(A) quantitative assessment methodology of pharyngeal swallow

이백희 Pohang University of Science and Technology 2016 국내박사

삼킴 장애(연하 곤란, dysphagia)는 음식을 먹는 과정에서 발생하는 어려움의 질병으로서 주로 신경계통 질병 환자와 65세 이상 노년층에서 유병률이 높다. 삼킴 장애는 주로 흡인(aspiration), 폐렴(pneumonia), 탈수(dehydration), 영양실조(malnutrition) 등을 유발하고 심해지면 사망에 이를 수 있어 정확하고 신속한 진단이 중요하다. 기존 삼킴 장애는 주로 비디오 투시 조영 검사(videofluorocopic swallowing study, VFSS)와 비디오 내시경 검사(fiberoptic endoscopic evaluation of swallowing, FEES)를 통하여 진단되고 있으나 낮은 안전성(VFSS: 방사능, FEES: 침습)과 육안 평가의 한계가 있다. 선행 연구(Lee et al., 2012)에서는 삼킴 측정에 특화된 장비로서 인체에 무해한 ultrasonic Doppler를 사용하여 삼킴 시 인두(pharynx)의 움직임을 측정하는 장비가 개발되었는데, 측정된 인두 삼킴(pharyngeal swallow) 신호 중 삼킴 움직임만을 선별, 정량화, 분석, 해석하고 삼킴 장애 진단에 특화 시키는 연구가 필요하다. 본 연구는 ultrasonic Doppler를 사용하여 측정되는 인두 삼킴 신호를 사용하여 삼킴을 정량적으로 평가하기 위하여 (1) 인두 움직임 신호 중 삼킴 선별, (2) 삼킴 정량화 protocol 정립, (3) 삼킴 신호와 인두 움직임의 연동 해석, (4) 정상인과 삼킴 장애 환자의 삼킴 특성 비교 분석, 그리고 (5) 삼킴 장애 판별 모형 개발의 다섯 가지 세부 연구를 수행하였다. 첫째, ultrasonic Doppler로 측정되는 다양한 인두 움직임 중 삼킴 움직임만이 선별하는 알고리즘이 개발되었다. 인두 삼킴 시 소리가 발생할 수 없는 삼킴 무호흡(swallowing apnea) 개념을 적용하기 위하여 ultrasonic Doppler sensor에 소리 신호 획득을 위한 microphone이 연동되었다. 인두 삼킴 시 인두 움직임이 발생하지만 소리 발생이 불가능한 개념 구현에 특화된 신호 처리(예: moving average)와 통계 기법(예: maximum-likelihood function)을 적용하여 삼킴 선별 알고리즘이 개발되었다. 효용성 평가 결과, 삼킴 선별 알고리즘은 삼킴과 기침 및 발성 같이 소리가 함께 발생하는 인두 움직임을 100% 구별하였다. 둘째, 삼킴 신호 분석에 특화된 신호 처리 기법이 개발되고 삼킴 정량화 척도가 정립되었다. 네 단계 삼킴 신호 처리 기법(S1. rectification, S2. smoothing, S3. peak detection, S4. starting/ending points detection)을 적용하여 삼킴 움직임 특성을 나타내는 다섯 가지 삼킴 정량화 척도(peak amplitude, duration time, number of peaks, peak-to-peak interval, 그리고 impulse)가 개발되었다. 삼킴 신호만 입력되면 삼킴 정량화 척도가 자동으로 추출되는 S/W도 개발되었다. 셋째, 삼킴 시 삼킴 신호와 VFSS 영상을 동시에 획득하여 삼킴 신호와 인두 움직임이 연동 해석되었다. 정상 삼킴 신호의 peak 개수는 대부분 2가지로 나타나며, 첫 번째 peak는 삼킴 시 인후두(laryngopharynx) 상승 움직임을 두 번째 peak는 삼킴 시 laryngopharynx 하강 움직임으로 파악되었다. VFSS 영상 분석 결과에 근간하여 peak amplitude는 laryngopharynx의 순간 최대 움직임 정도, duration time은 laryngopharynx의 총 움직임 시간, number of peaks는 laryngopharynx의 움직임 변환 횟수, peak-to-peak interval는 인두 삼킴 시 bolus 이동 시간, 그리고 impulse는 laryngopharynx의 총 움직임 정도로 의미가 정립되었다. 넷째, 정상인과 삼킴 장애 환자를 대상으로 삼킴 실험을 수행하여 삼킴 특성이 비교 분석되었다. 정상인 120명과 삼킴 장애 환자 36명에 대해 침, thin liquid 1, 3, 9 ml, thick liquid 1, 3, 9 ml 삼킴에 대한 삼킴 신호가 획득되었다. 정상인의 number of peaks는 1개(49%) 또는 2개(39%)일 때가 88%로 나타났다. 삼킴 정량화 척도에 대해 K-mean clustering을 적용(K = 3)한 별과, 정상인은 short-double peak (duration < 1 s and # peaks = 2)가 43%, short-single peak (duration < 1 s and # peaks = 1)가 39%, short-multiple peak (duration < 1 s and # peaks ≥ 3)가 18%로 나타났으며, 삼킴 장애 환자는 short-double peak (duration < 1 s and # peaks = 2)가 58%, long-double peak (duration ≥ 1 s and # peaks = 2)가 33%, long-multiple peak (duration ≥ 1 s and # peaks ≥ 3)가 9%인 것으로 나타났다. 정상인의 highest peak amplitude에는 성별(female:male = 1:0.8), 삼킴 종류(thick liquid:thin liquid = 1:1.2), 삼킴 용량(1 ml:3 ml:9 ml = 1:1.1:1.3)이 유의하였으며, impulse에는 삼킴 종류(thick liquid:thin liquid = 1:1.4)와 삼킴 용량(1 ml:3 ml:9 ml = 1:1.1:1.3)이 유의한 것으로 나타났다. 삼킴 장애 환자는 정상인에 비해 평균적으로 peak amplitude가 0.7배 낮고, duration time이 2.6배 길고, number of peaks가 1.7배 많고, peak-to-peak interval이 4.3배 길고, 그리고 impulse가 0.8배 낮은 것으로 나타났다. 마지막으로, 삼킴 장애 심각도를 normal, mild, 그리고 moderate/severe로 분류하는 삼킴 장애 판별 모형이 개발되었다. 정상인 120명과 삼킴 장애 환자 31명(VFSS 진단 결과: mild 18명, moderate/severe: 13명)의 침, thin liquid 1 ml, 3 ml, thick liquid 1 ml, 그리고 3 ml 삼킴에 대한 5가지 cumulative logit model이 개발되었다. 최적 모형은 판별 성능과 실용성이 우수한 thin liquid 1 ml 삼킴에 대한 cumulative logit model (입력 변수: 연령, 성별, duration time, number of peaks, longest peak-to-peak interval, impulse; 판별 성능: sensitivity for mild = 50%, sensitivity for moderate/severe = 92%, specificity = 100%, accuracy = 81%)로 선정되었다. 본 연구의 ultrasonic Doppler를 사용한 삼킴 시 laryngopharynx 움직임 정량화 방법론은 인두 삼킴을 실시간 정확하고 효과적으로 평가하는데 기여할 수 있다. 본 연구의 정상인과 삼킴 장애 환자의 삼킴 시 laryngopharynx 움직임 특성 비교 분석 결과와 삼킴 장애 심각도 판별 모형은 임상에서의 VFSS 검사와 더불어 삼킴 장애의 과학적 진단에 적용될 수 있을 것으로 기대된다. Dysphagia is the disorder related to difficulty in swallowing and is more frequently observed among patients with neurologic diseases such as stroke or people aged 65 and over. Undiagnosed or untreated dysphagia may lead to aspiration, pneumonia, dehydration, malnutrition, or even asphyxiation and death; therefore, early identification and appropriate treatment of dysphagia are important. Dysphagia has been mainly diagnosed by videofluoroscopic swallowing study (VFSS) and fiberoptic endoscopic evaluation of swallowing (FEES); but, both VFSS and FEES have limitations in terms of qualitative analysis and low safety (VFSS: radiation, FEES: invasion). The precedent study (Lee et al., 2012) developed a swallowing measurement device employing ultrasonic Doppler to measure a pharyngeal movement during swallowing. As a follow-up study, quantification, analysis, and interpretation of the measured pharyngeal swallowing signal and specialization