Complete nanopore repeat sequencing of SCA27B (GAA-FGF14 ataxia) in Japanese.

BACKGROUND: Although pure GAA expansion is considered pathogenic in SCA27B, non-GAA repeat motif is mostly mixed into longer repeat sequences. This study aimed to unravel the complete sequencing of FGF14 repeat expansion to elucidate its repeat motifs and pathogenicity. METHODS: We screened FGF14 repeat expansion in a Japanese cohort of 460 molecularly undiagnosed adult-onset cerebellar ataxia patients and 1022 controls, together with 92 non-Japanese controls, and performed nanopore sequencing of FGF14 repeat expansion. RESULTS: In the Japanese population, the GCA motif was predominantly observed as the non-GAA motif, whereas the GGA motif was frequently detected in non-Japanese controls. The 5'-common flanking variant was observed in all Japanese GAA repeat alleles within normal length, demonstrating its meiotic stability against repeat expansion. In both patients and controls, pure GAA repeat was up to 400 units in length, whereas non-pathogenic GAA-GCA repeat was larger, up to 900 units, but they evolved from different haplotypes, as rs534066520, located just upstream of the repeat sequence, completely discriminated them. Both (GAA)≥250 and (GAA)≥200 were enriched in patients, whereas (GAA-GCA)≥200 was similarly observed in patients and controls, suggesting the pathogenic threshold of (GAA)≥200 for cerebellar ataxia. We identified 14 patients with SCA27B (3.0%), but their single-nucleotide polymorphism genotype indicated different founder alleles between Japanese and Caucasians. The low prevalence of SCA27B in Japanese may be due to the lower allele frequency of (GAA)≥250 in the Japanese population than in Caucasians (0.15% vs 0.32%-1.26%). CONCLUSIONS: FGF14 repeat expansion has unique features of pathogenicity and allelic origin, as revealed by a single ethnic study.

Sliced Jelly Whole Swallowing Reduces Deglutition Risk: A Novel Feeding Method for Patients with Dysphagia.

Texture modification in the form of gels or jellies is used for patients with dysphagia. For over 20 years, our group has been using gelatin jellies, a type of gel, as a starting diet for patients with dysphagia. Gelatin jellies are served in a small-sliced form and swallowed whole. In sliced jelly whole swallowing (SJWS), sliced gelatin jelly (SGJ) passes through the pharynx in one lump without collapsing. This study aimed to examine the usefulness of SJWS. We analyzed the images of videofluoroscopic swallowing studies performed using the normalized residue ratio scale (NRRSv: vallecula, NRRSp: pyriform sinus), the penetration-aspiration scale (PAS), and pharyngeal transit time (PTT) in 50 patients with dysphagia and compared the results in a prospective study. SJWS had significantly less residue in both NRRSv and NRRSp than in moderately thickened liquid swallowing. No significant differences in PAS scores were found between SGJ and moderately thickened liquid. Additionally, no significant differences in PTT scores were noted between the two. This study demonstrated the usefulness of SJWS in improving swallowing safety in patients with dysphagia. Further studies are needed to evaluate the reproducibility of the test, the comparison of SGJ with other thickened liquids, and the safety of SJWS for different diseases.

A Novel Exercise to Improve Suprahyoid Muscle Area and Intensity as Evaluated by Ultrasonography.

Insufficient suprahyoid muscle strength with poor opening of the upper esophageal sphincter can cause dysphagia. This study investigated whether an exercise of the suprahyoid muscle, named forehead exercise for suprahyoid muscles (FESM, "Enge-Odeko-Taiso" in Japanese), improves the geniohyoid muscle area and intensity using ultrasonography. Sixty-four participants (15 men and 49 women, 82.8 ± 6.0 years) living independently with no symptoms of swallowing difficulties were enrolled. The participants were divided into the FESM and the control group. The FESM is an isometric exercise involving repetitions of looking into the navel as if the chin is pulled back with little neck motion using a hand pushed against the forehead for resistance. This exercise is performed five times in 10 courses a day (total 50 times) for 8 weeks. Participants in the control group did not conduct any exercises. Body mass index, hand grip strength, gait speed, calf circumference, Mini Nutritional Assessment short-form, eating assessment tool, repetitive saliva swallowing test (RSST), and Food Intake LEVEL Scale scores were examined. The ultrasonographic geniohyoid muscle area, intensity, and RSST were investigated before and after the program. In the FESM group, the geniohyoid muscle area increased from 2.24 to 2.52 cm2 (P < 0.05), intensity decreased from 34.6 to 32.0 (P < 0.05), and the median RSST increased from 5 to 6 (P < 0.05) significantly. Conversely, no significant differences were observed in the control group. The FESM was effective to increase the area and decrease the intensity of the geniohyoid muscle and may improve swallowing function.

