 약화로 음식물이 기도로 침습 또는 흡인이 될 수 있는 상황을 초래할 수 있다. 때문에 구인두연하장애환자들의 삼킴 기능을 향상시키기 위한 다양한 보상적 기법, 메뉴버 및 재활치료 접근법들이 폭 넓게 사용되어지고 있다. 이 중 근력 강화 를 위한 재활 운동방법경우 현재 임상에서의 필요성과 중요성이 꾸준히 늘고 있으나 실제 적용할 수 있는 방법이 제한되어 있다. 최근의 경우 운동에 기반을 둔 재활치료 접근 방법에 초점이 맞추어져 있으며, 이와 관련한 기존의 운동 방법들을 보 완하거나, 연구를 통해 새롭게 제안된 운동방법들이 소개되고 있다. 본 고찰에서는 현재 연구되고 있는 근거 기반 연하재활 운동방법에 대해 고찰함으로써 목뿔위근의 약화가 동반된 구인두연하장애를 가진 뇌졸중 환자들의 삼킴 기능 향상에 도움 을 줄 수 있는 방법으로 고려될 수 있음을 제안 하고자 한다.

Patients of stroke with oropharyngeal dysphagia can face the situation that foods may be aspirated or infiltrated to the airway upon decreased movement of hyolaryngeal complex involved in hyoid bone due to the weakened swallowing muscle. Multiple compensation and rehabilitation approaches and maneuvers are widely used to enhance the swallowing function in the patients with oropharyngeal dysphagia. Out of these, the needs and importance of rehabilitation approaches have been continuously increased while the methods of practical applications are limited. Recently, rehabilitation approaches based on the exercise are focused and complemented methods related to these or new methods have been studied and introduced. In this article, it is suggested that evidence-based rehabilitation approaches for swallowing can be considered as the methods to assist to enhance the swallowing function in the patient with oropharyngeal dysphagia related on suprahyoid muscle weakness due to stroke.