for diagnosis of dysphagia are needed. The objective of the present study is to develop a quantitative assessment methodology of pharyngeal swallow. The specific objectives are as follows: (1) screening of swallowing out of pharyngeal movement signals, (2) establishment of a swallowing quantification protocol, (3) interpretation of pharyngeal movement signal by interoperating with VFSS video, (4) comparison of pharyngeal movement between healthy adults and dysphagic patients, and (5) development of a diagnostic model for discriminating the severity of dysphagia. First, a swallowing screening algorithm was developed to extract swallowing movements only out of various pharyngeal movements such as cough and vocalization measured by ultrasonic Doppler. Utilizing a concept of swallowing apnea that vocalization is impossible during pharyngeal swallow, a microphone for measuring audio signals was interoperated with the ultrasonic Doppler sensor. Signal processing techniques (e.g., moving average) and statistical methods (e.g., maximum-likelihood function) were also incorporated into the swallowing screening algorithm. As a result, the swallowing movement was completely discriminated from cough and vocalization that are also involved with pharyngeal movement. Second, to represent the characteristics of the pharyngeal movement during swallowing, the present study proposed five quantitative measures such as peak amplitude, duration time, number of peaks, peak-to-peak interval, and impulse by applying the four-step swallowing signal processing technique (S1. rectification, S2. smoothing, S3. peak detection, and S4. starting/ending points detection). A program that automatically calculates aforementioned five measures for a given swallowing signal was also developed. Third, pharyngeal movement signals were interpreted by interoperating with the corresponding VFSS video. The majority of pharyngeal movement signals showed two peaks, and 1st and 2nd peaks indicates ascending and descending movements of the laryngopharynx during swallowing, respectively. Based on VFSS video analysis, five measures of swallowing movement were interpreted as follows: peak amplitude – maximum instant movement of the laryngopharynx; duration time – total movement time in the laryngopharynx; number of peaks – number of movement changes in the laryngopharynx; peak-to-peak interval – bolus transportation time in the pharyngeal stage; and impulse – total movement of the laryngopharynx. Fourth, swallowing characteristics of healthy adults and dysphagic patients were analyzed by swallowing experiment. Swallowing signals for dry saliva, thin liquid 1, 3, 9 ml, thick liquid 1, 3, 9 ml were acquired from 120 healthy adults and 36 dysphagic patients. The swallowing signals from 88% of healthy adults showed one peak (49%) or two peaks (39%). Healthy adults were categorized as short-double peak (duration < 1 s and # peaks = 2; 43%), short-single peak (< 1 s and 1; 39%), and short-multiple peak (< 1 s and ≥ 3; 18%); dysphagic patients as short-double peak (< 1 s and 2; 58%), long-double peak (≥ 1 s and 2; 33%), and long-multiple peak (≥ 1 s and ≥ 3; 9%). Gender (F:M = 1:0.8), swallowing type (thick:thin = 1:1.2), and volume (1:3:9 ml = 1:1.1:1.3) were found significant on highest peak amplitude; swallowing type (thick:thin = 1:1.4) and volume (1:3:9 ml = 1:1.1:1.3) on impulse. Peak amplitude of dysphagic patients was 0.7 times lower compared with that of healthy adults; duration time 2.6 times longer; number of peaks 1.7 times higher; peak-to-peak interval 4.3 times longer; and impulse 0.8 times lower. Lastly, diagnostic models for discriminating the severity of dysphagia into normal, mild, and moderate/severe were developed. Five cumulative logit models for swallowing dry saliva, thin liquid 1 ml, 3 ml, thick liquid 1 ml, and 3 ml were developed using swallowing data of 120 healthy adults (normal) and 31 dysphagic patients (mild for 18 and moderate/severe for 13). The cumulative logit model for swallowing thin liquid 1 ml (input variables: age, gender, duration time, number of peaks, longest peak-to-peak interval, and impulse; sensitivity for mild = 50%, sensitivity for moderate/severe = 92%, specificity = 100%, and accuracy = 81%) was selected as the best model in terms of discriminant performances and practicality in clinics. The quantitative assessment methodology of the laryngopharyngeal movement during swallowing developed in the present study can contribute to real-time, accurate, and effective evaluation of the pharyngeal swallow. The swallowing analyses results of the laryngopharyngeal movement of healthy adults and dysphagic patients and the diagnostic model for discriminating the severity of dysphagia are readily applicable to medical diagnosis of dysphagia with VFSS in clinics.

