Rapid Aspiration Screening for Suspected Stroke: Part 2: Initial and Sustained Nurse Accuracy and Reliability.

OBJECTIVE: To determine registered nurses' (RNs') ability to obtain and maintain accurate procedural skills and reliable interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. DESIGN: Prospective, observation study. SETTING: A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS: RNs (N=15) were recruited and trained in the administration and interpretation of the screening items under study to develop the Rapid Aspiration Screening for Suspected Stroke. INTERVENTIONS: RNs completed a total of 239 screenings of patients admitted with suspected stroke over a 2-year period. RNs administered the swallowing screening items and interpreted the patient's response to each item. Independent of the RN, a speech-language pathologist simultaneously interpreted the response of the participant with stroke to each swallowing screening item. MAIN OUTCOME MEASURES: Reliability of the interpretation and accuracy of the administration of the swallowing screening items. RESULTS: The average accuracy rate for the administration of the Rapid Aspiration Screening for Suspected Stroke was 98.33%, with the overall accuracy rate for each procedural task ranging from 95.42% to 100%. For the specific swallowing screening items that formed the Rapid Aspiration Screening for Suspected Stroke, dysarthria and a positive sign after water swallow, reliability was high (k=.817). The accuracy rate for the administration and reliability of the interpretation of the swallowing screening items improved as RNs gained experience, and both were maximized at 20 screening opportunities. CONCLUSIONS: RNs demonstrate both excellent accuracy of procedural administration and reliability of interpretation of the items of the Rapid Aspiration Screening for Suspected Stroke. With feedback and repeated opportunities to practice, maintenance of skills is achievable.

Rapid Aspiration Screening for Suspected Stroke: Part 1: Development and Validation.

OBJECTIVE: To develop and validate a nurse-administered screening tool to identify aspiration risk in patients with suspected stroke. DESIGN: Validity study comparing evidence-based swallowing screening items with the videofluoroscopic swallowing study (VFSS) results. SETTING: A certified primary stroke center in a major metropolitan medical facility. PARTICIPANTS: Consecutive patients (N=250) admitted with suspected stroke. INTERVENTIONS: Patients were administered evidence-based swallowing screening items by nurses. A VFSS was completed within 2 hours of swallowing screening. MAIN OUTCOME MEASURES: Validity relative to identifying VFSS-determined aspiration for each screening item and for various combinations of items. RESULTS: Aspiration was identified in 29 of 250 participants (12%). Logistic regression revealed that age (P=.012), dysarthria (P=.001), abnormal volitional cough (P=.030), and signs related to the water swallow trial (P=.021) were significantly associated with aspiration. Validity was then determined on the basis of the best combination of significant items for predicting aspiration. The results revealed that age >70 years, dysarthria, or signs related to the water swallow trial (ie, cough, throat clear, wet vocal quality, and inability to continuously drink 90mL water) yielded 93% sensitivity and 98% negative predictive value. CONCLUSIONS: The final validated tool, Rapid Aspiration Screening for Suspected Stroke, is a valid nurse-administered tool to detect risk of aspiration in patients presenting with suspected stroke.

Respiratory-swallowing coordination and swallowing safety in patients with Parkinson's disease.

The purpose of this study was to determine if individuals with Parkinson's disease (PD) demonstrate abnormal respiratory events when swallowing thin liquids. In addition, this study sought to define associations between respiratory events, swallowing apnea duration, and penetration-aspiration (P-A) scale scores. Thirty-nine individuals with PD were administered ten trials of a 5-ml thin liquid bolus. P-A scale score quantified the presence of penetration and aspiration during the swallowing of a 3-oz sequential bolus. Participants were divided into two groups based on swallowing safety judged during the 3-oz sequential swallowing: Group 1 = P-A ≤ 2; Group 2 = P-A ≥ 3. Swallows were examined using videofluoroscopy coupled with a nasal cannula to record respiratory signals during the event(s). Findings indicated that expiration was the predominant respiratory event before and after swallowing apnea. The data revealed no differences in our cohort versus the percentages of post-swallowing events reported in the literature for healthy adults. In addition, individuals with decreased swallowing safety, as measured by the P-A scale, were more likely to inspire after swallows and to have shorter swallowing apnea duration. Individuals who inspired before swallow also had longer swallowing apnea duration. The occurrence of inspiratory events after a swallow and the occurrence of shorter swallowing apnea durations may serve as important indicators during clinical swallowing assessments in patients at risk for penetration or aspiration with PD.

