Criterion (Concurrent) Validity and Clinical Utility of the Tongueometer Device.

PURPOSE: Tongue manometry (i.e., tongue pressure measurement) is a commonly used assessment for patients with suspected oral-motor involvement in swallowing disorders. Availability of lingual manometry has changed in recent years, with the introduction of the Tongueometer device being a more affordable tongue manometry system. The purpose of this study was to test concurrent (criterion) validity of the Tongueometer compared to the current standard reference device, the Iowa Oral Performance Instrument (IOPI). METHOD: Adults without dysphagia were recruited for participation in this study. Standard lingual measurements (swallowing-related pressures, maximum isometric pressure [MIP], and maximum isometric endurance) were recorded, with the bulb anteriorly placed, with both devices, in a randomized order. The Bland-Altman method was used to determine concurrent (criterion) validity of these measurements compared to the clinical standard IOPI device. A recently available suggested corrective value by Curtis et al. (2023) was also applied, with comparisons made between devices both with and without the Curtis correction. RESULTS: The final sample included 70 adult participants aged 20-89 years (Mage = 52.3 years). Measures with the Tongueometer device were significantly lower when compared with the same measures taken using the IOPI (p < .01) for all measures including MIP, endurance, and swallow pressures. The correction suggested by Curtis and colleagues did not ameliorate these differences. CONCLUSIONS: The Tongueometer lingual measurements were consistently lower compared to the IOPI. Clinical use of values taken with the Tongueometer device should be compared to normative data published for each specific device. Available features of each device (e.g., display, bulb texture, technology/application) should be considered when selecting which device to use with an individual patient.

Cricopharyngeus muscle dysfunction: a poorly defined disorder from diagnosis to treatment.

PURPOSE: Cricopharyngeus muscle dysfunction (CPMD) is a common clinical occurrence with very few clear diagnostic criteria and multiple pathways for treatment. Incidence of CPMD is not known, but some data suggest around 25% of people with dysphagia experience some degree of CPMD, which negatively impacts swallowing safety and efficiency. Workup and treatment of CPMD can require multidisciplinary collaboration across laryngologists, speech-language pathologists with training in dysphagia management, and gastroenterologists. The purpose of this paper is to review what is known about CPMD and identify areas of future research in CPMD diagnosis and treatment. METHODS: An overview of CPMD, relative treatments and disorders, and a discussion of future areas of research needed to improve clinical care of CPMD. RESULTS: Details regarding historical background, pathophysiology and treatment practiced for CPMD are included. CONCLUSION: In summary, CPMD is a poorly defined disease due to a lack of understanding of its pathophysiology and the lack of consensus diagnostic criteria. Well-designed, prospective clinical trials are necessary to develop a better understanding of clinical incidence of CPMD, impact of the disorder on oropharyngeal swallowing, and how to approach treatment of the disorder surgically or in conjunction with therapy directed by a specialized speech-language pathologist.

Health Factors Associated With Development and Severity of Poststroke Dysphagia: An Epidemiological Investigation.

BACKGROUND: Dysphagia after stroke is common and can impact morbidity and death. The purpose of this population-based study was to determine specific epidemiological and health risk factors that impact development of dysphagia after acute stroke. METHODS AND RESULTS: Ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review from the GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study), a representative sample of ≈1.3 million adults from southwestern Ohio and northern Kentucky. Dysphagia status was determined on the basis of clinical assessments and necessity for alternative access to nutrition via nasogastric or percutaneous endoscopic gastrostomy tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and premorbid conditions. Multivariable logistic regression determined factors associated with increased risk of dysphagia. Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed that increased age, Black race, higher National Institutes of Health Stroke Scale score at admission, having a hemorrhagic stroke (versus infarct), and right hemispheric stroke increased the risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower prestroke modified Rankin Scale score, and white matter disease. CONCLUSIONS: This study replicated previous findings of variables associated with dysphagia (older age, worse stroke, right-sided hemorrhagic lesions), whereas other variables identified were without clear biological rationale (eg, Black race, history of high cholesterol, and presence of white matter disease) and should be investigated in future studies to determine biological relevance and potential influence in stroke recovery.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study.