한국판 삼킴장애지수의 타당도와 신뢰도

김태연 대구가톨릭대학교 의료보건산업대학원 2020 국내석사

본 연구는 삼킴 곤란 정밀검사인 비디오투시연하검사(VFSS)와 주관적 체크리스트인 한국판 삼킴장애지수(K-DHI)를 비교하여 K-DHI의 타당도 및 신뢰도를 분석하고 절단값을 산출하여 민감도, 특이도, 양성 및 음성 예측률을 알아보고자 하였다. 연구의 대상은 대구 경북에 거주하는 정상인과 경북 포항시에 위치한 에스포항병원에 신경학적 질환으로 입원한 환자를 대상으로 하였다. 또한, 신뢰도 검증을 위해 내적 일관성을 확인하였으며, 검사-재검사 신뢰도를 위해 환자군의 K-DHI는 첫 검사 2주 후 재검사를 실시하였다. 준거타당도를 검증하기 위하여 기존 임상에서 활용하고 있는 선별검사인 Gugging Swallowing Screen(GUSS)과 K-DHI를 비교하고, VFSS 판독 결과를 토대로 활용하는 검사인 ASHA-NOMS, Videofluoroscopic Dysphagia Scale(VDS)와 K-DHI를 비교하였다. 임상에서 활용하기 위해 K-DHI에서 삼킴 곤란의 유무를 판별하는 절단값을 산출하였다. 이를 토대로 VFSS의 흡인 유무와 비교하여 민감도, 특이도, 양성 및 음성 예측률을 확인하였다. 본 연구의 결과는 다음과 같다. 환자군과 대조군의 K-DHI 총 점수를 비교한 결과, 환자군의 평균점수는 20.88, 대조군의 평균점수는 2.57로 두 집단의 평균 차이는 18.31로 유의한 차이를 보였다. K-DHI의 구성타당도를 확인하기 위해 K-DHI의 총 점수와 세부항목 별 점수를 비교하였다. 먼저, K-DHI의 총 점수와 신체적 항목의 점수를 비교한 결과 매우 높은 상관관계를 보였다. 마찬가지로 각각 기능적 항목, 감정적 항목의 점수를 비교한 결과 두 항목 모두 매우 높은 상관관계를 보였다. 또한, 세부항목 간 상관관계를 분석한 결과 세 항목 간 모두 높은 상관관계를 보였으며, 특히 감정적 항목과 기능적 항목은 매우 높은 상관관계를 보였다. K-DHI의 신뢰도를 확인하기 위해 내적일관성 및 검사-재검사 신뢰도를 분석하였다. 내적일관성 확인을 위해 크론바흐 알파계수를 사용한 결과 매우 높은 내적일관성을 보였다. 검사-재검사 신뢰도를 확인하기 위해 1차 K-DHI와 2차 K-DHI를 비교한 결과 높은 상관관계를 보였으며, 급내 상관계수를 확인한 결과 높은 상관관계를 보였다. K-DHI의 준거타당도를 검증하기 위해 선별검사인 GUSS와의 점수를 비교하고, 정밀검사인 VFSS를 판독한 결과를 토대로 VDS 점수 및 ASHA-NOMS의 단계를 비교하였다. K-DHI와 GUSS 점수를 비교한 결과 중간정도의 음의 상관관계를 보였다. K-DHI와 VDS 점수를 비교한 결과 중간정도의 양의 상관관계를 보였다. ASHA-NOMS와의 비교에서는 중간정도의 음의 상관관계를 보였다. 세 검사와 비교한 결과 매우 높은 상관관계를 보이지는 않았으나 모두 유의한 상관관계를 보였다. K-DHI의 ROC곡선을 그려 민감도와 특이도를 통한 절단값을 산출하였다. 삼킴 곤란 판별을 위해 VFSS 판독을 통한 흡인의 유무에 따라 K-DHI 점수를 검정하였으며 그 결과, 절단값 15점을 기준으로 민감도 69.6%, 특이도 75%로 확인되었다. K-DHI와 VFSS의 흡인 유무 판정에 대한 양성 및 음성 예측률을 확인하였다. 절단값 15점을 기준으로 VFSS의 흡인 유무와 비교한 결과, 양성예측률 34%, 음성예측률 93%로 확인되었다. 음성예측률에 비해 양성예측률은 저조한 확률을 보이나, 삼킴 곤란의 선별검사로 활용할 수 있는 기준이 되었다. 본 연구는 K-DHI의 타당도와 신뢰도를 확인하고 절단값을 산출하여 주관적 체크리스트의 임상적 활용도를 높이는 것에 초점을 두었다. 표준화된 정밀검사인 VFSS와 임상에서 선별검사로 널리 활용하고 있는 GUSS를 비교하여 유의한 상관관계를 보인 것은 K-DHI 검사가 임상적으로 활용할 수 있는 가치를 증명한 것으로 판단된다. 또한, 선행연구에서 확인하지 않았던 절단값을 산출하여 선별검사 시 생리적 평가와 더불어 삼킴 곤란을 감별하는데 유용하게 활용할 수 있을 것으로 기대된다. Dysphagia handicap index(DHI) is a subjective patient’s self-report to measure swallowing difficulties in daily life. This study adapted DHI into Korean- version of DHI and investigated validity and reliablity. A total of one hundred ninety two subjects participated in this study; 104 patients with dysphagia hospitalized with neurological disorders at Pohang Stroke and Spine Hospital located in Pohang, North Gyeongsang Province and 88 normal people living in Daegu and North Gyeongsang Province were included. DHI translated to Korean version of DHI and all participants completed the K-DHI and 104 patients with dysphagia retested K-DHI after two weeks to measure the test-retest reliablity using Pearson product-moment correlation coefficients. The internal consistency of the K-DHI was analyzed through Cronbach’s α coefficient. Independent t-test was used to compare the Korean version-DHI scores between normal and dysphagia group. For measuring construct validity, the relationship between Korean version-DHI total scores and physical, functional, and emotional scores was investigated using Pearson correlation coefficients. To verify the criterion-related validity, we compared the screening tests GUSS(GUSS) and K-DHI, which were previously used in clinical trials, and the tests ASHA-NOMS, Videofluoroscopic Dysphagia Scale(VDS) and K-DHI were compared based on the results of VFSS readings. For clinical use, a cut value was calculated to determine the presence of Dysphagia in K-DHI. Based on this, sensitivity, specificity, positive and negative prediction rates were determined by comparison with the presence of aspiration through reading the VFSS. The results of this study are as follows. The comparison of the K-DHI total scores between the patient group and the control group showed a significant difference of 18.31 with an average score of 20.88 for the parients group and 2.57 for the control group. To identify the construct validity of K-DHI, the total score of K-DHI was compared with the score by detail. First, the comparison of the total score of K-DHI with the score of the physical item showed a very high correlation(r = .941). Similarly, a comparison of the scores of functional(r = .973) and emotional items(r = .970) showed that both items were very highly correlated. In addition, to measure the construct validity, the analysis of the correlation was conducted between the sub-items and high correlations were found among all three items, especially a very high correlation between emotion and functional scores(r = .940). In order to verify the reliability of K-DHI, the internal consistency and test-retest reliability were analyzed. The results of using Cronbach's Alpha to check the internal consistency showed a very high internal consistency (Cronbach's alpha=.957). To confirm test-retest reliability, the comparison of primary and secondary K-DHI showed high correlation(r = .879), and the checking of intraclass correlation showed high correlation(r = .877). The scores from the screening test GUSS were compared with the K-DHI scores to verify the criterion-related validity of the K-DHI, and the VDS scores and ASHA-NOMS steps were also compared based on the results of reading the precision test VFSS. When compared K-DHI with GUSS scores, the medium degree of negative correlation was shown(r = - .652). Comparing K-DHI and VDS scores, a moderate positive correlation appeared(r = .556). The comparison with ASHA-NOMS showed a medium degree of negative correlation(r = - .602). By ROC curve of K-DHI, the cut value through sensitivity and specificity was calculated. For the distinction of Dysphagia, K-DHI scores were tested according to the presence or absence of aspiration through VFSS readings, and the results showed that sensitivity was 69.6% and specificity was 75% based on the 15 scores cut value. Sensitivity, specificity, positive and negative prediction rates were determined by comparison with the presence of aspiration reading in VFSS. Comparing with the presence of aspiration reading by VFSS based on a cut value of 15 score, positive prediction rate was 34% while negative prediction rate was 93%. Although the positive prediction rate was less likely than the negative prediction rate, it can be feasible as a screening test for dysphagia. This study focused on checking the validity and reliability of K-DHI and increasing clinical utilization of subjective checklists by calculating cut values. The significant correlation between VFSS, a standardized precision test, and GUSS, which is widely used as a screening test in clinical practice, demonstrated the value that K-DHI can use clinically. It is also expected that the cut values of K-DHI can be used to identify the dysphagia with physiological evaluation during the screening test.