The relationship between quality of life and swallowing in Parkinson's disease.

Few studies exist in the literature investigating the impact of idiopathic Parkinson's Disease (IPD) on swallow-related quality of life. We therefore aimed in this project to: (1) evaluate swallow-specific quality of life in IPD; (2) delineate potential relationships between IPD duration and severity with swallow-specific quality of life; (3) investigate relationships between swallow-specific quality of life and general health-related quality of life; and (4) investigate relationships between swallow-specific quality of life and depression. Thirty-six patients diagnosed with IPD with and without dysphagia filled out self-report assessments of the SWAL-QOL, Parkinson's Disease Questionnaire-39 (PDQ-39), and Beck Depression Inventory (BDI). A series of Mann Whitney U tests were performed between non-dysphagic and dysphagic groups for the total SWAL-QOL score and the 10 SWAL-QOL domains. Spearman's Rho correlation analyses were performed between the SWAL-QOL and (1) PDQ-39; (2) Hoehn and Yahr stage; (3) PD disease duration; (4) UPDRS "on" score; and (5) the BDI. The dysphagia swallowing group reported significant reductions compared to the non-dysphagic group for the total SWAL-QOL score (P = 0.02), mental health domain score (P = 0.002) and social domain score (P = 0.002). No relationships existed between swallow-specific quality of life and disease duration or severity. Significant relationships existed between swallow-specific quality of life and general health-related quality of life (r(s) =-0.56, P = 0.000) and depression (r(s) = -0.48, P = 0.003). These exploratory data highlight the psychosocial sequelae that swallowing impairment can have in those with IPD and suggest a possible association between swallowing, social function, and depression.

Defining and measuring dysphagia following stroke.

PURPOSE: To continue the development of a quantified, standard method to differentiate individuals with stroke and dysphagia from individuals without dysphagia. METHOD: Videofluoroscopic swallowing studies (VFSS) were completed on a group of participants with acute stroke (n = 42) and healthy age-matched individuals (n = 25). Calibrated liquid volumes of 3, 5, 10, and 20 ml were administered during the VFSS. Six measures in 3 domains of bolus flow (timing, direction, and clearance) were measured. Values of these measures obtained from the control group were used to classify dysphagia within the participants. RESULTS: The use of a single measure or single liquid volumes to classify dysphagia did not distinguish between healthy adults and individuals following stroke with and without dysphagia. Abnormality on more than 1 measure across multiple volumes appears to be a more robust method in defining dysphagia for liquids. CONCLUSIONS: Our findings indicate that the definition of dysphagia is critical in determining whether persons are classified with disordered swallowing. The definition is dependent on materials and measures evaluated. Each measure provides independent aspects to the evaluation. Determining the level of importance of each depends on the purpose of the evaluation.

Phoneme-based rehabilitation of anomia in aphasia.

This study investigated the effects of phonologic treatment for anomia in aphasia. We proposed that if treatment were directed at the level of the phonologic processor, opportunities for naming via a phonological route, as opposed to a strictly whole word route, would be enhanced, thereby improving naming. The participants, ten people with anomia and aphasia due to left hemisphere stroke, received 96 h of phoneme based treatment in 12 weeks. To learn if treatment improved naming, a single-subject, repeated probe design with replication was employed. The primary outcome measure was confrontation naming. Secondary outcome measures included phonologic production, nonword repetition and discourse production. Results suggest a positive treatment effect (confrontation naming), improvements in phonologic production and nonword repetition, and generalization to discourse production. When tested 3 months after the completion of treatment the effects appeared to be maintained.

Submental sEMG and hyoid movement during Mendelsohn maneuver, effortful swallow, and expiratory muscle strength training.

