Tongue Pressure Resistance Training for Post-Stroke Dysphagia: A Case Study.

PURPOSE: The purpose of this study was to explore the effect of a lingual resistance training protocol on the swallowing function of an individual presenting with dysphagia and reduced tongue pressures following a supratentorial ischemic stroke. METHODS: A study involving a lingual resistance training protocol with videofluoroscopy to measure outcomes comparing different parameters to ASPEKT normative reference values at three timepoints: baseline (VFSS A), following a 4-week lead-in period to control for spontaneous recovery (VFSS B), and at the 8-week endpoint of treatment (VFSS C). The study was interrupted due to the COVID-19 pandemic after 1 participant enrollment and is presented as single case study. RESULTS: Isometric tongue pressures: Following the 4-week lead-in, a decline in maximum isometric anterior tongue pressure (MAIP) and regular effort saliva swallow pressures (RESS) was noted, however there was no change in maximum posterior isometric tongue pressures (MPIP). Isometric tongue pressures improved post-treatment, with increases in MAIP, MPIP, and to a lesser degree RESS. Swallowing Function: Impairments in swallowing safety continued between the baseline VFSS A (Penetration-Aspiration Scale score [PAS]=8) and lead-in VFSS B (PAS=5). Swallowing safety improved following the intervention, with PAS scores = 1 at the endpoint VFSS C. Pixel-based measures of swallowing efficiency revealed a reduced frequency of post-swallow total pharyngeal reside following the treatment. Improvements were found in two other swallowing parameters, laryngeal vestibule closure integrity and pharyngeal area at maximum pharyngeal constriction, at the endpoint VFSS. CONCLUSION: These pilot data suggest improvements in some swallowing parameters as an outcome of intervention.

Food-Grade Activated Charcoal for Contrast-Enhanced Photoacoustic Imaging of Aspiration: A Phantom Study.

Aspiration pneumonia has the highest attributable mortality of all medical complications post-stroke, or in individuals with progressive neurological diseases. For optimum health outcomes for individuals with dysphagia, a non-invasive and convenient method for objectively detecting aspiration is needed. This study introduces a potential new aspiration screening method based on photoacoustic imaging (PAI), a medical imaging technology that measures the optical contrast of tissue rather than mechanical or elastic properties. In this preliminary study, a tissue-mimicking neck phantom was designed to test the performance of PAI for aspiration screening with a charcoal solution as a contrast agent. A 1064 nm wavelength light source was illuminated on the anterior of the neck phantom to induce the photoacoustic effect. The resulting photoacoustic signal of the charcoal contrast in the mock trachea was detected by a linear transducer array with a 2.25 MHz central ultrasound frequency. The phantom results showed that charcoal solution at 10 mg/ml exhibited strong photoacoustic signals when flowing into the phantom trachea. By overlaying the photoacoustic signals of the charcoal contrast on top of the ultrasound image, we were able to simultaneously visualize the movement of food contrast and a cross-section of tissue structures during mock swallowing. Moreover, we confirmed the ability to detect the flow of charcoal contrast at a small bolus volume of ~ 7 µl through the phantom, suggesting high sensitivity to detect small aspiration events. The study suggests that PAI holds promise to be developed as an aspiration detection tool with charcoal powder as a contrast agent.

A Preliminary Videofluoroscopic Investigation of Swallowing Physiology and Function in Individuals with Oculopharyngeal Muscular Dystrophy (OPMD).