요양병원 노인의 연하장애에 따른 인지기능과 신체기능

김진수 부경대학교 대학원 2019 국내석사

Purpose The purpose of this study was to examine the cognitive and physical functions based on dysphagia in elderly patients geriatric hospitals. Method This study included 210 elderly persons aged ≥65 years who were in three geriatric hospitals in the city of B. The data were collected between January 28, 2019 and March 28, 2019. The presence of dysphagia was evaluated using the Gugging Swallowing Screen (GUSS), cognitive function was evaluated using the Korean Mini Mental State Examination (K-MMSE), and physical function was evaluated using the Korean Activity of Daily Living (K-ADL). The data were analyzed by descriptive statistics, χ-test, Fisher’s exact test and independent t-test using SPSS/WIN 23.0 program. Results 1. The prevalence of dysphagia was 66.7% in elderly patients geriatric hospitals. 2. There were statistically significant differences in the dysphagia according to age (χ=4.58, p=.032), nervous system disease (χ=38.76, p<.001), respiratory system disease (χ=22.0, p<.001), medication related to dysphagia (χ=8.33, p=.004) and BMI (χ=9.10, p=.018). 3. There were statistically significant differences cognitive function (t=10.11, p<.001) and physical function (t=-11.0, p<.001) according to the dysphagia. Conclusion Elderly patients with dysphagia at geriatric hospitals exhibited reduced cognitive and physical functions. These findings are expected to be utilized in clinical practice and training of patients and nurses to provide a foundation for early screening of dysphagia, with the ultimate goal of reducing and preventing complications.

Effects of Tongue Pressure Strength and Accuracy Training on Tongue-Pressure Strength, Swallowing Function, and Quality of Life in Subacute Stroke Patients with Dysphagia

Jong-Hoon Moon 가천대학교 보건대학원 2017 국내석사

The aim of this study was to investigate the effect of tongue pressure strength and accuracy training (TPSAT) on tongue pressure strength, swallowing function, and quality of life in subacute stroke patients with dysphagia. Sixteen subacute stroke patients were randomly assigned into either the TPSAT group (n = 8) or the control group (n = 8). In the TPSAT group, both TPSAT and traditional dysphagia therapies were performed for 30 min each per day; in the control group, only traditional dysphagia therapy was performed for 30 min twice a day. Both groups performed each daily intervention five times per week for 8-weeks. To assess the tongue pressure strength, anterior and posterior maximum isometric tongue pressures (MIPs) using Iowa Oral Performance Instrument (IOPI) were measured before and after the intervention. Mann assessment of swallowing ability (MASA) and swallowing-quality of life (SWAL-QOL) were also used to assess the swallowing function and quality of life, respectively. TPSAT with traditional dysphagia therapy significantly improved MIPs, MASA, and SWAL-QOL both anteriorly and posteriorly, and traditional dysphagia therapy significantly increased MIPs, MASA, and SWAL-QOL anteriorly compared with the pre-values (p < 0.05). The TPSAT group showed a significant improvement of anterior and posterior MIPs and tongue movement score in MASA compared with the control group (p < 0.05). Our findings suggest that TPSAT may be used for dysphagia management in subacute stroke patients clinically.