PURPOSE: This study investigated the concurrent biomechanical and electromyographic properties of 2 swallow-specific tasks (effortful swallow and Mendelsohn maneuver) and 1 swallow-nonspecific (expiratory muscle strength training [EMST]) swallow therapy task in order to examine the differential effects of each on hyoid motion and associated submental activation in healthy adults, with the overall goal of characterizing task-specific and overload properties of each task. METHOD: Twenty-five healthy male and female adults (M = 25 years of age) participated in this prospective, experimental study with 1 participant group. Each participant completed all study tasks (including normal swallow, Mendelsohn maneuver swallow, effortful swallow, and EMST task) in random order during concurrent videofluoroscopy and surface electromyography recording. RESULTS: Results revealed significant differences in the trajectory of hyoid motion as measured by overall displacement and angle of elevation of the hyoid bone. As well, timing of hyoid movement and amplitude differences existed between tasks with regard to the activation of the submental musculature. CONCLUSIONS: Study results demonstrated differential effects of the 3 experimental tasks on the principles of task specificity and overload. These principles are important in the development of effective rehabilitative programs. Subsequent direction for future research is suggested.

Neuroplasticity and rehabilitation research for speech, language, and swallowing disorders.

PURPOSE: This article introduces a collection of consensus statements regarding the application of neuroplasticity principles to rehabilitation of dysphagia, dysarthria, apraxia, and aphasia.

The communicative effectiveness survey: preliminary evidence of construct validity.

PURPOSE: To provide preliminary evidence of the construct validity of the Communicative Effectiveness Survey (CES) for individuals with dysarthria and idiopathic Parkinson's disease (PD). METHOD: In a prospective, quasi-experimental design, 25 participants each were assigned to 3 groups (N = 75): PD and dysarthria, non-PD and no dysarthria, and PD significant others (SOs). Mean CES ratings were used to test for significant differences between the PD and non-PD group, and PD and SO rating of PD's communicative effectiveness. Multiple linear regression tested for significant predictors of CES ratings for PD group only using sentence intelligibility and spontaneous speech intelligibility scores as predictor variables. RESULTS: The PD group rated their CES significantly lower than did the non-PD group. The PD group rated their CES significantly higher than their SOs rated them. Neither speech intelligibility score was a significant predictor of CES ratings. In follow-up analysis, the Hoehn and Yahr PD staging accounted for 47% of the variability in CES ratings for the PD group participants. CONCLUSIONS: This study provides preliminary evidence of the CES's construct validity. Clinicians and researchers who assess and treat individuals with PD may consider adding an additional assessment to the traditional clinical measures (i.e., speech intelligibility) by obtaining a measure of communicative effectiveness.

Listener agreement for auditory-perceptual ratings of dysarthria.

PURPOSE: Darley, Aronson, and Brown (1969a, 1969b) detailed methods and results of auditory-perceptual assessment for speakers with dysarthrias of varying etiology. They reported adequate listener reliability for use of the rating system as a tool for differential diagnosis, but several more recent studies have raised concerns about listener reliability using this approach. METHOD: In the present study, the authors examined intrarater and interrater agreement for perceptual ratings of 47 speakers with various dysarthria types by 2 listener groups (inexperienced and experienced). The entire set of perceptual features proposed by Darley et al. was rated based on a 40-s conversational speech sample. RESULTS: No differences in levels of agreement were found between the listener groups. Agreement was within 1 scale value or better for 67% of the pairwise comparisons. Levels of agreement were lower when the average rating fell in the mid-range of the scale compared with samples that had an average rating near either of the scale endpoints; agreement was above chance level. No significant differences in agreement were found between the perceptual features. DISCUSSION: The levels of listener agreement that were found indicate that auditory-perceptual ratings show promise during clinical assessment for identifying salient features of dysarthria for speakers with various etiologies.

Effects of verbal cue on bolus flow during swallowing.

PURPOSE: To examine the effects of verbal cuing to initiate swallowing on bolus flow measures in healthy adults. METHOD: Videofluoroscopic examinations were completed in 12 healthy older adults (median age=69 years) as they swallowed 5 ml of self-administered liquid barium in 2 conditions: verbally cued and noncued swallows. In the cued condition, participants held the liquid in their mouths until instructed to swallow. In the noncued condition, participants swallowed in their usual manner. RESULTS: Verbal cue affected bolus position at onset of timing measures, thereby influencing duration. The bolus was positioned more posterior in the oral cavity at onset of oral transit for cued as compared with noncued swallows. The leading edge of the bolus at onset of the pharyngeal swallow was more superior in the pharynx for cued as compared with noncued swallows. Durations of the cued swallows were significantly shorter than for noncued swallows for all timing measures. Bolus direction scores were not significantly different between conditions. CONCLUSIONS: Findings suggest that swallowing is altered by the use of verbal cues to initiate swallowing in healthy adults. Determining whether shorter durations with implementation of verbal cues are evident in individuals with dysphagia and whether effects are beneficial or deleterious requires continued research.