Dysphagia is one of the primary symptoms experienced by individuals with Oculopharyngeal Muscular Dystrophy (OPMD). However, we lack understanding of the discrete changes in swallowing physiology that are seen in OPMD, and the resulting relationship to impairments of swallowing safety and efficiency. This study sought to describe the pathophysiology of dysphagia in a small sample of patients with OPMD using a videofluoroscopy examination (VFSS) involving 3 × 5 mL boluses of thin liquid barium (22% w/v). The aim of this study is to extend what is known about the pathophysiology of dysphagia in OPMD, by quantifying changes in swallow timing, kinematics, safety, and efficiency, measured from VFSS. This study is a secondary analysis of baseline VFSS collected from 11 adults (4 male), aged 48-62 (mean 57) enrolled in an industry-sponsored phase 2 therapeutic drug trial. Blinded raters scored the VFSS recordings for safety [Penetration-Aspiration Scale (PAS)], efficiency [Normalized Residue Ratio Scale (NRRS)], timing [Pharyngeal Transit Time (PTT), Swallow Reaction Time (SRT), Laryngeal Vestibule Closure Reaction Time (LVCrt), Upper Esophageal Sphincter Opening Duration (UESD)], and kinematics (hyoid movement, pharyngeal constriction, UES opening width). Impairment thresholds from existing literature were defined to characterize swallowing physiology and function. Further, Fisher's Exact tests and Pearson's correlations were used to conduct a preliminary exploration of associations between swallowing physiology (e.g., kinematics, timing) and function (i.e., safety, efficiency). Compared to published norms, we identified significant differences in the degree of maximum pharyngeal constriction, hyoid movement distance and speed, as well as degree and timeliness of airway closure. Unsafe swallowing (PAS ≥ 3) was seen in only 3/11 patients. By contrast, clinically significant residue (i.e., NRRS scores ≥ 0.09 vallecular; ≥ 0.2 pyriform) was seen in 7/11 patients. Fisher's Exact tests revealed associations between prolonged SRT, PTT, and unsafe swallowing. Weak associations were also identified between post-swallow residue and poor pharyngeal constriction during the swallow. Detailed analysis of swallowing physiology in this series of adults with OPMD aligns with impaired muscular function (e.g., reduced pharyngeal constriction, incomplete laryngeal vestibule closure) associated with the disease, and primary functional challenges with swallow efficiency. Further work is needed to explore a greater range of food and liquid textures, and to identify additional physiological mechanisms underlying swallowing impairment in OPMD.

Trends in Research Literature Describing Dysphagia in Motor Neuron Diseases (MND): A Scoping Review.

Dysphagia in motor neuron diseases (MNDs) is highly complex, affecting all stages of swallowing and leading to impaired swallowing safety and efficiency. In order to explore the degree to which research is capturing the symptom of dysphagia in MND, we conducted a scoping review of the existing literature. The primary aims of this review were to identify common themes within the literature on dysphagia in MND, explore patterns and trends in research focus, and identify if any imbalances exist between the research themes related to dysphagia description and management. A comprehensive search strategy yielded 1690 unique articles for review. Following relevance screening, a total of 157 articles were included in the synthesis. Relevant data and keywords were extracted from each article and grouped into themes. Frequency estimates were calculated for each theme to identify trends across research literature. Swallowing impairment in MNDs is described in a variety of ways across current research. The most commonly reported theme was Aspiration/Penetration, mentioned in 73.2% of all included articles; a significant imbalance was identified between reports of swallowing safety and efficiency (p = 0.008). The most frequently reported theme related to dysphagia management was Enteral Nutrition, and very few studies have reported on the efficacy of Rehabilitation/Compensatory recommendations. It is suggested that researchers and clinicians remain mindful of imbalances and gaps in research, and aim to characterize dysphagia in MNDs in a comprehensive manner. Further research investigating discrete, measureable changes in swallowing pathophysiology would be beneficial to delineate the key factors contributing to impaired swallowing safety and efficiency.

A Randomized Trial Comparing Two Tongue-Pressure Resistance Training Protocols for Post-Stroke Dysphagia.

The objective of this study was to compare the outcomes of two tongue resistance training protocols. One protocol ("tongue-pressure profile training") emphasized the pressure-timing patterns that are typically seen in healthy swallows by focusing on gradual pressure release and saliva swallowing tasks. The second protocol ("tongue-pressure strength and accuracy training") emphasized strength and accuracy in tongue-palate pressure generation and did not include swallowing tasks. A prospective, randomized, parallel allocation trial was conducted. Of 26 participants who were screened for eligibility, 14 received up to 24 sessions of treatment. Outcome measures of posterior tongue strength, oral bolus control, penetration-aspiration and vallecular residue were made based on videofluoroscopy analysis by blinded raters. Complete data were available for 11 participants. Significant improvements were seen in tongue strength and post-swallow vallecular residue with thin liquids, regardless of treatment condition. Stage transition duration (a measure of the duration of the bolus presence in the pharynx prior to swallow initiation, which had been chosen to capture impairments in oral bolus control) showed no significant differences. Similarly, significant improvements were not seen in median scores on the penetration-aspiration scale. This trial suggests that tongue strength can be improved with resistance training for individuals with tongue weakness following stroke. We conclude that improved penetration-aspiration does not necessarily accompany improvements in tongue strength; however, tongue-pressure resistance training does appear to be effective for reducing thin liquid vallecular residue.