OBJECTIVE: To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS: One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION: Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:97-102, 2024.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Health factors associated with development and severity of post-stroke dysphagia: an epidemiological investigation.

Background and Purpose: Dysphagia is a common post-stroke occurrence and has been shown to impact patients' morbidity and mortality. The purpose of this study was to use a large population-based dataset to determine specific epidemiological and patient health risk factors that impact development and severity of dysphagia after acute stroke. Methods: Using data from the Greater Cincinnati Northern Kentucky Stroke Study, GCNKSS, involving a representative sample of approximately 1.3 million people from Southwest Ohio and Northern Kentucky of adults (age ≥18), ischemic and hemorrhagic stroke cases from 2010 and 2015 were identified via chart review. Dysphagia status was determined based on bedside and clinical assessments, and severity by necessity for alternative access to nutrition via nasogastric (NG) or percutaneous endoscopic gastrostomy (PEG) tube placement. Comparisons between patients with and without dysphagia were made to determine differences in baseline characteristics and pre-morbid conditions. Multivariable logistic regression was used to determine factors associated with increased risk of developing dysphagia. Results: Dysphagia status was ascertained from 4139 cases (1709 with dysphagia). Logistic regression showed: increased age, Black race, higher NIHSS score at admission, having a hemorrhagic stroke (vs infarct), and right hemispheric stroke increased risk of developing dysphagia after stroke. Factors associated with reduced risk included history of high cholesterol, lower pre-stroke mRS score, and white matter disease. Conclusions: This study replicated many previous findings of variables associated with dysphagia (older age, worse stroke, right sided hemorrhagic lesions), while other variables identified were without clear biological rationale (e.g. Black race, history of high cholesterol and presence of white matter disease). These factors should be investigated in future, prospective studies to determine biological relevance and potential influence in stroke recovery.

Stratifying Risk of Nonadherence in Lingual Strengthening Dysphagia Rehabilitation.

PURPOSE: Exercise-based treatments may improve swallowing safety and efficiency; yet, it is not clearly understood which factors predict nonadherence to recommended treatment protocols. The aim of this study was to construct an algorithm for stratifying risk of nonadherence to a lingual strengthening dysphagia treatment program. METHOD: Using recursive partitioning, we created a classification tree built from a pool of sociodemographic, clinical, and functional status indicators to identify risk groups for nonadherence to an intensive lingual strengthening treatment program. Nonadherence, or noncompletion, was defined as not completing two or more follow-up sessions or a final session within 84 days. RESULTS: The study cohort consisted of 243 Veterans enrolled in the Intensive Dysphagia Treatment program across six sites from January 2012 to August 2019. The overall rate of nonadherence in this cohort was 38%. The classification tree demonstrated good discriminate validity (C-statistic = 0.74) and contained eight groups from five variables: primary diagnosis, marital status, Penetration-Aspiration Scale (PAS) severity score, race/ethnicity, and age. Nonadherence risk was categorized as high (range: 69%-77%), intermediate (27%-33%), and low risk (≤ 13%-22%). CONCLUSIONS: This study identified distinct risk groups for nonadherence to lingual strengthening dysphagia rehabilitation. Additional research is necessary to understand how these factors may drive nonadherence. With external validation and refinement through prospective studies, a clinically relevant risk stratification tool can be developed to identify patients who may be at high risk for nonadherence and provide targeted patient support to mitigate risk and provide for unmet needs.

Effects of Device-Facilitated Lingual Strengthening Therapy on Dysphagia Related Outcomes in Patients Post-Stroke: A Randomized Controlled Trial.