Speech-Swallow Dissociation of Velopharyngeal Incompetence with Pseudobulbar Palsy: Evaluation by High-Resolution Manometry.

Patients with pseudobulbar palsy often present with velopharyngeal incompetence. Velopharyngeal incompetence is usually observed during expiratory activities such as speech and/or blowing during laryngoscopy. These patients typically exhibit good velopharyngeal closure during swallowing, which is dissociated from expiratory activities. We named this phenomenon "speech-swallow dissociation" (SSD). SSD on endoscopic findings can help in diagnosing the underlying disease causing dysphagia. This endoscopic finding is qualitative, and the quantitative characteristics of SSD are still unclear. Accordingly, the current study aimed to quantitatively evaluate SSD in patients with pseudobulbar palsy. We evaluated velopharyngeal pressure during swallowing and expiratory activity in 10 healthy subjects and 10 patients with pseudobulbar palsy using high-resolution manometry, and compared the results between the two groups. No significant differences in maximal velopharyngeal contraction pressure (V-Pmax) were observed during dry swallowing between the pseudobulbar palsy group and healthy subjects (190.5 mmHg vs. 173.6 mmHg; P = 0.583). V-Pmax during speech was significantly decreased in the pseudobulbar palsy group (85.4 mmHg vs. 34.5 mmHg; P < 0.001). The degree of dissociation of speech to swallowing in V-Pmax, when compared across groups, exhibited a larger difference in the pseudobulbar palsy group, at 52% versus 80% (P = 0.001). Velopharyngeal pressure during blowing was similar to that during speech. Velopharyngeal closure in patients with pseudobulbar palsy exhibited weaker pressure during speech and blowing compared with swallowing, quantitatively confirming the presence of SSD. Pseudobulbar palsy often presents with SSD, and this finding may be helpful in differentiating the etiology of dysphagia.

Efficacy and Safety of "Vacuum Swallowing" Based on a Strong Negative Esophageal Pressure in Healthy Individuals.

Vacuum swallowing is a unique method for improving the pharyngeal passage of a bolus by creating subatmospheric negative pressure in the esophagus. However, whether healthy individuals and other patients with dysphagia can reproduce vacuum swallowing remains unclear. Therefore, this study aimed to assess whether healthy individuals verified using high-resolution manometry (HRM) could reproduce vacuum swallowing and evaluate its safety using a swallowing and breathing monitoring system (SBMS). Two healthy individuals who mastered vacuum swallowing taught this method to 12 healthy individuals, who performed normal and vacuum swallowing with 5 mL of water five times each. The minimum esophageal pressure and the maximum pressure of the lower esophageal sphincter (LES) were evaluated during each swallow using the HRM. Additionally, respiratory-swallowing coordination was evaluated using the SBMS. Ten individuals reproduced vacuum swallowing, and a total of 50 vacuum swallows were analyzed. The minimum esophageal pressure (-15.0 ± 4.9 vs. -46.6 ± 16.7 mmHg; P < 0.001) was significantly lower, and the maximum pressure of the LES (25.4 ± 37.7 vs. 159.5 ± 83.6 mmHg; P < 0.001) was significantly higher during vacuum swallowing. The frequencies of the I-SW and SW-I patterns in vacuum swallowing were 38.9% and 0%, respectively, using the SBMS. Vacuum swallowing could be reproduced safely in healthy participants with instruction. Therefore, instructing exhalation before and after vacuum swallowing is recommended to prevent aspiration.

Cricopharyngeal muscle origin transection for oropharyngeal dysphagia, a novel surgical technique.