The Effect of Bolus Consistency on Hyoid Velocity in Healthy Swallowing.

The aim of this study was to determine whether measures of hyoid velocity increase when swallowing liquids of thicker consistency at a constant volume. A gender-balanced sample of 20 healthy young participants (mean age 31.5) each swallowed 3 boluses of 5 ml volume in 3 consistencies (ultrathin, thin, and nectar-thick barium). Using frame-by-frame tracking of hyoid position, we identified the onset and peak of the hyoid movement and derived measures of velocity (i.e., distance in anatomically normalized units, i.e., % of the C2-4 vertebral distance, divided by duration in ms) for the X, Y, and XY movement directions. Peak hyoid velocity was also identified for each movement direction. Where significant differences were identified, the component measures of hyoid movement distance and duration were further explored to determine the strategies used to alter velocity. The results showed increased velocities and higher peak velocities with the nectar-thick stimuli compared to thin and ultrathin stimuli. This was achieved by a primary strategy of larger hyoid movement distances per unit of time when swallowing nectar-thick liquids. These results point to one mechanism by which thickened liquids may contribute to improved airway protection by facilitating more timely laryngeal vestibule closure.

The Relationship Between Pharyngeal Constriction and Post-swallow Residue.

Pharyngeal constriction has been proposed as a parameter that may distinguish functional from impaired swallows. We employed anatomically normalized pixel-based measures of pharyngeal area at maximum constriction, and the ratio of this measure to area at rest, and explored the association between these measures and post-swallow residue using the normalized residue ratio scale (NRRS). Videofluoroscopy data for 5 ml boluses of 22 % (w/v) liquid barium were analyzed from 20 healthy young adults and 40 patients with suspected neurogenic dysphagia. The frames of maximum pharyngeal constriction and post-swallow hyoid rest were extracted. Pixel-based measures of pharyngeal area were made using ImageJ and size-normalized using the squared C2-C4 vertebral distance as a reference scalar. Post-swallow residue and the areas of the vallecular and pyriform sinus spaces were measured on the hyoid rest frame to calculate the NRRSv and NRRSp. The dataset was divided into swallows with residue within or exceeding the upper confidence interval boundary seen in the healthy participants. Mixed model repeated measures ANOVAs were used to compare pharyngeal area (rest, constriction) and the pharyngeal constriction ratio, between individuals with and without residue. Measures of pharyngeal area at maximum constriction were significantly larger (i.e., less constricted, p = 0.000) in individuals with post-swallow residue in either the valleculae or the pyriform sinus. These results support the idea that interventions targeted toward improving pharyngeal constriction have the potential to be effective in reducing post-swallow residue.

Variations in tongue-palate swallowing pressures when swallowing xanthan gum-thickened liquids.

Thickened liquids are frequently recommended to reduce the risk of aspiration in patients with oropharyngeal dysphagia. Although it has previously been reported that tongue-palate pressures increase when swallowing spoon-thick and semi-solid consistencies compared to thin liquids, relatively little is known about how swallowing behaviors differ when swallowing liquids of nectar- or honey-thick consistency. Furthermore, previous studies have primarily used starch-based thickeners, and little is known about swallowing behaviors with xanthan gum-thickened liquids, which have recently been introduced for dysphagia management. In this study, we measured variations in tongue-palate pressures during the swallowing of liquids thickened to apparent viscosities of 190, 250, and 380 mPa s at 50/s using increasing concentrations of xanthan gum (0.5, 0.63 and 0.87 w/w%). The viscosity differences between these nectar- and honey-thick stimuli were confirmed to exceed sensory perceptual discrimination thresholds. Data were collected from 78 healthy adults in two sex-balanced age-groups (young; mature) and compared to reference values obtained during water swallowing. The results confirm that increased amplitudes of tongue-palate pressure were used when swallowing the thickened liquid stimuli, compared to swallows of water, and for the honey-thick liquid compared to the two nectar-thick liquids. Age-related reductions were seen in tongue strength but not in swallowing pressures, which fell below 40 % of maximum isometric pressure values. Thus, the use of xanthan gum-thickened liquids is unlikely to tax the swallowing system in terms of tongue pressure generation requirements, even in seniors with reduced maximum isometric tongue pressure measures.