BACKGROUND: Swallowing impairments resulting from stroke have few rehabilitative options. Prior evidence suggests lingual strengthening exercise may provide some benefit, but more randomized controlled trials are required. The purpose of this study was to examine efficacy of progressive lingual resistance training on lingual pressure generative capacity and swallowing outcomes for individuals with dysphagia after stroke. METHODS: Participants with dysphagia within 6 months of acute stroke were randomly assigned to: (1) treatment: progressive resistance tongue exercise using pressure sensors for 12 weeks with usual care; or (2) control: usual care only. Outcomes were measured at baseline, 8 and 12 weeks to assess group differences in lingual pressure generation, swallow safety, efficiency, oral intake, and swallowing quality of life. RESULTS: Final sample included 19 participants [treatment (N = 9) and control (N = 10)] with 16 males and 3 females (mean age = 69.33). Functional Oral Intake Scale (FOIS) scores improved significantly (p = 0.04) in the treatment group from baseline to 8 weeks compared to usual care (control). No significant differences between treatment groups were identified for other outcomes; large effect sizes were detected for group differences in lingual pressure generative capacity from baseline to 8 weeks at the anterior sensor (d = .95) and posterior sensor (d = 0.96), and vallecular residue of liquids (baseline to 8-week d = 1.2). CONCLUSIONS: Lingual strengthening exercise resulted in significant improvements in functional oral intake for patients with post-stroke dysphagia as compared to usual care after 8 weeks. Future studies should include a larger sample size and address treatment impact on specific aspects of swallow physiology.

Determining Swallowing Biomechanics Underlying Modified Barium Swallow Impairment Profile Scoring Using Computational Analysis of Swallowing Mechanics.

PURPOSE: The elements of impaired swallowing biomechanics are visually assessed and scored by clinicians using a standardized and validated tool for assessing type and severity of physiological impairments using the Modified Barium Swallow Impairment Profile (MBSImP). However, the functional anatomical correlates that underly noted impairments using MBSImP scoring have not been measured. The purpose of this study was to determine whether differences in MBSImP component scores represent differences in underlying swallowing mechanics as measured by computational analysis of swallowing mechanics (CASM) to better define underlying mechanisms of impairment. METHOD: A retrospective analysis of modified barium swallow studies from physician-referred adult patients with dysphagia was scored using the MBSImP for laryngeal elevation, anterior hyoid excursion, epiglottic movement, pharyngoesophageal segment opening, and tongue base retraction. A canonical variate analysis (CVA) was performed to determine the movement of anatomical landmarks associated with MBSImP component scores using the CASM method. Mahalanobis distances (D) were then used to detect differences among MBSImP scores for each component assessed. RESULTS: CVA showed significant differences (p < .0001) in Mahalanobis distance (D > 1) between MBSImP component scores of 0-1, 0-2, 0-3, or 0-4, as applicable, depending on the component. Discriminant function analyses revealed concomitant increase/worsening in MBSImP score with changes in anatomical positioning of structures. CONCLUSIONS: Ratings of swallowing impairment and physiology using the MBSImP have distinct biomechanical correlates with anatomical movements of swallowing. These data further demonstrate how swallowing mechanics are highly interrelated. Understanding these linkages between anatomical and physiological movement within impaired swallowing biomechanics is essential in more specific characterization and treatment of dysphagia. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.20816788.

Alterations in white matter microstructural properties after lingual strength exercise in patients with dysphagia.