BACKGROUND: Cricopharyngeal myotomy improves pharyngeal dysphagia by resecting the cricopharyngeal muscle. METHODS: Our procedure, cricopharyngeal muscle origin transection (CPM-OT) is performed through a midline skin incision at the cricoid cartilage level under local anesthesia. CONCLUSIONS: Sixteen patients demonstrated preservation of vocal fold movement without laryngeal nerve injury immediately after CPM-OT in the awake state during aspiration prevention surgery using the glottic closure technique. Postoperative videofluoroscopic examination of swallowing revealed the cricopharyngeal bar was absent and pharyngeal passage of the bolus and Food Intake LEVEL Scale was improved in all patients. CPM-OT is a feasible and less invasive treatment option.

A Safe Way to Administer Drugs Through a Nutrition Tube-The Simple Suspension Method.

The simple suspension method (SSM), developed by Kurata in 1997, is a way to suspend tablets and capsules in warm water for decay and suspension prior to their administration. This method is safe and has various advantages such as the avoidance of tube clogging and the loss of the drug. This study aimed to investigate whether a higher percentage of commonly used drugs could pass through nutrition tubes effectively using SSM, relative to that using the conventional crushing method. A tablet or capsule was inserted into a 20 mL syringe with warm water (at 55 °C). After 10 min, it was shaken in the syringe. The suspension liquid was injected into tubes of the following sizes: 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, and 18 Fr. A total of 3686 tablets and 432 capsules that are frequently used in Japan were tested. Using SSM, 3377 (91.6%) tablets and 359 (83.1%) capsules disintegrated within 10 min and passed through the tube without clogging it in the tube passage test. With the conventional crushing method, 2117 tablets (57.4%) and 272 capsules (63.0%) could be crushed. SSM reduced the risk of tube clogging and drug loss with more drugs than that with the conventional crushing method. The number of drugs indicated for administration by SSM is greater than that indicated by the conventional crushing method. Further studies are needed to consider its utility compared to conventional methods for dysphagia patients in clinical settings.

A Novel Method for Triggering the Swallowing Reflex in Patients with Amyotrophic Lateral Sclerosis: the Ishizaki Press Method.

This study describes the identification of specific maxillofacial points triggering the swallowing reflex by finger pressure in a patient with severe amyotrophic lateral sclerosis. This method has been named as the "Ishizaki Press Method." The first point was identified in a serendipitous encounter during training sessions to aid communication. This led to the search for such additional points, after obtaining informed consent from the patient and his relatives. Seven effective points were identified: the depressions in front of the left and right tragus (Ting gong points), bilateral points over the parotid and submandibular glands, and a point over the mentum in the midline of the face. The efficacy of these trigger points was noted to be ≥ 70%. The mean time taken for swallowing to occur in response to the stimulation at each of these points was less than 10 s, and the induction of a rapid swallowing reflex was recognized. Alternating left and right stimulations of the Ting gong points and the parotid points triggered the swallowing reflex significantly faster than unilateral stimulations alone. The Ishizaki Press Method may improve the management of dysphagia in patients with amyotrophic lateral sclerosis.

Cough-Inducing Method Using a Tartaric Acid Nebulizer for Patients with Silent Aspiration.

The tartaric acid nebulizer is a well-known cough test to evaluate cough function. This study aimed to evaluate the effectiveness of a cough-inducing method using tartaric acid (CiTA). Patients with dysphagia examined by videofluoroscopic examination of swallowing (VF) at a single institution from May 2017 to August 2017 were included in this retrospective observational study. Although undergoing VF, patients who had aspirated without reflexively coughing or who had coughed insufficiently, were instructed to cough voluntarily. Patients who could not cough voluntarily or had expectorated insufficiently underwent the CiTA method. The rate of cough induction and the effectiveness of expectoration using the CiTA method were evaluated. One hundred fifty-four patients (mean age 69.2 ± 16.8 years) were evaluated. Eighty-seven patients aspirated during VF. Of those patients, 15 were able to expectorate via the cough reflex, 18 were able to expectorate with a voluntary cough, and 12 required suctioning for removal of aspirated material. The remaining 42 patients underwent the CiTA method. Thirty-eight patients (90.4%) could reflexively cough, and 30 (71.4%) could expectorate the aspirated material. This novel method, CiTA, was effective for cough induction in patients with dysphagia, especially for those with silent aspiration.