Age and strength influences on lingual tactile acuity.

Sensory function during the oral processing of liquids is thought to play a key role in informing the tailoring of swallowing motor behaviours to the flow characteristics of the bolus. In addition to taste receptors, the mouth and tongue house trigeminal nerve receptors that support the sensory detection of bolus size, shape (stereognosis), mass, temperature and movement. Recent studies suggest that healthy adults lose tongue strength with advancing age. However, little is known about changes in the sensory function of the tongue attributable to age, or associated with reductions in strength. In this study, we explored lingual tactile acuity in healthy young and older adults, and measured the relationship between tactile acuity and measures of tongue strength. The results showed an age-related reduction in lingual tactile acuity that was not explained by variations in tongue strength. PRACTICAL APPLICATIONS: Sensory motor interactions are a topic of interest in understanding the processing activities that take place in the mouth during eating and swallowing. In this paper, we explore a test of sensory acuity in the mouth, in which the tongue is used to "read" embossed letters on Teflon strips. Our questions were to determine whether sensory acuity for this task declines with age, or with age-related reductions in tongue strength. We determined that older people perform this task with less accuracy, suggesting some changes in oral sensory function with age. However, these changes were not related to tongue strength. The findings suggest that strength does not play a major role in the kind of sensory discrimination task tested in this study.

How Do Quantitative Videofluoroscopy Measures Differ Between People With Amyotrophic Lateral Sclerosis and Age-Matched Healthy Adults?

PURPOSE: Dysphagia is a leading cause of morbidity in people with amyotrophic lateral sclerosis (PwALS). Previous videofluoroscopic swallowing studies (VFSS) in PwALS do not account for the influence of senescence. We aimed to compare swallowing in PwALS and an age- and sex-matched control group using healthy reference data to define typical and atypical values. METHOD: We conducted retrospective analysis of VFSS data from 19 PwALS (10 male, Mage = 63 years, range: 47-82) compared to control data from a cohort of healthy adults. Participants swallowed 20% w/v liquid barium from thin to extremely thick consistency. Blinded duplicate VFSS analysis using the ASPEKT (Analysis of Swallowing Physiology: Events, Kinematics and Timing) method yielded descriptive statistics for 16 quantitative VFSS parameters by consistency. Mann-Whitney U tests were used to identify significant cohort differences. Additionally, the frequencies of atypical values (in the 25% tails of the reference distribution) were tabulated by cohort and compared using odds ratios. RESULTS: PwALS showed increased frequencies of multiple swallows per bolus, incomplete laryngeal vestibule closure, and reduced hyoid speed across consistencies. By contrast, similar frequencies of atypical values for pharyngeal constriction and residue in both cohorts suggest that age-related changes may contribute to the presence of these features in PwALS. CONCLUSIONS: This analysis builds on previous descriptions of swallowing pathophysiology in amyotrophic lateral sclerosis (ALS) by clarifying the extent to which aging may account for some of the atypical findings seen in this patient population. Longitudinal studies are recommended to further differentiate the effects of ALS from age-related changes in swallowing over the course of disease progression.

A Preliminary Study of Vallecular Bolus Aggregation in Healthy Swallowing of Solid Food Boluses.