OBJECTIVES: Central nervous system effects of lingual strengthening exercise to treat dysphagia remain largely unknown. This pilot study measured changes in microstructural white matter to capture alterations in neural signal processing following lingual strengthening exercise. METHODS: Diffusion-weighted images were acquired from seven participants with dysphagia of varying etiologies, before and after lingual strengthening exercise (20 reps, 3×/day, 3 days/week, 8 weeks), using a 10-min diffusion sequence (9 b0, 56 directions with b1000) on GE750 3T scanner. Tract-Based Spatial Statistics evaluated voxel-based group differences for fractional anisotropy, mean diffusivity, axial diffusivity, radial diffusivity and local diffusion homogeneity (LDH). Paired t-tests evaluated treatment differences on each metric (P < 0.05). RESULTS: After lingual strengthening exercise, lingual pressure generation increased (avg increase = 46.1 hPa; nonsignificant P = 0.52) with these changes in imaging metrics: (1) decrease in fractional anisotropy, forceps minor; (2) increase in mean diffusivity, right inferior fronto-occipital fasciculus (IFOF); (3) decrease in mean diffusivity, left uncinate fasciculus; (4) decrease in axial diffusivity, both left IFOF and left uncinate fasciculus; (5) increase in LDH, right anterior thalamic radiation and (6) decrease in LDH, temporal portion of right superior longitudinal fasciculus. There was a positive correlation between diffusion tensor imaging metrics and change in lingual pressure generation in left IFOF and the temporal portion of right superior longitudinal fasciculus. CONCLUSIONS: These findings suggest that lingual strengthening exercise can induce changes in white matter structural and functional properties in a small group of patients with dysphagia of heterogeneous etiologies. These procedures should be repeated with a larger group of patients to improve interpretation of overall lingual strengthening exercise effects on cortical structure and function.

Progressive Protrusive Tongue Exercise Does Not Alter Aging Effects in Retrusive Tongue Muscles.

Purpose: Exercise-based treatment approaches for dysphagia may improve swallow function in part by inducing adaptive changes to muscles involved in swallowing and deglutition. We have previously shown that both aging and progressive resistance tongue exercise, in a rat model, can induce biological changes in the genioglossus (GG); a muscle that elevates and protrudes the tongue. However, the impacts of progressive resistance tongue exercise on the retrusive muscles (styloglossus, SG; hyoglossus, HG) of the tongue are unknown. The purpose of this study was to examine the impact of a progressive resistance tongue exercise regimen on the retrusive tongue musculature in the context of aging. Given that aging alters retrusive tongue muscles to more slowly contracting fiber types, we hypothesized that these biological changes may be mitigated by tongue exercise. Methods: Hyoglossus (HG) and styloglossus (SG) muscles of male Fischer 344/Brown Norway rats were assayed in age groups of young (9 months old, n = 24), middle-aged (24 months old, n = 23), and old (32 months old, n = 26), after receiving an 8-week period of either progressive resistance protrusive tongue exercise, or sham exercise conditions. Following exercise, HG and SG tongue muscle contractile properties were assessed in vivo. HG and SG muscles were then isolated and assayed to determine myosin heavy chain isoform (MyHC) composition. Results: Both retrusive tongue muscle contractile properties and MyHC profiles of the HG and SG muscles were significantly impacted by age, but were not significantly impacted by tongue exercise. Old rats had significantly longer retrusive tongue contraction times and longer decay times than young rats. Additionally, HG and SG muscles showed significant MyHC profile changes with age, in that old groups had slower MyHC profiles as compared to young groups. However, the exercise condition did not induce significant effects in any of the biological outcome measures. Conclusion: In a rat model of protrusive tongue exercise, aging induced significant changes in retrusive tongue muscles, and these age-induced changes were unaffected by the tongue exercise regimen. Collectively, results are compatible with the interpretation that protrusive tongue exercise does not induce changes to retrusive tongue muscle function.

Lingual Exercise in Older Veterans With Dysphagia: A Pilot Investigation of Patient Adherence.