Food appearance affects reward-related brain activity in healthy adults: a functional magnetic resonance imaging study.

A good appearance of food increases appetite. A new food product called iEat® resembles the appearance and softness of familiar foods. Previous studies have reported that iEat® foods increase appetite. However, the neuronal substrates underlying the increase in appetite following the observation of iEat® foods remain unknown. In the present study, the brain activity of 20 healthy adults during the visual presentation of iEat® and pureed foods and non-food objects was examined using functional magnetic resonance imaging. Compared with pureed foods and non-food objects, iEat® foods showed significantly greater activation in regions of the brain reward system, such as the amygdala, ventral striatum and orbital frontal cortex. In addition, individual differences in the activity of the left amygdala were positively correlated with subjective appetite ratings. These results suggest that the good appearance of foods, such as iEat® foods, may be useful for stimulating the appetite of patients with poor appetite.

Persistent intrathecal interleukin-8 production in a patient with SARS-CoV-2-related encephalopathy presenting aphasia: a case report.

BACKGROUND: Neurological manifestations of coronavirus disease 2019 (COVID-19) are increasingly recognized and include encephalopathy, although direct infection of the brain by SARS-CoV-2 remains controversial. We herein report the clinical course and cytokine profiles of a patient with severe SARS-CoV-2-related encephalopathy presenting aphasia. CASE PRESENTATION: An 81-year-old man developed acute consciousness disturbance and status epileptics several days after SARS-CoV-2 infection. Following treatment with remdesivir and dexamethasone, his consciousness and epileptic seizures improved; however, amnestic aphasia and agraphia remained. Two months after methylprednisolone pulse and intravenous immunoglobulin, his neurological deficits improved. We found increased levels of interleukin (IL)-6, IL-8, and monocyte chemoattractant protein-1 (MCP-1), but not IL-2 and IL-10 in the serum and cerebrospinal fluid (CSF), and the levels of serum IL-6 and MCP-1 were much higher than those in the CSF. The level of IL-8 in the CSF after immunotherapy was four times higher than that before immunotherapy. CONCLUSION: The cytokine profile of our patient was similar to that seen in severe SARS-CoV-2-related encephalopathy. We demonstrated (i) that the characteristic aphasia can occur as a focal neurological deficit associated with SARS-CoV-2-related encephalopathy, and (ii) that IL8-mediated central nervous system inflammation follows systemic inflammation in SARS-CoV-2-related encephalopathy and can persist and worsen even after immunotherapy. Monitoring IL-8 in CSF, and long-term corticosteroids may be required for treating SARS-CoV-2-related encephalopathy.

Effect of Bridge Position Swallow on Esophageal Motility in Healthy Individuals Using High-Resolution Manometry.

Recently, there has been clinical interest in the effect of different body positions on esophageal motility. This study aimed to identify the effect of three different body positions on esophageal motility using high-resolution manometry. Thirteen healthy adults swallowed 5 mL of water in the upright, supine, and bridge positions. For the bridge position, each subject raised their waist against gravity, placed a cushion under their back, and bent their knees. The proximal contractile integral (PCI) and distal contractile integral (DCI), integrated relaxation pressure (IRP), distal latency (DL), peristaltic breaks (PBs), intrabolus pressure (IBP), and expiratory and inspiratory esophagoesophageal junction (EGJ) pressure were measured. In the bridge position, PCI, DCI, IRP, and expiratory and inspiratory EGJ pressure were significantly higher than those in the upright position (bridge PCI vs. upright PCI [p = 0.001], bridge DCI vs. upright DCI [p < 0.001], bridge IRP vs. upright IRP [p = 0.018], bridge EGJ pressure vs. upright EGJ pressure [expiratory: p = 0.001] [inspiratory: p < 0.001]). PBs were significantly shorter and DL was significantly longer in the bridge position compared to upright (bridge PBs vs. upright PBs [p = 0.001], bridge DL vs. upright DL [p = 0.001]). IBP was significantly higher in the bridge position compared to supine (bridge IBP vs. supine IBP [p = 0.01]). These results demonstrated changes in esophageal motility according to changes in position while swallowing, where esophageal contractions became stronger against gravity. Further study is required to examine the effectiveness of swallowing in the bridge position.

