Patient Selection
Approval for this study was granted by the Non-Clinical Research Ethics Committee of Karatay Technical University Medical Faculty (decision no:2018/014, dated:06.02.2018). Patients who were diagnosed with schizophrenia and were hospitalized in the Psychiatry ward of Necmettin Erbakan University Meram Faculty of Medicine between April 2018 and January 2020, who had swallowing difficulties, who agreed to participate in the study, who had no comprehension and communication problems, and who met the inclusion criteria were included in the study (Table 1). For the study, 53 patients who were diagnosed with schizophrenia and had swallowing complaints were screened with the Eating Assessment Tool (EAT-10), 6 patients were not included in the study because they did not meet the criteria for dysphagia. The study started with 47 patients. 36 patients due to cooperation problems and difficulties in adapting to exercises during the treatment and 4 more patients who did not complete the treatment sessions due to discharge were excluded from the study. Thus, the study was completed with 7 patients (4 men, 3 women).
Table 1
The inclusion and exclusion criteria of the study
Inclusion Criteria | Exclusion Criteria |
Diagnosed with schizophrenia Age ≥ 18 years EAT-10 score > 3 Saliva problem severity scale score ≥ 3 | • EAT-10 score < 3 • Receiving medical treatment for saliva problem • A history of surgical treatment for saliva problem • A history of physical therapy for saliva problem • A history of Botox application for saliva problem • The use of an orthosis for oral motor treatment |
Method Evaluation
A sociodemographic data form was prepared for the information obtained from the study participants of age, gender, height, weight, disease history, education level, and level of physical activity. The evaluation of disease history6 (the time since psychiatric diagnosis) was classified in 4 groups; < 2 years, 2–5 years, 5–10 years, > 10 years. The evaluation of education level was classified in 7 categories, similar to previous literature7; illiterate, primary school, middle school, high school, further education, university.
The swallowing function was evaluated using the Eating Assessment Tool (EAT-10). This test, which is simple, inexpensive, and can be applied in approximately 8 mins, is a test which provides subjective data in the evaluation of dysphagic patients. The questionnaire measures the level of the swallowing problem with 10 questions scored from 0 (no problem) to 4 (severe problem). Patients with a total score of ≥ 3 are evaluated as dysphagic8. However, with this evaluation, it is not possible to determine whether the causes of dysphagia are of oral or pharyngeal origin. It only gives information about the severity of swallowing difficulties. The Saliva Control Problem Severity and Frequency Scale, developed by Stonell and Greenberg, is a scale in which the severity section is scored from 1 to 5, and the frequency section from 1 to 4. Higher scale points indicate a greater problem. This scale is a valid method, which has often been used in literature9,10. The severity and frequency of the saliva problems of the patients were determined using this scale. Evaluation of restricted mouth opening (trismus) is made by measuring the distance between the mesioincisal edge of the right 1st upper incisor and the mesioincisal edge of the right 1st lower incisor with calipers in mm while the patient is in an upright sitting position11. This evaluation provides information about the mobilization of the jaw joint. Considering that especially the chewing muscles may be affected by medical treatments, it was thought that mouth opening should be evaluated.
The Application of Swallowing Disorder Rehabilitation
A total of 12 sessions of swallowing disorder rehabilitation program were applied to the patients included in the study, 3 sessions per week for 4 weeks. In the rehabilitation of swallowing disorder, in each session, with the chewing apparatus placed between the molar teeth, in order to create intraoral awareness and to strengthen the chewing muscles, 3 minutes of chewing training on both sides, resistance 5 repetitions with an exercise band in the direction of jaw collapse, was performed for 5 seconds with isometric contraction exercise. In order to strengthen the tongue muscles, a resistive exercise was performed with 10 repetitions of 5 seconds isometric contraction in the up, down, right and left directions of the tongue with the help of abeslang. The tongue muscle was stretched by holding it with the hand for 5 seconds at the end point with 5 repetitions, providing maximal extraoral extension. For laryngeal mobilization, the laryngeal region was mobilized in the right-left, up-down direction for 3 minutes.
Thermal-tactile stimulation treatment procedures were standardized and conducted by a collaborative therapist12. Thermal tactile stimulation was applied by 180 repetitive contact of cooled steel rods with the oropharyngeal arches in the mouth. It took about 15 minutes of practice. Oropharyngeal arches are known to facilitate swallowing in the cold. Subjects were periodically asked whether they felt the cold and whether they felt uncomfortable13.
Electrical stimulation was applied by an therapist, using a modified hand-held battery-powered electrical stimulator (VitalStim® Dual Channel Unit and electrodes, Chattanooga Group, Hixson, TN, USA). NMES application was applied by placing the electrodes on the masseter muscle for 20 minutes in to improve saliva control. Two sets of electrodes were used simultaneously for the right and left sides. The cheek skin of the masseter area was prepared with 70% isopropyl alcohol cotton. Referring to Freed et al., the electrodes were attached to the masseter muscles, the frequency of vibration was set at 80 Hz with a width of 300 ms, and the wave pattern was bi-phasic14. The electric current intensity started at 2.5 mA and, set at a comfortable level for the patients by increases in 2.5-mA increments, and had a maximum of 20.0 mA.
All the patients were evaluated before and after the Swallowing Disorder Rehabilitation with the EAT-10, the Saliva Control Problem Severity and Frequency Scale, and the Trismus measurements. The data obtained were evaluated according to appropriate statistical analyses. SPSS 21.0 (IBM Inc., Chicago, IL, USA) was used for the analysis, and the significance level was 0.05.