OBJECTIVE: The pharyngeal swallow typically begins within 400 ms following the arrival of a liquid bolus in the pharynx. By contrast, processed food particles aggregate in the valleculae prior to swallow initiation. With solid foods, swallow reaction time (SRT), the interval between bolus passing the ramus of mandible and hyoid burst onset (HYB) can be subdivided into components of vallecular aggregation time (VAT) and the subsequent end of aggregation to hyoid burst interval (EOA-to-HYB). However, expected durations of these timing measures remain unclear. We aimed to study bolus aggregation in healthy swallowing for International Dysphagia Diet Standardisation Initiative Food Levels 5 (minced and moist [MM5]), 6 (soft and bite-sized [SB6]), and 7 (regular [RG7]). Understanding typical patterns and durations of vallecular aggregation with solids in healthy swallowing will inform the identification of impaired swallow timing in patient populations. DESIGN: Twenty healthy adults (10 males, Mage = 28 years, range: 23-55 years) swallowed two boluses each of MM5, SB6, and RG7 foods in videofluoroscopy. Blinded duplicate ratings determined bolus location at swallow onset, SRT, VAT, and EOA-to-HYB. Texture-based differences were measured using Friedman's tests. Bolus location was at/above the valleculae at swallow onset for 85% of boluses, with no differences by texture. SRT, VAT, and EOA-to-HYB did not vary by texture, with overall median values (interquartile range) of 99 ms (-66 to 743 ms) for SRT, 347 ms (66 to 891 ms) for VAT, and -132 ms (-231 to -83 ms) for EOA-to-HYB. CONCLUSIONS: These data corroborate prior evidence that it is not unusual for food particles to aggregate in the valleculae prior to swallow initiation in healthy swallowing. However, durations of vallecular aggregation are typically < 1 s in healthy adults.

Validation of the IDDSI funnel for liquid flow testing.

In 2017, the International Dysphagia Diet Standardisation Initiative (IDDSI) introduced the IDDSI flow test which enables patients, clinicians, caregivers, food service professionals and researchers to classify liquid thickness into five levels based on the volume of liquid remaining in a standard 10 mL slip tip syringe after 10 s of flow under gravity. Within a few months of publishing the IDDSI flow test instructions, several barriers emerged: (1) the preferred model of syringe (BD 303134) was not equally accessible around the world, causing some users to perform flow tests with alternate models of syringe; (2) differences in syringe geometry across models led to variations in IDDSI flow test results; and (3) the need to use a second syringe for sample loading added complexity and cost to end users. To address these barriers, IDDSI designed the IDDSI funnel, a novel device, which combines the geometry of the BD 303134 syringe with a kitchen funnel to facilitate easy loading of liquid samples without need for a second syringe. In this report, we compare the IDDSI flow test results across two devices: syringe BD 303134 and IDDSI funnel. IDDSI level classifications were in complete agreement with the syringe reference test results in 67/73 (92%) of the test fluids and temperature conditions with mean difference of residual liquid across devices of 0.2 (2% full scale). These results demonstrate excellent correspondence between the two devices.

The Effectiveness of Slightly Thick Liquids for Improving Swallowing in Bottle-Fed Children With Aerodigestive Concerns.

Purpose: Strategies for facilitating safe and functional bottle feeding in children with dysphagia include selecting nipples that reduce flow rate, pacing, altered positioning, and thickening liquid consistencies. We aimed to determine the impact of slightly thick liquids on swallowing through retrospective review of a convenience sample of clinical videofluoroscopic swallowing studies (VFSS) from 60 bottle-fed children (21 boys and 39 girls, mean age of 9.9 months) referred due to suspected aspiration. Method: Eligible VFSS exams were those in which the child swallowed both thin and slightly thick barium (40% w/v Varibar barium) using the same nipple. VFSS sequences (i.e., uninterrupted portions of the VFSS recording) were randomly assigned in duplicate for rating by trained raters; discrepancies were resolved by consensus. Parameters measured included number of swallows/sequence, sucks/swallow, swallow and sequence duration, number and timing of penetration or aspiration events, laryngeal vestibule closure integrity, and pharyngeal residue. Chi-square tests, linear mixed-model analyses of variance, and Wilcoxon signed-ranks tests identified consistency effects. Results: There were no aspiration events in these recordings. Slightly thick liquids resulted in significantly fewer penetration events (p < .05), increased sucks/swallow, fewer swallows/sequence, and longer swallow and sequence durations. The number of children with ≥ 1 sequence showing pyriform sinus residue was significantly higher with slightly thick liquids. Conclusions: Slightly thick liquids can be effective in reducing penetration in bottle-fed children with dysphagia. However, slightly thick liquids may also lead to a safety-efficiency trade-off, with increased risk of pyriform sinus residue. Thickening for children with dysphagia should be considered only when other approaches are not effective. Overthickening should be avoided to limit negative impact on swallowing efficiency.

Age-related differences in tongue-palate pressures for strength and swallowing tasks.

