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April 22, 1998 Medical College of Wisconsin Researchers Develop Simple Exercise To Return Tube Fed Patients To Oral Eating
Chew up that bite of steak - yuuum - and swallow it down. It's such a simple process, one that we all complete dozens of times a day. Sometimes it's deliberate such as when we enjoy a mouth-watering meal. Sometimes it's entirely unconscious such as when we swallow excess saliva without even thinking about it.
Medical College of Wisconsin researchers, led by Reza Shaker, M.D., director of the Digestive Disease Center, have found a simple and effective way to help when the process goes wrong. The results of their study will be published in the May issue of Gastroenterology.
That seemingly uncomplicated act of swallowing is actually very complex. It involves a whole group of muscles that open and close the round sphincter muscle that sits in the top of the esophagus like a drawstring on a purse, preventing anything unwanted from sliding down the tube. When something goes wrong - it could be stroke, cancer surgery done on the throat or neck, or just the general weakness of old age - swallowing can become a nightmare. It can become so difficult that patients can't eat and have to be fed through a tube. While no one likes that unpleasant process, it can lead to significant health problems such as malnutrition, reflux and infection at the tube site.
Medical College physicians have long suspected the reason elderly people often have difficulty swallowing is because the muscles that open and close the esophageal sphincter become weak. Several years ago they did a study with two groups of elderly people who were basically healthy but had trouble swallowing. They were x-rayed and the motion of their swallowing muscles documented. Then half the group was put on a regimen of exercise to strengthen those muscles.
The Shaker exercise was simple, and aimed at making the swallowing muscles located in front of neck work harder.
Patients were asked to lie flat on their back and raise the head enough to see the toes without raising the shoulders. Meanwhile, the other group did a "sham exercise" - opening and closing their fists. They all did the exercises three times a day for six weeks; at the end of that time the x-rays were repeated. There was no doubt about the results. The real exercisers improved their muscle function; those doing the sham exercise did not.
Dr. Shaker and his group began to wonder if the same exercise could help those who had experienced surgery, stroke or other illness that impaired their ability to swallow. They decided to find out.
They carefully selected seven patients from Froedtert Hospital and the VA Medical Center who had experienced a stroke, radiation to the neck, or surgery for head and neck cancer who were being tube fed due to inability to swallow but who were alert and strong enough to do the exercise. They were x-rayed to evaluate their swallowing muscle function. These patients also did the exercise three times a day for six weeks. The results were remarkable; they all showed significant improvement in their ability to swallow as measured on the x-rays. Even more important, they began to eat normally! All seven patients were able to return to oral feeding with a soft diet.
"We compared the results, and low-and-behold, there was improvement," says Dr. Shaker. "Research in this area has lagged behind other fields. We needed to further define the basic physiology of swallowing, and our Medical College researchers have been one of the pioneers in this field. Now, because we understand the physiology better we can cope with pathological conditions and devise methods to remedy them. This exercise is a good example of that and probably a flagship for more to come."
The researchers are planning a multi-institutional study with 200 patients to validate the pilot study.
Difficulty swallowing, which includes such symptoms as coughing and throat clearing during eating, as well as actual choking, affects one out of 17 Americans; as many as half of nursing home patients have the problem. This simple exercise routine, developed and tested at the Medical College of Wisconsin, offers them hope of improvement without surgery or drugs. Dr. Shaker's gastroenterology and hepatology research colleagues include Walter Hogan, M.D., professor of medicine, Benson Massey, M.D., assistant professor of medicine, Mark Kern, M.D., research scientist, and Caryn Easterling, M.S., speech pathologist with Curative Rehabilitation Services.
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