İNMELİ HASTALARDA EKSPİRATUAR KAS EĞİTİMİNİN STOMATOGNATİK SİSTEME ETKİSİ

Öz

Amaç: Bu çalışmanın amacı ekspiratuar kas eğitiminin inmeli hastaların stomatognatik sistemine etkisini incelemekti. Yöntem: Çalışmaya kontrol grubuna 16 inmeli hasta (yaş=66.63±8.35, boy=166.38±8.59, BKİ=28.09±4.81), çalışma grubuna 15 inmeli hasta (yaş=65.60±7.62, boy=168.20±8.78, BKİ=28.95±6.42) olmak üzere toplam 31 inmeli hasta dahil edildi. İnmeli hastaların temporomandibular eklem hareket açıklığı ve disfonksiyonu, çiğneme kasları ağrı eşiği, fasiyal asimetri varlığı, baş postürü, oral hijyen ve oral hijyen alışkanlıkları, çiğneme performansı, intraoral pH, yutma ve derin boyun fleksör kasları enduransı değerlendirildi. Değerlendirme yöntemleri sırasıyla; dijital kaliper, Fonseka Anketi, algometre, labial kommissür ve kranioservikal açı ölçümü, genel oral sağlık değerlendirme indeksi ve anket, elek testi, dijital pH ölçer, tekrarlı saliva yutma testi, yeme değerlendirme envanteri ve derin boyun fleksörleri endurans testiydi. Çalışma grubundaki inmeli hastalar konvansiyonel fizyoterapi programına ek olarak üç hafta süresince, haftada her gün 5 set 10 tekrardan oluşan ekspiratuar kas eğitimi programına, kontrol grubuysa konvansiyonel fizyoterapi programına alındı. Çalışma grubundaki inmeli hastalar haftada iki gün aranarak, ekspiratuar kas eğitimi programına olan uyumları değerlendirildi. Bulgular: Grup içi karşılaştırmada kontrol grubundaki bireylerin sol masseter inferior parçası ağrı eşiklerinde ve protrüzyon hareketinde artış, labial kommissür açılarında ve Fonseka Anketi skorlarında ise azalma gözlendi (p<0.05). Çalışma grubunda yer alan inmeli hastaların ise mandibular depresyonunda artış bulundu (p<0.05). Grup içi karşılaştırmada gruplar benzer intraoral pH, çiğneme performansı, kranioservikal açı ve derin boyun fleksörleri enduransı değerlerine sahipti (p>0.05). Gruplar arası karşılaştırmada ise lateral deviasyon, yeme değerlendirme envanteri ve labial kommissür açısında anlamlı fark bulunurken (p<0.05), diğer parametreler benzerdi (p>0.05). Labial kommissür açısındaki iyileşme kontrol grubu lehineydi (p<0.05) Sonuç: Ekspiratuar kas eğitimi sub akut ya da kronik dönem inme hastalarında mandibular lateral deviasyonun arttırılmasında ve yutmanın iyileştirilmesinde tercih edilebilir.

Anahtar Kelimeler

• Çiğneme
• Yutma
• Temporomandibular Eklem

EFFECT OF EXPIRATORY MUSCLE TRAINING ON STOMATOGNATHIC SYSTEM IN PATIENTS WITH STROKE

Öz

Objective: The aim of this study was to assess the effect of expiratory muscle training on the stomatognathic system in patients with stroke. Method: A total of 31 patients with stroke were included in the study: 16 patients with stroke (age=66.63±8.38, height=166.38±8.59, BMI=28.09±4.81) as the control group and 15 patients with stroke (age=65.60±7.62, height=168.20±8.78, BMI=28.95±6.92) as the study group. Temporomandibular joint range of motion and dysfunction, pressure pain threshold of masticatory muscles, facial asymmetry existence, head posture, oral hygiene, oral hygiene habit, masticatory performance, intraoral pH, deglutition, and deep neck flexor muscle endurance of the patients with stroke were assessed. Assessment methods were in order by digital caliper, the Fonseca Questionnaire, algometry, labial commissure and craniocervical angle measurement, general oral health assessment index, and questionnaire, sieve test, digital pH gauge, repetitive saliva swallow test, Eating Assessment Tool, and deep neck flexor endurance test. Patients with stroke in the study group were enrolled in an expiratory muscle training program consisting of 5 sets of 10 repetitions daily for three weeks in addition to conventional physiotherapy; the control group enrolled in the conventional physiotherapy program. Patients with stroke in the study group were called twice a week to assess their compliance with the expiratory muscle training. Results: In intragroup comparison significant increase was found in the inferior portion of the left masseter, mandibular protrusion, and a decrease in labial commissure angle and Fonseca Questionnaire score of the control group (p<0.05). In the study group a significant increase was observed in mandibular depression (p<0.05). In intragroup comparison, both groups had similar intraoral pH, masticatory performance, craniocervical angle and neck flexor muscle endurance (p>0.05). While significant difference was found in lateral deviation, eating assessment inventory and labial commissure angle in intergroup comparison (p<0.05), other parameters were similar (p>0.05). Improvement in labial commissure angle was in favor of the control group (p<0.05). Conclusion: Expiratory muscle training might be preferred to increase mandibular lateral deviation and improve deglutition in subacute or chronic-stage patients with stroke.