Coping by stroke caregivers: sex similarities and differences.

Informal care provision presents many challenges. As the population ages, more people are forced to enter the role of informal caretaker. Despite the increase in the need for caregivers and the importance of providing care, there is little empirical research examining how men and women approach and cope with providing care. The current study examined stroke patients and their care providers to assess possible gender differences in the impact of caretaking on caretakers and care recipients. Results indicate no significant difference in patient well-being based on the gender of the caregiver. Some measures indicated that men have advantages as caregivers. Results are discussed with regard to the accuracy and utility of sex-role stereotypes about caregivers. In addition, these data provide potential insight about how to decrease caregiver burden, delay long-term hospitalization of the patient, and increase the quality of life for caretakers and patients.

Tyranny of the randomised clinical trial.

Researchers and clinicians often disagree about what it means to provide the best possible care. This paper's purpose is to propose ways of resolving the disagreements. The first is to have both groups re-examine the three equal components of evidence-based practice, a re-examination that begins with rejection of the randomised clinical trial's tyranny. The second is for researchers to design rehabilitation research based on a biopsychosocial rather than a biomedical model. The third is for both groups to redefine translational research so that it means both translation from the laboratory to the clinic and from the clinic to the laboratory. The fourth is to advocate for a science of dissemination that is as robust as rehabilitation's present science of discovery. Most examples are drawn from the literature on acquired neurologic speech and language disorders.

Active treatments for aprosodia secondary to right hemisphere stroke.

This study investigates the effects of two mechanism-based treatments for expressive aprosodia. Three participants, two women and one man, had a right hemisphere cerebral infarction resulting in affective aprosodia with greater expressive than receptive deficits. Trained raters determined presence of aprosodia by judging participants' performance on two emotional communication batteries. A single-subject design with replication across three participants was employed. Sentence production with the use of treated and nontreated emotions was measured during baseline and treatment phases. Sentences were scored for accuracy by a trained rater blind to time of testing and analyzed visually and statistically. Effect sizes calculated on the resulting data for each participant and treatment confirmed modest to substantial treatment effects for both treatments in all three participants. Because of a relative paucity of treatment studies investigating expressive aprosodia, these data are among the first to suggest that aprosodia may be amenable to behavioral treatments.

Narrative Discourse Cohesion in Early Stage Parkinson's Disease.

BACKGROUND: Models of basal ganglia (BG) function suggest that expressive language deficits will likely and consistently present in BG disease. Disparities currently exist between the predictions of models of BG function in expressive language and data from studies of BG disease. Traditional expressive language assessment methodologies that emphasize measures of language form (word and sentence productivity) while not carefully considering how language is used, may only partially account for these disparities. OBJECTIVE: To use measures of cohesion to examine the use of cohesive markers in narrative discourse. METHODS: Twelve individuals with idiopathic Parkinson's disease (PD) were compared to 12 matched neurologically intact controls on measures of discourse performance. Three discourse samples (typical day, memorable vacation and family) were analyzed for measures of narrative productivity, number of cohesive ties and cohesive adequacy. Mixed model analyses were completed for group comparisons. RESULTS: Group differences were not observed on measures of language form as measured by narrative productivity, communication units, and number of cohesive ties produced. In contrast, group differences were observed in cohesive adequacy as individuals with PD produced a higher percentage of incomplete and erroneous cohesive ties relative the control subjects across narratives. CONCLUSIONS: These results support the conclusion that the BG in PD may have an executive role in expressive language use that can be disrupted without impacting language form.

Affective aprosodia from a medial frontal stroke.

BACKGROUND AND OBJECTIVES: Whereas injury to the left hemisphere induces aphasia, injury to the right hemisphere's perisylvian region induces an impairment of emotional speech prosody (affective aprosodia). Left-sided medial frontal lesions are associated with reduced verbal fluency with relatively intact comprehension and repetition (transcortical motor aphasia), but persistent affective prosodic defects associated with right medial frontal lesions have not been described. METHODS: We assessed the prosody of a man who sustained a right medial frontal cerebral infarction seven years prior. RESULTS: While propositional speech expression was normal including syntactic prosody, the patient was impaired at expressing emotions using prosody. His comprehension and repetition of prosody were also impaired but less so than expression. CONCLUSIONS: Right medial frontal lesions can induce an affective aprosodia that primarily impairs expression.