Purpose Adherence is a concern in dysphagia management. Poor adherence with recommendations can negatively affect treatment efficacy and patient outcomes. For exercise-based therapies, low adherence can alter the dose of exercise delivered to the muscle, which can diminish impact of exercise. It has been established that low adherence is a problem in dysphagia treatments; however, relationships among levels of adherence and outcomes from exercise-based interventions have not been explored. Method In this retrospective pilot study, data were collected from a multicenter clinical demonstration program in the Veterans Affairs hospital system to examine the relationships between patient adherence with a device-facilitated lingual exercise regimen. Outcomes were compared pre- and posttreatment using a paired t test or Wilcoxon matched-pairs signed-ranks test, and relationships among adherence and outcome measures were evaluated using Pearson or Spearman rank correlation coefficients, as appropriate. Results Patient adherence was evenly distributed across participants: Adherence at the front sensor was 59.3% (SD = 28.2), ranging from 5.5% to 95.8%; the back sensor adherence was 55.9% (SD = 29.8), ranging from 1.1% to 97.2%. Maximum isometric pressure (MIP) generation, at both the front and back sensors, was increased from pre- to posttreatment (p < .0001, front; p = .008, back). Functional Oral Intake Scale (FOIS) scores were also significantly improved at the posttreatment time point as compared to baseline (p = .005). However, there were no significant correlations among adherence and outcome measures (front sensor adherence vs. ΔMIP, r = -.161, p = .342; back sensor adherence vs. ΔMIP, r = .002, p = .991; front sensor adherence vs. ΔFOIS, r = -.183, p = .279; back sensor adherence vs. ΔFOIS, r = -.160, p = .399). Conclusions These findings suggest that patient adherence with this lingual exercise program was not related to the increases in lingual pressure generation or improvement in functional oral intake observed in this cohort. These preliminary findings suggest the need for future, prospective, controlled, and randomized clinical trials to further investigate patient adherence with a lingual exercise program and related impacts of adherence on exercise dose and swallowing-related outcomes.

Dose in Exercise-Based Dysphagia Therapies: A Scoping Review.

BACKGROUND: Optimal exercise doses for exercise-based approaches to dysphagia treatment are unclear. To address this gap in knowledge, we performed a scoping review to provide a record of doses reported in the literature. A larger goal of this work was to promote detailed consideration of dosing parameters in dysphagia exercise treatments in intervention planning and outcome reporting. METHODS: We searched PubMed, Scopus[Embase], CINAHL, and Cochrane databases from inception to July 2019, with search terms relating to dysphagia and exercises to treat swallowing impairments. Of the eligible 1906 peer-reviewed articles, 72 met inclusionary criteria by reporting, at minimum, both the frequency and duration of their exercise-based treatments. RESULTS: Study interventions included tongue exercise (n = 16), Shaker/head lift (n = 13), respiratory muscle strength training (n = 6), combination exercise programs (n = 20), mandibular movement exercises (n = 7), lip muscle training (n = 5), and other programs that did not fit into the categories described above (n = 5). Frequency recommendations varied greatly by exercise type. Duration recommendations ranged from 4 weeks to 1 year. In articles reporting repetitions (n = 66), the range was 1 to 120 reps/day. In articles reporting intensity (n = 59), descriptions included values for force, movement duration, or descriptive verbal cues, such as "as hard as possible." Outcome measures were highly varied across and within specific exercise types. CONCLUSIONS: We recommend inclusion of at least the frequency, duration, repetition, and intensity components of exercise dose to improve reproducibility, interpretation, and comparison across studies. Further research is required to determine optimal dose ranges for the wide variety of exercise-based dysphagia interventions.

Adherence to Dysphagia Treatment Recommendations: A Conceptual Model.

Purpose Conceptual models of complex health problems are useful when designing targeted clinical interventions and focused research studies. Understanding and studying patient adherence often involves interplay among many factors that influence whether a patient successfully follows recommendations or completes a therapy program. Functional frameworks serve to arrange these factors visually, increasing interpretability and allowing for empirical testing of relationships among concepts. The purpose of this article is to integrate relevant factors from the literature into a comprehensive framework that describes adherence to dysphagia treatment. Method Using peer-reviewed, published guidelines regarding conceptual model construction, the authors created a list of potential factors that influence patient adherence to dysphagia-related treatment recommendations. During model construction, following extensive review of the literature and existing theories that have been applied in other areas of health care, factors were identified and grouped into conceptually similar domains (clusters). Clusters were arranged into larger categories that emerged during model optimization. Ultimately, two models were created: one that illustrates the interrelated factors of patient adherence and another that illustrates a subset of modifiable risk factors that a clinical speech-language pathologist may influence when developing a dysphagia treatment plan. Results Three general categories from 14 factors emerged based on relationships between factors and aspects of patient care: health factors, individual patient factors, and contextual factors. A second model consisting of modifiable risk factors included access, treatment type, patient perceptions, self-efficacy, health literacy, support factors, and provider bias. Conclusions This conceptual model allows clinicians and researchers to identify and explore the mechanisms driving adherence. Continual refinements of this model should be made as future studies uncover how the interconnectedness of factors affects adherence in dysphagia management. The models we have presented here are ready for clinical application and should also serve researchers as they generate hypotheses and design targeted research questions.