신경계 질환을 지닌 노인의 연하관련 삶의 질 영향요인

정수진 중앙대학교 건강간호대학원 2021 국내석사

본 연구는 신경계 질환을 지닌 노인의 연하관련 삶의 질을 파악하고 주관적 삼킴곤란, 영양상태, 사회적 지지가 연하관련 삶의 질에 미치는 영향을 알아보고자 시도된 서술적 조사연구이다. 서울 소재 종합병원 신경과에서 신경계 질환을 진단받은 65세 이상 노인 외래 환자 120명을 대상으로 하였다. 연하관련 삶의 질을 측정하기 위한 연구도구는 한국판 MDADI를 이용하였고, 주관적 삼킴곤란은 K-SDQ, 영양상태는 MNA®-SF, 사회적지지는 MOS-SSS도구의 번역본을 이용하여 측정하였다. 연구 결과 연하관련 삶의 질과 주관적 삼킴곤란은 유의한 부적 상관관계가 있는 것으로 나타났으며, 영양상태와 사회적 지지는 유의한 정적 상관관계가 있는 것으로 나타났다. 대상자의 연하관련 삶의 질에 영향을 미치는 요인을 알기 위하여 단계선택법을 이용한 다중회귀분석 실시 결과 유의한 영향요인은 성별, 교육수준, 신경계 주 진단, 식사유형, 주관적 삼킴곤란, 사회적 지지의 하위 영역인 애정적 지지인 것으로 나타났다. 위 요인의 연하관련 삶의 질에 대한 설명력은 42.1%로 나타났다. This study is a descriptive research study attempting to understand the Dysphagia-specific quality of life in the aged patients with neurologic disorders and to find out the effects of perceived swallowing disturbance, nutritional status, and social support on the Dysphagia-specific quality of life. This study included 120 outpatients aged 65 years or older who were diagnosed with neurological disorders at the Department of Neurology at a general hospital in Seoul. The Korean version of MDADI was used as a research tool to measure the Dysphagia-specific quality of life. Subjective swallowing disturbance was measured using K-SDQ, nutritional status was measured using MNA®-SF, and social support was measured using a translation of the MOS-SSS tool. As a result of the study, the Dysphagia-specific quality of life in the aged patients with neurologic disorders differed according to the general characteristics of education level, economic status, and type of diet. There was a significant negative correlation between the Dysphagia-specific quality of life and perceived swallowing disturbance. Nutritional status and social support were significantly positively correlated with Dysphagia-specific quality of life. Multiple regression analysis was performed to find out the factors related to Dysphagia-specific quality of life. As a result the study, factors related to Dysphagia-specific quality of life were gender, education level, neurological diagnosis, type of diet, perceived swallowing disturbance and affectionate support which is a sub-domain of social support. The explanatory power of the factors related to Dysphagia-specific quality of life was 42.1%.

연하장애 보호자 교육 프로그램이 보호자의 간병지식과 부담 및 삶의 질에 미치는 영향

김진영 원광대학교 대학원 2024 국내석사

본 연구는 연하장애 환자를 간병하는 보호자를 대상으로 교육 프로그램 중재가 간병 지식과 부담 및 삶의 질에 미치는 영향을 알아보고자 시행하였다. 연구 대상자는 D 재활 병원에 입원하여 연하치료를 받고 있는 환자의 보호자 28명이다. 교육 프로그램 중재는 1회 30분, 주 1회, 총 8 주 동안 8회기로 중재를 제공하였으며 치료사와 보호자 일대일로 진행하였다. 교육 프로그램은 Part 1. 함께 배우는 연하장애와 Part 2. 쉽게 관리 하는 연하장애로 각각 4회기로 구성하였다. Part 1에서는 연하장애의 전반적인 이론을 중심으로 구성하였고 Part 2는 질의응답 및 상담을 중심 으로 구성하여 진행하였다. 중재 기간 별 효과를 확인하기 위해 중재 전, 4주 후, 8주 후의 연하장 애 지식 정도, 간병 부담, 삶의 질 변화를 측정하였다. 중재 기간 별 연하 장애 지식척도, K-RCAS, WHOQOL-BREF 점수를 비교하고 각 평가 도구별 하위 항목에 따른 변화를 비교하기 위해 반복측정 분산분석 (Repeated ANOVA)을 사용하였다. 각 중재 기간별 효과 비교를 위해 본 페로니 검정(Bonferroni test)을 사용하여 분석하였다. 본 연구 결과 학력에 따른 간병 부담 정도, 일주일 당 간병 횟수에 따른 간병 부담 정도는 유의한 차이가 있었다. 교육 프로그램을 적용한 결과 중재 전, 4주 후, 8주 후의 연하장애 지식척도, K-RCAS, WHOQOL-BREF 모두 점수에 변화가 있었으며 유의미한 차이가 있었다. 각 평가 도구의 하위 항목의 변화도 유의미한 차이가 있었으며 간병 부담이 감소함에 따라 삶의 질이 향상하였음을 확인하였다. 본 연구는 선행 연구들에 근거하여 체계적으로 교육 프로그램을 개발 및 적용하여 효과성을 검증한 점에서 의의가 있다. 본 연구에서 개발된 연하장애 보호자 교육 프로그램은 보호자의 간병 부담과 삶의 질에 긍정 적인 영향을 미치는 것으로 확인하였다. 추후에는 지역사회로 적용 대상 자를 확장하여 효과성을 확인하고 가족 단위의 교육 프로그램 제공 시 긍정적인 자료로 사용할 수 있을 것으로 사료된다. 또한 작업치료사는 지속적인 교육을 제공할 수 있는 교육자로서 역할이 강화되어야 할 것이다. This study was conducted to investigate the effect of education program for carers on the dysphagia knowledge, burden, and quality of life. The subjects were 28 carers of patients admitted to the hospital and receiving dysphagia treatment in a single group. Education program was provided for 30 minutes per session, once a week, for a total of 8 sessions. It was consisted each 8 sessions that ‘Part 1. Learning together about dysphagia’ was consisted theory of dysphagia, and ‘Part 2. Easily managed dysphagia’ was consultation. It was conducted in the form of education that combined face-to-face education, pamphlet, distance education, and counseling. Changes of dysphagia knowledge, burden, quality of life were measured before the start of study, after 4 and 8 weeks by period. Repeated ANOVA was used to compare the dysphagia knowledge, K-RCAS, and WHOQOL-BREF scores for each period and to compare the changes according to subscales for each tools. In addition, the analysis was performed using the Bonferroni test to compare the effects of each intervention period. As a result, there were changes in total and subscale scores by evaluation tools. In addition, it was confirmed that the quality of life improved as the care burden decreased. This study is meaningful it developed a systematic educational program through consideration and applied it directly to carers. Also, participants rate was high because it consists of education that the carers wants. In the future, it is believed that it will be applied to family-educational and local community. Accordingly, occupational therapists should strengthen their role as educators who can provide continuous education.