Anahtar Kelimeler

• Mastication
• Deglutition
• Temporomandibular Joint

Kaynakça

1. Mackay J, Mensah GA, Mendis S, Greenlund K. The atlas of heart disease and stroke World Health Organization. 2004.
2. Mayer NH, Esquenazi A. Muscle overactivity and movement dysfunction in upper motoneuron syndrome. Phys Med Rehabil Clin N Am. 2003;14:855-883.
3. Tyson SF, Hanley M, Chillala J, Selley A, Tallis RC. Balance disability after stroke. Phys Ther. 2006;86(1):30-38.
4. Dursun Ö, Çankaya T. Assessment of temporomandibular joint dysfunction in patients with stroke. J Stroke Cerebrovasc Dis. 2018;27(8):2141-2146.
5. Okeson JP. Management of Temporomandibular Disorders and Occlusion. Missouri: Mosby/Elsevier Publishing Company; 2012.
6. Selley WG, Flack FC, Ellis RE, Brooks WA. Respiratory patterns associated with swallowing: Part 1. The normal adult pattern and changes with age. Age Ageing. 1989;18(3):168-172.
7. Dai R, Lam OLT, Lo ECM, Li LSW, Wen Y, McGrath C. Orofacial functional impairments among patients following stroke: a systematic review. Oral Dis. 2015;21(7):836-849.
8. Brooks M, McLaughlin E, Shields N. Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: a systematic review. Int J Speech Lang Pathol. 2019;21(1):89-100.