Mechanism of sequential swallowing during straw drinking in healthy young and older adults.

Recent research has revealed differences between isolated and sequential swallowing in healthy young adults; however, the influence of normal aging on sequential swallowing has not been studied. Thus, the purpose of this investigation was to examine the effects of normal aging on deglutition during sequential straw drinking. Videofluoroscopic samples of two 10-s straw drinking trials were obtained for 20 healthy young men (age 29 +/- 3 years) and 18 healthy older men (age 69 +/- 7 years). Hyolaryngeal complex (HLC) movement patterns, leading edge of the bolus location at swallow onset, and occurrences of airway invasion were determined. Two HLC patterns were identified: (a). HLC lowering with the epiglottis returned to upright between swallows and (b). partially maintained HLC elevation with the epiglottis inverted between swallows. The bolus was frequently in the hypopharynx at swallow onset. Strong associations were identified between age and HLC pattern, age and leading edge of the bolus location, and HLC pattern and leading edge location. Laryngeal penetration was uncommon overall; however, it occurred more frequently in the older adults than in the young adults. A significant relation was identified between age and the average Penetration-Aspiration Scale score. Laryngeal penetration was associated with both HLC movement patterns and hypopharyngeal bolus location, particularly in older adults. Results indicate that subtle age-related differences are evident in healthy young and older adults with sequential straw drinking. These data suggest that specific inherent swallowing patterns may increase the risk of laryngeal penetration with normal aging.

Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing.

UNLABELLED: A hotly debated topic in oropharyngeal dysphagia is the Clinical Swallowing Examination's (CSE) importance in clinical practice. That debate can profit from the application of evidence-based medicine's (EBM) principles and procedures. These can guide both appropriate data collection and interpretation as will be demonstrated in the present report. The study's purpose from which data for this report are drawn was to determine the relationship among signs elicited by a CSE and aspiration on a subsequent videofluoroscopic swallowing examination (VFSE). Sensitivity, specificity; positive and negative predictive values (NPV); likelihood ratios; and post-test probabilities for a variety of signs in isolation and in combinations are reported. These data, if judiciously selected and interpreted contribute to the clinician's knowledge about whether to follow a CSE with a VFSE and about what to expect if the VFSE is completed. LEARNING OUTCOMES: (1) Clinicians will learn how to use EBM principles in conjunction with clinical assessments of swallowing to enhance patient care. (2) Clinicians will learn how to identify combinations of patient signs during he CSE to predict VFSE performance.

Functional outcomes associated with expiratory muscle strength training: narrative review.

This review presents the available evidence for the effects of expiratory muscle strength training (EMST) with the use of a pressure threshold device. The investigators used computerized database searches for studies reporting the outcomes of pressure threshold EMST published after 1994. A total of 24 selected articles presented outcomes related but not limited to respiratory function, such as speech, swallow, voice, and cough function in persons with neurologic conditions such as Parkinson disease, multiple sclerosis, and Lance-Adams syndrome; in persons with respiratory diseases, such as chronic obstructive pulmonary disease; and in healthy young adults and sedentary and active elderly. Several studies demonstrated promising outcomes of EMST as a non-task-specific training for airway protection in persons with dysphagia secondary to neuromuscular impairments; however, further research is needed to confirm and generalize the reported findings.

Detraining outcomes with expiratory muscle strength training in Parkinson disease.

Expiratory muscle strength training (EMST) is efficacious for improving maximum expiratory pressure (MEP), cough function, and swallowing safety in Parkinson disease (PD). However, there are no published reports describing detraining effects following EMST in persons with PD. Moreover, there are no published reports describing detraining effects following any behavioral swallowing intervention. Ten participants with PD underwent 3 mo of detraining following EMST. Measures of MEP and swallowing safety were made prior to beginning EMST (baseline), posttreatment (predetraining), and 3 mo postdetraining. Participants demonstrated, on average, a 19% improvement in MEP from pre- to post-EMST. Following the 3 mo detraining period, MEP declined by 2% yet remained 17% above the baseline value. No statistically significant changes were found in swallowing safety from post-EMST to postdetraining period. Following the 3 mo detraining period, seven participants demonstrated no change in swallowing safety, one worsened, and two had improvements. This preliminary study highlights the need for the design of maintenance programs to sustain function following intensive periods of training.