Implementation Strategies for the International Dysphagia Diet Standardization Initiative (IDDSI)

Rule, David University of Cincinnati ProQuest Dissertations & 2019 해외박사(DDOD)

The purpose of this study was to examine and explore implementation strategies for the International Dysphagia Diet Standardization Initiative (IDDSI) in terms of training effects and on the classification and preparation of texture-modified foods and liquids for people with dysphagia. The IDDSI is a culturally sensitive, international rating system for the classification and preparation of texture-modified foods and thickened liquids for people with swallowing disorders. This is important in that providing inaccurately classified foods and liquids to people with swallowing disorders may be adverse, resulting in aspiration of swallowed material into the airway which may lead to negative respiratory health outcomes or asphyxiation. Though self-study materials for the IDDSI are available online at no cost, no investigations to date have formally evaluated self-study as an educational modality and the associated effects on classification and preparation accuracy for food and liquid consistencies. Furthermore, no investigations to date have evaluated whether additional training beyond self-study may be necessary to produce reliable and accurate classification and preparation of foods and drinks. Finally, no published research to date has investigated the generalization of a training program to patients and potential caregivers without formal dysphagia experience.This investigation used a quantitative, between and within-subjects research design. Sixty-eight participants completed three tasks: (a) knowledge quiz, (b) diet classification, and (c) preparation. Participants were enrolled in self-study (SS) or self-study plus hands-on training (SS+) tracks. In summary, both SS and SS+ groups improved in their ability to accurately classify foods and drinks using IDDSI testing methods however they were not statistically significantly different from one another. Second, there were no significant predictive factors for performance found in any task for socioeconomic status or personal and professional identity. Regarding training experiences, participants felt they learned valuable information and improved in their ability to use IDDSI testing methods for diet classification. However, participants indicated that additional training would be important as they consider implementing the IDDSI framework outside of a training environment. These findings suggest that the improvements in classification accuracy using IDDSI testing methods can be gained through self-study and self-study plus hands-on training. However, neither group performed perfectly in classification and preparation of foods and drinks. Therefore, future studies should aim to recruit more robust participant groups and explore underlying reasons for incorrect classification and preparation of texture-modified diets. The long-term goal of this work is to improve overall health outcomes for people with dysphagia and provide patients and caregivers of those with dysphagia the tools necessary for optimal health outcomes.

Application of Chinese version of SWAL-QOL in Parkinson's disease

진효풍 Graduate School, Yonsei University 2018 국내석사

파킨슨병은 신경퇴행성 질환으로 안정 시 진전, 강직, 서동, 자세불안정 등의 특징적 증상을 보인다. 홍콩 파킨슨병 환자의 일반적인 삶의 질에 관한 다양한 연구가 진행되었지만, 홍콩 파킨슨병 환자의 삼킴 관련 삶의 질을 고려한 연구는 많지 않다. 본 연구는 홍콩 파킨슨병 환자의 삼킴 관련 삶의 질을 이해하고자 자기보고가 가능한 특발성 파킨슨병(idiopathic Parkinson’s disease, IPD) 환자 67 명을 대상으로 중문판 C-SWAL-QOL (Chinese Version of Swallowing-Quality Of Life) 척도를 적용하였다. 연구 결과 및 그에 따른 해석은 다음과 같다. 첫째, 파킨슨병 환자의 우울증상이 높을수록, 삼킴 관련 삶의 질이 낮아졌다. CSWAL- QOL 의 하위 범주 10 개 중 7 개의 영역(음식에 대한 부담감, 의사소통, 두려움, 정신건강, 사회기능, 수면, 피로)과 우울증 간에 유의한 상관관계가 나타났다. 둘째, 삼킴 장애 관련 증상 빈도(Dysphagia Symptom Battery, DSB)가 높아질수록 삼킴 관련 삶의 질이 낮아졌다. 파킨슨병 환자는 증상 DSB 중 ‘침 흘림’ 문항에서 가장 낮은 점수를 보였으며, 이는 ‘침 흘림’ 증상이 파킨슨병 환자의 주 호소임을 알 수 있다. 본 연구는 질병 특이적 도구를 사용하여 홍콩 파킨슨병 환자의 삼킴관련 삶의 질을 측정하고, 임상학적 (우울증상, 유병기간) 특징을 포함한 관련 요인들 간의 상관관계를 확인하였다는 점에 의의가 있다. 파킨슨병 환자의 삼킴 평가 및 중재 시, 우울증과 삼킴장애 관련 증상이 높은 환자들에 대한 개별적인 접근이 필요하다고 생각되며, 환자 개개인의 삼킴 관련 삶의 질을 개선할 방안을 모색해야 한다. 본 연구에서 살펴본 C-SWAL-QOL 은 향후 홍콩 파킨슨병 환자들의 삼킴 삶의 질 개선에 도움이 될 것이라 사료된다. Background: Parkinson’s disease (PD) is the world’s second most prevalent neurodegenerative disease, being characterized by cardinal symptoms such as bradykinesia, tremor, rigidity, and postural instability. As the disease progresses, patients with PD develop dysphagia, with choking, coughing, and globus sensation being observed. The aims of this study are (1) to evaluate swallowing-related quality of life in PD by using the validated Chinese version of the Swallowing Quality-of-Life Questionnaire (C-SWAL-QOL); (2) to delineate potential relationships between the 10 subscales in C-SWAL-QOL and the score in the 14-item Dysphagia Symptom Battery (DSB), in order to evaluate if the severity of dysphagia symptoms is associated with each subscale score; and (3) to identify factors (socio-demographic variables and clinical variables) associated with swallowing-related quality of life by using C-SWAL-QOL. Methods: C-SWAL-QOL was administered to 67 subjects with PD after cognitive assessment. After the completion of C-SWAL-QOL, participants were also asked to fill out the 15-item Geriatric Depression Scale in Chinese version (GDS-C), which is a self-report depression assessment. A series of non-parametric Spearman’s Rho correlation analyses were performed to examine the relationship between the 10-subscale scores in C-SWAL-QOL and (1) age, (2) disease duration, (3) depression and (4) the 14-item DSB. Correlations were regarded as weak if |r|<0.3, moderate if 0.3≤|r|<0.5, strong if 0.5≤|r|<0.7, and very strong if |r|≥0.7. Results: In the current study, it is found that sleep, fatigue, eating duration and communication were the most severely affected subscales in C-SWAL-QOL incurred by PD. Significant relationships existed between composite C-SWAL-QOL score (rho = -.433, p = 0.000), total C-SWAL-QOL score (rho = -.248, p = 0.043), DSB score (rho = -.287, p = 0.019) and depression. Significant relationships were also observed between subscales of communication (rho = -.379, p = 0.002), fear (rho = -.446, p = 0.000), mental health (rho = -.347, p = 0.004), social functioning (rho = -.388, p = 0.001), fatigue (rho = -.567, p = 0.000) and depression. Yet, no relationships existed between score of C-SWAL-QOL and age or disease duration in PD. Correlations were found between the 14-item DSB and nearly all dysphagia-specific subscales, except eating duration subscale. Conclusion: Most of the subscales in C-SWAL-QOL measures swallowing-related quality of life accurately in PD. The current findings reveal that the worse the depression (e.g. higher the GDS-C score), the worse the swallowing-related quality of life (e.g. lower the C-SWAL-QOL score). Results in this study shed light on the psychosocial sequelae that dysphagia can have in PD patients. Further studies using the Hoehn and Yahr staging or Unified Parkinson’s Disease Rating Scale (UPDRS) to compare the C-SWAL-QOL score of Chinese PD patients at different stages is recommended.