Relationship Between Tongue Pressure and Pharyngeal Function Assessed Using High-Resolution Manometry in Older Dysphagia Patients with Sarcopenia: A Pilot Study.

Tongue pressure is often used to evaluate swallowing muscle strength in dysphagia patients with sarcopenia. However, the amount of tongue pressure that reflects pharyngeal swallowing function is unclear. The aims of this descriptive study were (1) to assess the association between tongue pressure and swallowing function using high-resolution manometry (HRM), (2) to evaluate whether manometric parameters were related to maximum tongue pressure (MTP) and other sarcopenia-related factors, and (3) to evaluate the manometric characteristics of pharyngeal swallowing in sarcopenic dysphagia. Sixteen patients with dysphagia (13 men; mean age 85.0 ± 6.6) who were diagnosed with sarcopenia and sixteen healthy subjects (10 men; mean age 33.6 ± 7.2) were included. Evaluation of HRM parameters including velopharyngeal contractile integral (VPCI), mesohypopharyngeal contractile integral (MHPCI), upper esophageal sphincter (UES) relaxation duration, and UES nadir pressure was performed. HRM parameters of patients were compared with MTP, sarcopenia factors, and manometric parameters of healthy subjects. The VPCI showed no statistically significant differences between patient and healthy groups. In the patient group, the MHPCI was significantly lower (126.1 ± 76.6 vs 193.2 ± 34.1 mmHg cm s; p = 0.003), UES nadir pressure was significantly higher (10.5 ± 27.5 vs - 11.2 ± 6.7 mmHg; p < 0.001), and UES relaxation duration (318.0 ± 152.4 vs 520.6 ± 60.0 ms; p = 0.007) was significantly shorter than those in the healthy group. HRM parameters were not significantly correlated with MTP and sarcopenia factors. Older dysphagia patients with sarcopenia had weaker pharyngeal contractility and UES dysfunction. Manometric evaluation of pharyngeal function may not be significantly associated with MTP and sarcopenia-related factors. Further study is needed to clinically apply tongue pressure for evaluating sarcopenic dysphagia.

Diagnosis and Treatment of Sarcopenic Dysphagia: A Scoping Review.

BACKGROUND: Sarcopenic dysphagia is a swallowing disorder due to sarcopenia involving the whole-body skeletal muscles and swallowing muscles. This scoping review aimed to explore the currently known information on the diagnosis and treatment of sarcopenic dysphagia and to clarify the types of research required to develop the field. METHODS: We searched the PubMed, MEDLINE, CINAHL, and Cochrane databases from their inception to October 2020, using the search terms "(sarcopenia or sarcopenic or myopenia or dynapenia) and (dysphagia or swallowing or deglutition) and (diagnosis or treatment)". Articles reporting diagnosis method and treatment of sarcopenic dysphagia were included. RESULTS: Twenty-one and eight articles reported on the diagnostic and treatment method, respectively. A diagnostic algorithm for sarcopenic dysphagia was most frequently used (n = 10). Other diagnostic methods included consensus diagnostic criteria for sarcopenic dysphagia (n = 4), sarcopenia and dysphagia without other causes of dysphagia (n = 4), and both sarcopenia and dysphagia (n = 3). The medical treatments for patients with sarcopenic dysphagia were described in single-patient case reports (n = 8) only. There were six articles reporting on a combination of rehabilitation and nutritional support. These reports showed the importance of interdisciplinary rehabilitation nutrition for improving patients' nutritional status and sarcopenia. CONCLUSIONS: A reliable and validated diagnostic algorithm was the most widely used diagnostic method for sarcopenic dysphagia. Only case reports have been published for the medical treatment of patients with sarcopenic dysphagia. Interdisciplinary rehabilitation nutrition may be useful for treating patients with sarcopenic dysphagia.