The tongue plays a key role in the generation of pressures for transporting liquids and foods through the mouth in swallowing. Recent studies suggest that there is an age-related decline in tongue strength in healthy adults. However, whether age-related changes occur in tongue pressures generated for the purpose of swallowing remains unclear. Prior literature in this regard does not clearly explore the influence of task on apparent age-related differences in tongue pressure amplitudes. Furthermore, differences attributable to variations across individuals in strength, independent of age, have not clearly been elucidated. In this study, our goal was to clarify whether older adults have reduced tongue-palate pressures during maximum isometric, saliva swallowing, and water swallowing tasks, while controlling for individual variations in strength. Data were collected from 40 healthy younger adults (under age 40) and 38 healthy mature adults (over age 60). As a group, the mature participants had significantly lower maximum isometric pressures (MIPs). Swallowing pressures differed significantly by task, with higher pressures seen in saliva swallows than in water swallows. Age-group differences were not seen in swallowing pressures. Consideration of MIP as a covariate in the analysis of swallowing pressures revealed significant correlations between strength and swallowing pressures in the older participant group. Age-group differences were evident only when strength was considered in the model, suggesting that apparent age-related differences are, in fact, explained by differences in strength, which tends to be lower in healthy older adults. Our results show no evidence of independent differences in swallowing pressures attributable to age.

Exploring the Efficacy of the Effortful Swallow Maneuver for Improving Swallowing in People With Parkinson Disease-A Pilot Study.

Objectives: To determine the immediate (compensatory) and longer term (rehabilitative) effect of the effortful swallow (ES) maneuver on physiological swallowing parameters in Parkinson disease. Design: Virtual intervention protocol via Microsoft Teams with pre- and post-videofluoroscopic swallowing studies. Setting: Outpatient hospital setting, with intervention performed virtually. Participants: Eight participants (median age 74 years [63-82])with Parkinson disease (years post onset 3-20) with a Hoehn and Yahr scale score between 2 and 4 (N=8). Interventions: ES maneuver, initiated using a maximum effort isometric tongue-to-palate press, with biofeedback provided using the Iowa Oral Performance Instrument. The protocol included 30 minute sessions twice daily, 5 days/week for 4 weeks. Main Outcome Measures: Penetration-Aspiration Scale scores, time-to-laryngeal-vestibule-closure, total pharyngeal residue, and pharyngeal area at maximum constriction as seen on lateral view videofluoroscopy. Results: No consistent, systematic trends were identified in the direction of improvement or deterioration across Penetration-Aspiration Scale scores, time-to-laryngeal-vestibule-closure, pharyngeal area at maximum constriction, or total pharyngeal residue. Conclusions: Heterogeneous response to the ES as both a compensatory and rehabilitative technique. Positive response on the compensatory probe was predictive of positive response after rehabilitation.

The Influence of Sex, Age, and Repeated Measurement on Pixel-Based Measures of Pharyngeal Area at Rest.

PURPOSE: Videofluoroscopic (VFSS) measurements of pharyngeal swallow mechanics can differentiate age- and disease-related changes in swallowing. Pharyngeal area at rest (PhAR) may differ in people with dysphagia, although its impact is not clear. Before the role of PhAR in dysphagia can be explored, it is important to establish whether PhAR remains stable across repeated measures in healthy adults, and varies as a function of sex or age. We hypothesized that healthy adults would show stable PhAR across repeated measures, but that larger PhAR would be seen in men versus women and in older versus younger adults. METHOD: We collected VFSS data from 87 healthy adults (44 men, M age = 46 years, range: 21-82). Trained raters identified the swallow rest frame after the initial swallow of each bolus and measured unobliterated pharyngeal area on these frames, in %(C2-4)2 units. Repeated-measures analyses of variance with a factor of sex, a covariate of age, and a repeated factor of task repetition were performed across the first 12 available measures per participant (N = 1,044 swallows). RESULTS: There were no significant variations in PhAR across repeated measures. A significant Sex × Age interaction was seen (p = .04): Males had significantly larger PhAR than females (p = .001), but females showed larger PhAR with advancing age (R = .47). CONCLUSIONS: These data confirm stability in PhAR across repeated measurements in healthy individuals. However, significant sex and age differences should be taken into consideration in future studies exploring the role of PhAR in people with dysphagia. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.22043543.