(The) clinical efficacy of voice therapy for adult cerebral palsy with dysarthria and dysphagia

Park, Alyssa Mae Graduate School, Yonsei University 2021 국내석사

Cerebral palsy is the most common neurodevelopmental disorder, and it frequently results in comorbidities such as dysarthria and dysphagia. Children and adults with cerebral palsy experience restriction in activities and limitation in participation due to low speech intelligibility, negative social perception, complex dietary requirements, health risks from aspiration, and more effects of dysarthria and dysphagia. This study evaluated the clinical efficacy of intensive voice therapy in improving speech and swallowing functions and related quality of life measures in 11 Korean adults (males = 7, females = 4, mean age = 42.4±7.11) with cerebral palsy manifested with dysarthria and dysphagia. Significant post-treatment outcomes were found for speech functions (maximum phonation time, voice intensity, and diadochokinetic rate), swallowing functions (oral and pharyngeal phase symptoms for thick, semi-thin, and thin boluses), and quality of life measures (emotional impact of voice handicap, sleep distress, fatigue, and fear related to swallowing). Such improvements were observed in the all-participant group and the in-person LSVT-X group. These data support that LSVT-X and LSVT e-LOUD are equally effective in treating this population, and that voice therapy can significantly improve speech and swallowing functions and related quality of life measures in adults with cerebral palsy. 본 연구에서는 성인 뇌성마비 대상자 11명에게 LSVT 음성치료 16회기를 대면 및 비대면 환경으로 제공한 후, 각 대상자의 말·삼킴 기능과 삶의 질을 평가하였다. 예상대로 최대연장발성, 음성의 강도 및 조음속도를 포함한 여러 말 기능은 두 치료 집단에서 유의한 개선을 나타내었다. 또한 VFSS 촬영으로 시각적으로 평가한 삼킴 기능은 음성치료 후 현저한 개선을 보여, 구강 및 인두 모두에서 삼킴장애 증상의 감소를 보였다. 이어서 대상자들이 말, 음성, 삼킴 관련 삶의 질에 대한 설문조사를 통해 정서적 스트레스, 두려움, 수면 및 피로 측면에서도 유의한 개선을 느꼈다고 보고하였다. 본 결과는 신체 기능, 사회적 참여 및 활동에 대한 다차원적 개선을 확인시킴으로써 성인 뇌성마비의 증상을 치료하는 데 LSVT 음성치료의 효능을 시사한다. 더 나아가 바쁜 일정을 위한 LSVT-X 연장 과정과 거동이 불편한 비대면 치료의 의의가 확인하였다. LSVT를 임상에서 적용하는 데에 중요한 정보를 마련하기 위하여, 후속 연구는 LSVT-X 및 LSVT e-LOUD를 어렵게 만드는 요인, 혹은 LSVT의 적합성에 대한 성인 뇌성마비 대상자의 개인적 의견을 조사할 필요가 있다.