Weight and Muscle Mass Loss Associated with Acute Disease Can be Reversed with Appropriate Nutrition Therapy and Exercise in a Patient with Amyotrophic Lateral Sclerosisa: A Case Report.

Introduction Nutritional interventions targeting weight loss are useful for the treatment of amyotrophic lateral sclerosis (ALS). However, the changes in body composition after nutritional intervention remain unclear. We herein present a patient with ALS who experienced an increased weight and muscle mass owing to nutritional therapy and physical exercise. Case Presentation An 86-year-old man presented with dysphagia and dysarthria. The patient was diagnosed with bulbar-type ALS. As weight loss progressed, a gastrostomy was performed. After 21 months of disease onset, gastrointestinal bleeding due to a bumper ulcer led to further weight loss (from 40.2 kg to 36.8 kg). The patient experienced difficulty walking and ingesting food orally. Although the total daily energy expenditure (TDEE) was estimated to be 1,122 kcal/day, an intake of 1,500 kcal/day beyond the calculated TDEE was administered. The patient continued to perform daily voluntary exercises in addition to his usual rehabilitation. After 5 months, his weight increased from 36.8 kg to 40.4 kg. Muscle mass increased from 25.1 kg to 30.1 kg, as measured using a multifrequency bioelectrical impedance device. Muscle strength improved from 8.5/10.0 kg to 15.0/18.0 kg in grip strength and from 15.2 kPa to 20.4 kPa in tongue pressure. The patient's physical and swallowing functions also improved. Conclusion In patients with ALS, a decreased body weight and muscle mass due to acute disease may be improved by appropriate nutritional therapy and physical exercise.

Distal oesophageal spasm in a patient with multiple system atrophy: A case report.

A 74-year-old man developed orthostatic syncope, a feeling of food stuck in his chest, and postprandial vomiting 3 years before presentation. Examination revealed severe orthostatic hypotension and cerebellar ataxia, and he was diagnosed with multiple system atrophy (MSA) with predominant cerebellar ataxia. Videofluoroscopic examination of swallowing showed lower oesophageal stricture and barium stagnation within the oesophagus. Oesophagogastroduodenoscopy revealed hypercontraction of the lower oesophagus, and high-resolution oesophageal manometry showed premature contractions of the lower oesophagus and decreased oesophageal peristalsis. The median integrated relaxation pressure in the lower oesophageal sphincter was normal, and achalasia was therefore excluded. Based on the Chicago classification version 4.0, his oesophageal dysmotility was classified as distal oesophageal spasm (DES). The stuck feeling in his chest and vomiting improved following endoscopic balloon dilation. This case suggests that DES can cause oesophageal food stagnation and postprandial vomiting in patients with MSA.

Use of Pinching Nose Maneuver in a Patient With Severe Dysphagia Caused by Pseudobulbar Palsy.

Swallowing disorders resulting from pseudobulbar palsy are characterized by deficiencies in the oral preparatory and oral stages of the swallowing process. In certain cases, obstruction can occur when the tongue base comes into contact with the palate, impeding the intraoral bolus flow into the pharyngeal cavity. In this report, we discuss a case of severe pseudobulbar palsy, in which an intraoral bolus flowed into the pharyngeal cavity with pinching the nose. A 78-year-old man with a history of recurrent cerebral infarction was evaluated. The patient had severe dysphagia and cognitive impairment due to pseudobulbar palsy. A videofluoroscopic examination of swallowing (VF) was conducted while the patient was in a reclined position. In the oral cavity, when the bolus reached the posterior tongue section, the flow was hindered by the functional obstruction caused by the tongue base pressing against the palate. Despite the clinician's instructions to swallow, the patient was unable to comply due to the severity of his cognitive impairment. To alleviate this obstruction, the clinician pinched the patient's nose. This action opened the fauces, facilitating breathing and relieving the functional obstruction. Subsequently, the bolus flowed into the pharyngeal cavity and successfully flowed into the esophagus while swallowing. This maneuver was named the "pinching nose maneuver" (PNM). The PNM, as described here, can serve as a technique to improve the movement of an intraoral bolus into the pharyngeal cavity in patients with cognitive dysfunction.