Reference Values for Videofluoroscopic Measures of Swallowing: An Update.

PURPOSE: It is essential that clinicians have evidence-based benchmarks to support accurate diagnosis and clinical decision making. Recent studies report poor reliability for diagnostic judgments and identifying mechanisms of impairment from videofluoroscopy (VFSS). Establishing VFSS reference values for healthy swallowing would help resolve such discrepancies. Steele et al. (2019) released preliminary reference data for quantitative VFSS measures in healthy adults aged < 60 years. Here, we extend that work to provide reference percentiles for VFSS measures across a larger age span. METHOD: Data for 16 VFSS parameters were collected from 78 healthy adults aged 21-82 years (39 male). Participants swallowed three comfortable sips each of thin, slightly, mildly, moderately, and extremely thick barium (20% w/v). VFSS recordings were analyzed in duplicate by trained raters, blind to participant and task, using the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) Method. Reference percentiles (p2.5, 5, 25, 50, 75, 95, and 97.5) were determined as per Clinical and Laboratory Standards Institute EP28-A3c guidelines. RESULTS: We present VFSS reference percentile tables, by consistency, for (a) timing parameters (swallow reaction time; the hyoid burst-to-upper esophageal sphincter (UES)-opening interval; UES opening duration; time-to-laryngeal vestibule closure (LVC); and LVC duration) and (b) anatomically scaled pixel-based measures of maximum UES diameter, pharyngeal area at maximum pharyngeal constriction and rest, residue (vallecular, pyriform, other pharyngeal locations, total), and hyoid kinematics (X, Y, XY coordinates of peak position; speed). Clinical decision limits are proposed to demarcate atypical values of potential clinical concern. CONCLUSION: These updated reference percentiles and proposed clinical decision limits are intended to support interpretation and reliability for VFSS assessment data. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.24043041.

Using Reference Values to Identify Profiles of Swallowing Impairment in a Case Series of Individuals With Traumatic Spinal Cord Injury.

PURPOSE: In this article, we illustrate use of a systematic approach to rating videofluoroscopic swallowing studies (VFSS), the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) method. The method is applied to a clinical case series of individuals with a history of traumatic spinal cord injury (tSCI) requiring surgical intervention using a posterior approach. Previous studies suggest that swallowing is highly variable in this population given heterogeneity in mechanisms, location and extent of injury, and in surgical management approaches. METHOD: The case series involved 6 individuals who were at least 1 month postsurgery for management of tSCI. Participants completed a VFSS using a standardized bolus protocol. Each VFSS was blindly rated in duplicate using the ASPEKT method and compared with published reference values. RESULTS: The analysis revealed considerable heterogeneity across this clinical sample. Penetration-aspiration scale scores of 3 or higher were not observed in this cohort. Of note, patterns of impairment did emerge, suggesting there are some commonalities across profiles in this population, including the presence of residue associated with poor pharyngeal constriction, reduced upper esophageal opening diameter, and short upper esophageal sphincter opening duration. CONCLUSIONS: Although the participants in this clinical sample shared a history of tSCI requiring surgical intervention using a posterior approach, there was great heterogeneity in swallowing profile. Using a systematic method to identify atypical swallowing parameters can guide clinical decision making for determining rehabilitative targets and measuring swallowing outcomes.

Virtual Accessible Bilingual Conference Planning: The Parks Accessibility Conference.

Virtual events have become more popular recently, and while these events have the potential to be inclusive to a broader range of attendees, there is limited information available on how to plan and deliver a virtual, accessible, and bilingual event. The objective of this paper is to share how our team planned and delivered a virtual conference that was fully bilingual and accessible to individuals with disabilities by incorporating closed captions, sign language interpretation, language interpretation (audio), regularly scheduled breaks, and a multi-sensory experience. We describe our approaches to planning the conference, such as including individuals with disabilities in decision-making, selecting virtual conference platforms, captioners, and interpreters, and how we incorporated a multi-sensory experience. The paper also summarizes feedback we received from our attendees using a post-conference evaluation survey and our team's reflections on positive aspects of the conference and opportunities for improvement. We conclude by providing a set of practical recommendations that we feel may be helpful to others planning virtual accessible bilingual conferences in the future.