Shaker 운동과 신경근 전기자극 치료가 삼킴기능에 미치는 효과 : 뇌졸중 후 삼킴장애 환자를 대상으로

문태흥 인제대학교 대학원 2013 국내석사

Shaker 운동과 신경근 전기자극 치료가 삼킴기능에 미치는 효과 : 뇌졸중 후 삼킴장애 환자를 대상으로 문태흥 (지도교수: 장문영) 인제대학교 대학원 작업치료학 전공 본 연구의 목적은 뇌졸중 후 삼킴장애 환자를 대상으로 Shaker 운동과 신경근 전기자극 치료를 적용하여 삼킴기능의 회복에 미치는 효과를 알아보고자 하였다. 연구 대상자는 부산에 위치한 D의료원 입원환자 20명이었다. 연구기간은 2012년 1월 9일부터 동년 8월 30일까지이었다. 각 치료 적용 집단은 5명씩 네 집단으로, 실험군의 중재 시간은 40분, 주 5회, 4주간, 총 20회기 실시하였다. Shaker 운동은 실험군1, 3에 실시하였다. 신경근 전기자극 치료는 실험군2, 3에 실시하였다. 실험군 모두에게 전통적 삼킴재활치료를 30분씩 병행 적용하고, 대조군에는 전통적 삼킴재활치료만 실시하였다. 삼킴기능은 구강섭취기능 척도와 표면 근전도 검사를 사용하여 측정하였다. 집단 간 치료 효과는 Mann-Whitney U test를 사용하여 분석하였고, 집단 내 치료 전·후의 효과는 Wicoxon signed-rank test를 사용하였다. 연구 결과는 다음과 같다. 첫째, Shaker 운동을 적용한 집단 실험군1, 3은 다른 치료를 적용한 집단 보다 구강섭취기능에서 가장 크게 향상되었다(p<.05). 집단 내 실험군1, 3의 전·후 구강섭취기능에서도 유의한 향상을 보였다(p<.05). 둘째, Shaker 운동을 적용한 집단 실험군1, 3과 다른 치료를 적용한 집단과의 비교에서는 목뿔위근육의 근활성도에서 유의한 차이가 없었다(p>.05). 집단 내 실험군1, 3의 전·후 목뿔위근육의 근활성도에서는 유의한 증가를 보였다(p<.05). 셋째, 신경근 전기자극 치료를 적용한 집단 실험군2, 3과 다른 치료를 적용한 집단과의 비교에서는 구강섭취기능에서 유의한 차이가 없었다(p>.05). 집단 내 실험군2, 3의 전·후 구강섭취기능에서는 유의한 향상을 보였다(p<.05). 넷째, 신경근 전기자극 치료를 적용한 집단 실험군2, 3과 다른 치료를 적용한 집단 과의 비교에서는 목뿔위근육의 근활성도에서 유의한 차이가 없었다(p>.05). 집단 내 실험군2, 3의 전·후 목뿔위근육의 근활성도에서는 유의한 증가를 보였다(p<.05). 이상의 결과를 통해 Shaker 운동을 적용한 집단이 적용하지 않은 집단 보다 구강섭취기능에서 더 효과적이었으며, 목뿔위근육의 근활성도에서는 차이는 없었다. 신경근 전기자극 치료를 적용한 집단은 적용하지 않은 집단과의 비교에서 효과 차이는 없었지만, 중재 전·후 구강섭취기능과 목뿔위근육의 근활성도 향상에는 효과적이었음을 알 수 있었다. 다른 치료 방법들과의 비교에서 Shaker 운동은 뇌졸중 후 삼킴장애가 있는 환자에게 효과적인 치료방법임을 알 수 있었다. 하지만 신경근 전기자극 치료의 효과는 앞으로의 연구에서 다른 치료방법과의 치료 효과에 대한 효율성에 대한 연구가 더욱 필요할 것으로 생각된다. The Effects of Shaker Exercise and Neuromuscular Electrical Stimulation (NMES) Therapy on the Swallowing Function : On the Post-Stroke Patients With Dysphagia Tae-Heung Mun (Advisor: Prof. Moon-Young Chang, Ph.D., O.T.) Department of Occupational Therapy Graduate School, Inje University This study is intended to analyze the effects of Shaker exercise and neuromuscular electrical stimulation (NMES) Therapy on the improvement in swallowing function of post-stroke patients with dysphagia. This study was targeted at 20 inpatients of D medical center in Busan. This research was carried out for 8 months from January 9, 2012 to August 30, 2012. This study was targeted at four therapy groups which consisted of five people each. Intervention in the experimental groups was conducted total 20 times (for 40 minutes, five times per week and for four weeks). Shaker exercise applied to the experimental group 1 and 3, and neuromuscular electrical stimulation therapy applied to the experimental group 2 and 3. traditional swallowing therapy was carried out for thirty minutes in all the experimental groups, and the control group performed traditional swallowing therapy only. Swallowing functions of the subjects were measured using functional oral intake scale (FOIS) and surface electromyogram (sEMG). Between-group therapeutic effects were analyzed using the Mann-Whitney U test, for with-group effects before and after the therapy, the Wicoxon signed-rank test was employed. The findings of the study are as follows: First, as the result, the experimental group 1 and 3 that implemented Shaker exercise, showed the most improved oral intake functions, compared to other groups to carry out other therapies (p<.05). The within-group experimental group 1 and 3 showed a significant improvement in oral intake functions before and after the therapy, too (p<.05). Second, when comparing the experimental group 1 and 3 to perform Shaker exercise with other groups to carry out other therapies, there were no significant differences in suprahyoid muscle activity (p>.05). The within-group experimental group 1 and 3 showed a significant improvement in muscle activity of suprahyoid muscle before and after the therapy, too (p<.05). Third, when comparing the experimental group 2 and 3 to perform NMES therapy with other groups to carry out other therapies, there were no significant differences in oral intake functions, as well (p>.05). The within-group experimental group 2 and 3 showed a significant improvement in oral intake functions before and after the therapy, too (p<.05). Fourth, when comparing the experimental group 2 and 3 to perform NMES therapy with other groups to carry out other therapies, there were no significant differences in suprahyoid muscle activity, as well (p>.05). The within-group experimental group 2 and 3 showed a significant improvement in muscle activity of suprahyoid muscle before and after the therapy, too (p<.05). These results demonstrate what the groups to perform Shaker exercise showed more effective oral intake functions than those that didn't apply it, and there were no differences of suprahyoid muscle activity. Although there were no differences of the effect between the groups to apply NMES therapy and those that didn't apply it, it was effective in improving oral intake function and suprahyoid muscle activity before and after the intervention. In conclusion, Shaker exercise was an effective therapy for patients with dysphagia after a stroke, compared to other therapeutic methods. However, it is considered that further studies on the efficiency of the therapeutic effect of NMES therapy with other therapeutic methods would be needed.