A Case of a Patient With Spinal Muscular Atrophy With Dysphagia Who Acquired Vacuum Swallowing.

We present a case of acquired vacuum swallowing in a patient with spinal muscular atrophy associated with dysphagia. A 67-year-old male presented with spinal muscular atrophy. Even though he was able to eat orally, he required a long time to eat and faced difficulty while swallowing saliva, resulting in frequent spitting. Instructions regarding vacuum swallowing to eliminate pharyngeal residue were provided, and a reduction in meal duration and improved saliva swallowing were observed. High-resolution manometry revealed a significant increase in pharyngeal contractile integral and a significant decrease in esophageal pressure with vacuum swallowing, which enabled the passage of a bolus through the pharynx compared with non-vacuum swallowing. Furthermore, an increase in the lower esophageal sphincter pressure, reflecting diaphragmatic contraction, was also observed. Therefore, this case report elucidates that a patient with neuromuscular disorders could acquire vacuum swallowing with proper instructions.

Cutoff value of the geniohyoid muscle mass to identify sarcopenic dysphagia by ultrasonography.

PURPOSE: Determining the strength and area of the swallowing muscles is important in patients with sarcopenic dysphagia. Although the normative data on the strength of the swallowing muscles have been reported, those of the area of the geniohyoid muscle are poorly investigated. We investigated the cross-sectional area of the geniohyoid muscle in Japanese subjects without dysphagia using ultrasonography to determine the normative and cut-off values. METHODS: 142 subjects without dysphagia were included. The older group (age ≥ 65 years) included 36 (women 27/men 9) subjects, and the younger group (age ≤ 39 years) included 106 (women 54/men 52) subjects. The cross-sectional area of the geniohyoid muscle was measured by ultrasound. The mean of the younger group-2 standard deviation (SD) was calculated and used as a cut-off value for low swallowing muscle mass. RESULTS: The mean (SD) of the area of the geniohyoid muscle of each group was as follows: older women group 167.2 (32.6) mm2, older men group 193.2 (49.5) mm2, younger women group 247.3 (37.4) mm2, younger men group 313.1 (59.2) mm2. The mean 2SD of the geniohyoid muscle area in the younger women group was 172.5 mm2 and in the younger men group 194.7 mm2. CONCLUSION: We found that the cut-off value of the ultrasonographic cross-sectional area of the geniohyoid muscle was 172.5 mm2 for women and 194.7 mm2 for men. These values could be used as cut-off values for the mass of the geniohyoid muscle to identify patients with sarcopenic dysphagia.

Effect of a restrictive orthosis on the paralyzed hand in combination with constraint-induced movement therapy in a patient with chronic stroke: a case report.

PURPOSE: Many studies have reported the effects of constraint-induced movement therapy (CIMT) with an orthosis on the residual function of the impaired side of post-stroke patients. We encountered a case with left hemiparesis whose functioning of the impaired hand improved by CIMT with an orthosis not to assist as in the past but to restrict the residual function of the paralyzed fingers. METHODS: The patient was a 46-year-old woman with left hemiparesis due to cerebral infarction 18 months ago. The patient had resumed work but would easily tire while typing the keyboard. We found that the extrinsic hand muscles were more engaged in compensatory movements than the intrinsic muscles. Therefore, we designed an orthosis that would extend and fixation the distal interphalangeal joint and proximal interphalangeal joint muscles to promote the engagement of the intrinsic muscles and restrict the compensatory movements of the extrinsic muscles. RESULTS: The orthosis was used for 8 h/day for 2 weeks; CIMT were performed. Left hemiplegia improved from CIMT and the patient was able to handle the same amount of work as that before onset. CONCLUSION: Restrictive orthosis on the paralyzed hand in combination with CIMT was found to be a beneficial rehabilitation approach.IMPLICATIONS FOR REHABILITATIONThis case suggests that not assistive but suppressive orthosis with constraint-induced movement therapy can be effective in strengthening the intrinsic muscles of the hand and restricting compensatory movements by the extrinsic muscles in hemiplegic patients.Treating the paralyzed side with a suppressive orthosis may be an effective novel approach for improving the physical function of the paralyzed hand in post-stroke patients.