9. Khedr EM, Shinawy OE, Khedr T, Ali YAA, Awad EM. Assessment of corticodiaphragmatic pathway and pulmonary function in acute ischemic stroke patients. Eur J Neurol. 2000;7(5):509-516.
10. Kulnik ST, Birring SS, Moxham J, Rafferty GF, Kalra L. Does respiratory muscle training improve cough flow in acute stroke? Pilot randomized controlled trial. Stroke. 2015;46:447-453.
11. Hegland KW, Davenport PW, Brandimore AE, Singletary FF, Troche MS. Rehabilitation of swallowing and cough functions following stroke: an expiratory muscle strength training trial. Arch Phys Med. 2016;97(8):1345-1351.
12. Eom MJ, Chang MY, Oh DH, Kim HD, Han NM, Park JS. Effects of resistance expiratory muscle training in elderly patients with dysphagic stroke. Neurorehabil. 2017;41(4):747-725.
13. Folstein MF, Folstein SE, McHugh PR. "Mini-Mental State": A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189-198.
14. Da Fonseca DM, Bonfante G, Valle AL, De Freitas SFT. Diagnostico pela anamnese da disfunçao craniomandibular. Rev Gauch de Odontol. 1994;4(1):23-32.
15. Walker N, Bohannon RW, Cameron D. Discriminant validity of temporomandibular joint range of motion measurements obtained with a ruler. J Orthop Sport Phys. 2000;30(8):484-492.
16. Dawson PE. Functional Occlusion: From TMJ to Smile Design. St Louis: CV Mosby; 2007.
17. Farella M, Michelotti A, Steenks MH, Romeo R, Cimino R, Bosman F. The diagnostic value of pressure algometry in myofascial pain of the jaw muscles. J Oral Rehab. 2000;27(1):9-14.
18. Tessitore A, Magna LA, Paschoal JR. Angular measurement for determining muscle tonus in facial paralysis. Pro Fono. 2010;22(2):119-124.
19. Castien R, Blankenstein A, Van Der Wint D, Heymans MW, Dekker J. The working mechanism of manual therapy in participants with chronic tension-type headache. J Orthop Sport Phys. 2013;43(10):693-699.
20. Oguchi K, Saitoh E, Baba M, Kusudo S, Tanaka T, Onogi K. Repetitive saliva swallowing test (RSST) as a screening test of functional dysphagia (2) validity of RSST. Jpn J Rehabil Med. 2000;37:383-388.
21. Belafsky PC, Mouadeb DA, Rees CJ, et al. Validity and reliability of the eating assessment tool (EAT-10). Ann Otol Rhinol Laryngol. 2008;117(12):919-924.
22. Kapur KK, Soman S, Yurkstas A. Test foods for measuring masticatory performance of denture wearers. J Prosthet Dent. 1964;14(3):483-491.
23. Baliga S, Muglikar S, Kale R. Salivary pH: A diagnostic biomarker. J Indian Soc Periodontol. 2013;17(4):461-465.
24. Ediriweera DS, Dilina N, Saparamadu V, et al. Aspirin is associated with low oral pH levels and antacid helps to increase oral pH. BMC Res Notes. 2018;11:137.
25. Harris KD, Heer DM, Roy TC, Santos DM, Whitman JM, Wainner RS. Reliability of a measurement of neck flexor muscle endurance. Phys Ther. 2005;85(2):1349-1355.
26. Atchison KA, Dolan TA. Development of the geriatric oral health assessment index. J Dent Educ. 1990;54(11):680-687.
27. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc. 1982;14:377-381.
28. Marco E, Ramírez-Sarmiento AL, Coloma A, et al. High-intensity vs. sham inspiratory muscle training in patients with chronic heart failure: a prospective randomized trial. Eur J Heart Fail. 2013;15:892-901.
29. Guclu MB, Arıkan H, Savcı S, et al. Effects of inspiratory muscle training in patients with heart failure. Resp Med. 2011;105:1671-1681.
30. Ay S, Evcik D, Kutsal YG, et al. Compliance to home-based exercise therapy in elderly patients with knee osteoarthritis. Turk J Phys Med Rehab. 2016;62(4):323-328.
31. Ohmure H, Miyawaki S, Nagata J, Ikeda K, Yamasaki K, Al-Kalaly A. Influence of forward head posture on condylar position. J Oral Rehabil. 2008;35:795-800.
32. Kraaijenfa S, Molen L, Tinteren H, Hilgers F, Smeele L. Treatment of myogenic temporomandibular disorder: a prospective randomized clinical trial, comparing a mechanical stretching device (TheraBite) with standard physical therapy exercise. Cranio. 2014;32(3):208-216.
33. Poluha RL, Canales GD, Costa YM, Grossmann E, Bonjardim LR, Conti PCR. Temporomandibular joint disc displacement with reduction: a review of mechanisms and clinical presentation. J Appl Oral Sci. 2019;27:e20180433.
34. Uchida MC, Carvalho R, Tessutti VD, et al. Identification of muscle fatigue by tracking facial expressions. Plos One. 2018;18:1-11.
35. McGill SM, Brown S. Creep response of the lumbar spine to prolonged full flexion. Clin Biomech. 1992;7:43-46.
36. Setiawan S, Haroen ER, Hadidjah D. The difference in saliva pH before and after brushing with fluoride containing toothpaste and without toothpaste. Padjajaran J Dent. 2008;20(3):139-142.
37. Wheeler-Hegland KM, Rosenbek JC, Sapienza CM. Submental sEMG and hyoid movement during Mendelsohn maneuver, effortful swallow, and expiratory muscle strength training. J Speech Lang Hear Res. 2008;51(5):1072-1087.
38. Schimmel M, Ono T, Lam OLT, Müller F. Oro-facial impairment in stroke patients. J Oral Rehab. 2017;44:313-326.
39. Miyaura K, Morita M, Matsua Y, Yamashita A, Watanabe T. Rehabilitation of biting abilities in patients with different types of dental prosthesis. J Oral Rehabil. 2000;27:1073-1076.
40. Nam C, Park Y, Lee J. Impact of cervical stabilization exercises and breathing retraining impact on the respiratory function of elderly stroke patients with hemiplegia: a randomized controlled trial. Int J Biosci Biotech. 2015;7(4):159-168.