Effects of Tongue Exercise Frequency on Tongue Muscle Biology and Swallowing Physiology in a Rat Model.

Age-related changes in muscle composition and function are often treated using exercise, including muscles of the tongue to treat swallowing impairments (dysphagia). Although tongue exercise is commonly prescribed, optimal tongue exercise doses have not been determined. The purpose of this study was to evaluate effects of varying tongue exercise frequency on tongue force, genioglossus muscle fiber size, composition and metabolism, and swallowing in a rat model. We randomized 41 old and 40 young adult Fischer 344/Brown Norway rats into one of four tongue exercise groups: 5 days/week; 3 days/week; 1 day/week; or sham. Tongue force was higher following all exercise conditions (vs sham); the 5 day/week group had the greatest change in tongue force (p < 0.001). There were no exercise effects on genioglossus (GG) fiber size or MyHC composition (p > 0.05). Significant main effects for age showed a greater proportion of Type I fibers in (p < 0.0001) and increased fiber size of IIa fibers (p = 0.026) in old. There were no significant effects of citrate synthase activity or PGC-1α expression. Significant differences were found in bolus speed and area (size), but findings were potentially influenced by variability. Our findings suggest that tongue force is influenced by exercise frequency; however, these changes were not reflected in characteristics of the GG muscle assayed in this study. Informed by findings of this study, future work in tongue dose optimization will be required to provide better scientific premise for clinical treatments in humans.

Correction to: Patient Adherence to Dysphagia Recommendations: A Systematic Review.

The original version of this article unfortunately contains mistakes. The second sentence in the section "Results", under the heading "Study Design" was incorrect. It should read as: Two studies [24, 29] used a prospective cohort study design with a JAMA rating of 2. Four studies [17, 25, 27, 34] completed retrospective studies earning a JAMA score of 3. Four studies [26, 28, 30, 33] earned a JAMA quality rating score of 4 and used the following designs: case series [26, 28, 33], and pilot study [30]. In Table 1, "Study Population (n)" and "Design (JAMA quality rating)" values were incorrect for Shinn et al. (2013) [24]. The correct information is given here. HNC (n = 109) Prospective Cohort (2).

Patient-Reported Dysphagia After Thyroidectomy: A Qualitative Study.

