吞嚥運動強化及增進舌骨上肌群以改善中風患者吞嚥障礙及上食道括約肌功能異常：系統性文獻回顧

Swallowing Exercisesin Enforcing and Augmenting Suprahyoid Muscles to Improve Dysphagia and Upper Esophageal Sphincter Dysfunction for Stroke Patients: A Systematic Review

10.6315/TJPMR.202106_49(1).0003

葉桓安(Heng-An Yeh)；陳渝仁(Yu-Jen Chen)

吞嚥運動（swallowing exercise） ； 上食道括約肌（upper esophageal sphincter） ； 舌骨上肌群（suprahyoid muscle） ； 吞嚥障礙（dysphagia） ； 系統性文獻回顧（systematic review） ； wallowing exercise ； upper esophageal sphincter ； suprahyoid muscle ； dysphagia ； systematic review

台灣復健醫學雜誌

49卷1期（2021 / 06 / 01）

17 - 37

繁體中文

背景及目的：吞嚥障礙經常發生在中風患者上，而患者可能會出現口腔、咽部和上食道括約肌的功能受損，包括咀嚼和攪拌食團能力不足、咽部收縮能力不佳、咽部及上食道括約肌不協調及上食道括約肌放鬆不足。若上食道括約肌開啟幅度不足，食團從咽部流至食道的過程中，會變成阻礙。至今，除了語言治療提供吞嚥訓練外，對於治療上食道括約肌功能異常的處置方式，大部分為侵入性。然而，目前已有部分文獻發表幾種非侵入性之吞嚥運動，用以治療上食道括約肌功能異常。本文目的為系統性地回顧對中風患者吞嚥障礙有幫助的吞嚥運動，以及強化或增進舌骨上肌群功能以改善吞嚥障礙及上食道括約肌功能障礙之相關文獻。方法：經由PubMed、Embase、Medline、Web of Science及The Cochrane Library之電子資料庫平台，鍵入關鍵字吞嚥介入（swallow intervention）、開啟不足（insufficient opening）、上食道括約肌（upper esophageal sphincter, UES）、舌骨上肌群（suprahyoid muscle）及吞嚥運動（swallowing exercise）、吞嚥障礙（dysphagia）、咀嚼困難（deglutition disorders）、吞嚥訓練（swallowing training）、語言治療（speech therapy）及頷下肌群（submental muscle）尋找相關文獻，搜尋範圍從2008年1月至2020年12月，篩選符合納入標準之文獻進行分析與整理。結果：本系統性回顧共篩選出27篇文獻進行質性研究分析，並歸納出四大類型之吞嚥運動，而各類型吞嚥運動又衍伸出其他相似的吞嚥運動。不論是健康成人或中風導致吞嚥障礙的受試者，經過一段時間的訓練後，能有助於增進舌骨上肌群肌力、喉部上提的幅度、舌頭肌力、增進上食道括約肌開啟的寬度或減少吞嚥後殘留量…等吞嚥相關機制及生理的表現。結論：新興的吞嚥運動提供吞嚥障礙患者及臨床治療師另一種訓練的選擇，在執行Shaker運動、縮下巴阻抗運動或張口運動…等訓練後，可有效增進及強化吞嚥障礙患者的舌骨上肌群、喉部相關肌群及吞嚥生理之表現，改善因中風導致之吞嚥障礙或上食道括約肌功能異常。然而，不同的吞嚥運動各有其優缺點及使用限制，仍有賴語言治療師依患者病況及吞嚥障礙做綜合評估，選擇適當的吞嚥運動，再隨其吞嚥能力的變化適時調整，才能有效改善障礙，恢復患者從口進食的能力。

Dysphagia often occurs in stroke patients, who may present oral, pharynx, and upper esophageal sphincter dysfunction, including insufficient chewing and stirring bolus ability, poor pharyngeal contraction, pharynx to upper esophageal sphincter incoordination, and relaxation of the upper esophageal sphincter. Insufficient opening of the upper esophageal sphincter is an obstacle for moving a bolus from the pharynx to the esophagus. In addition to provide swallowing training, most of the treatments for upper esophageal sphincter dysfunction are invasive. However, several non-invasive swallowing exercises have been published with the aim of treating upper esophageal sphincter dysfunction. The purpose of this article is to systematically review the relevant literature on swallowing exercises that would be helpful for stroke patients with dysphagia in addition to strengthening or enhancing the function of suprahyoid muscles to improve dysphagia and upper esophageal sphincter dysfunction. Searching were conducted in databases including PubMed, Embase, Medline, Web of Science, and The Cochrane Library. Keywords were used included ＂Swallow interventions＂, ＂Insufficient opening＂, ＂Upper esophageal sphincter (UES)＂, ＂Suprahyoid muscle＂, ＂Swallowing exercises＂, ＂Dysphagia＂, ＂Deglutition disorders＂, ＂Swallowing training＂, ＂Speech therapy＂ and ＂Submental muscles＂. The search period extended from January 2008 to December 2020, and articles that met the inclusion criteria were selected for analysis and extract. A total of 27 articles were selected for analysis and extraction. Four major types of swallowing exercises were summarized; each type of swallowing exercise produces other similar swallowing exercises. Regardless of whether the subject is a healthy adult or stroke patient with dysphagia, after completing a period of training, swallowing exercises help increase the strength of the suprahyoid muscles, superior laryngeal movement, tongue strength, and cause an increase in the width of opening of the upper esophageal sphincter in addition to reducing residue after swallowing. The modern swallowing exercise provides another training option for therapists and patients with dysphagia. Conducting Shaker exercises and chin tuck against resistance or jaw opening exercises, could effectively enhance and strengthen suprahyoid muscles, laryngeal muscles, and other swallowing-related physiological manifestations, in addition to improving dysphagia or upper esophageal sphincter dysfunction in stroke patients with dysphagia. However, different swallowing exercises have their own advantages, disadvantages, and limitations. Swallowing assessment conducted by a speech therapist who chooses appropriate swallowing exercises for a patient and then modifies the exercises according to a patient's condition is necessary for those patients with dysphagia in order to help improve the symptoms of swallowing disorders.

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