Importance: It is important that clinicians understand consequences of thyoridectomy on swallowing from the patient perspective to better care for this population. Objective: Using rigorous qualitative methodology, this study set out to characterize the effect of swallowing-related symptoms after thyroidectomy on patient quality of life and swallowing-related outcomes. Design, Setting, and Participants: Prospective, grounded theory analysis of interviews with 26 patients at 3 time points after thyroidectomy (2 weeks, 6 weeks, and 6 months). Data were collected from an ongoing clinical trial (NCT02138214), and outpatient interviews were conducted at the University of Wisconsin Hospital and Clinics. All participants were age 21 to 73 years with a diagnosis of papillary thyroid cancer without cervical or distant metastases and had undergone total thyroidectomy. Exclusion criteria were preexisting vocal fold abnormalities (eg, polyps, nodules), neurological conditions affecting the voice or swallowing ability, and/or development of new-onset vocal fold paresis or paralysis (lasting longer than 6 months) after total thyroidectomy. Interventions: Total thyroidectomy. Main Outcomes and Measures: Symptoms of dysphagia and related effects on quality of life elicited through grounded theory analysis of semistructured interviews with patients after thyroidectomy designed to foster an open-ended, patient-driven discussion. Results: Of the 26 patients included, 69% were women (n = 18); mean (SD) age, 46.4 (14.1) years; mean (SD) tumor diameter 2.2 (1.4) cm. Two weeks after thyroidectomy, 80% of participants (n = 20) reported at least 1 swallowing-related symptom when prompted by the interview cards; during the open interview, 53% of participants (n = 14) volunteered discussion of swallowing-related symptoms unprompted. However, only 8% of participants in this study (n = 2) qualified for a follow-up dysphagia evaluation, indicating that the majority of reported symptoms were subjective in nature. Six weeks and 6 months after thyroidectomy, 42% (n = 11) and 17% (n = 4) of participants, respectively, reported continued swallowing symptoms using the prompts; 12% (n = 3) discussed symptoms without prompting cards at both time points. Conclusions and Relevance: Swallowing symptoms after thyroidectomy are underreported in the literature. This study revealed that as many as 80% of patients who have thyroidectomy may experience swallowing-related symptoms after surgery, and many develop compensatory strategies to manage or reduce the burden of these symptoms. Considering the large number of individuals who may experience subjective dysphagia, preoperative counseling should include education and management of such symptoms.

Tongue exercise and ageing effects on morphological and biochemical properties of the posterior digastric and temporalis muscles in a Fischer 344 Brown Norway rat model.

OBJECTIVE: This study sought to examin effects of age and tongue exercise on the posterior digastric (opener) and the temporalis (closer). We hypothesized 1) age would result in differing morphological (cross sectional area) and biochemical (myosin heavy chain isoform) components of these muscles; 2) tongue exercise would result in coactivation of these muscles inducing a decrease in age-related differences between age groups. DESIGN: Young adult (9 months) and old (32 months) Fischer 344 Brown Norway rats were randomized into a tongue exercise or control group. Post-training, posterior digastric and temporalis muscles were harvested and analyzed using: 1) Sodium Dodecyl Sulfate-Polyacrylamide Gel Electrophoresis (SDS-PAGE) to assess percent myosin heavy chain (MyHC) content; 2) Immunohistochemical staining to determine cross sectional area (CSA). RESULTS: A larger proportion of slowly contracting MyHC isoforms in the posterior digastric and temporalis muscles were found in old. No significant main effects for age or exercise in fiber size were found in posterior digastric muscle. An interaction between age and exercise for temporalis cross sectional area indicated the old exercise group had smaller average cross sectional area than all other groups. CONCLUSIONS FINDINGS: suggest that: 1) Increasing age induces biochemical changes in muscles of the jaw, specifically showing an increase the proportion of slower contracting MyHC isoforms; 2) Increasing age and tongue exercise induce a reduction in muscle fiber cross sectional area in the temporalis muscle only. However, continued study of these cranial muscle systems is warranted to better understand these changes that occur with age and exercise.

Patient Adherence to Dysphagia Recommendations: A Systematic Review.

Patient adherence to treatment recommendations is an important issue for healthcare providers, in a multitude of specialties, and is critical when assessing the efficacy and effectiveness of a particular treatment approach. Patients who have swallowing impairment often require complex and specific interventions requiring altered daily patterns of behavior. Patients with dysphagia who do not follow recommendations or prescribed exercises may not receive maximum benefit of an intervention. Poor adherence also makes it more difficult to evaluate efficacy of a treatment both clinically and in experimental settings. Further, swallow safety can be compromised if certain recommendations are not followed. Our purpose was to systematically review the literature to understand what is known about adherence within the field of dysphagia treatment. We systematically identified 12 studies that tracked and reported patient-specific adherence. In this review, we found that the average adherence rate from these studies ranges between 21.9 and 51.9%. Adherence to prophylactic treatment recommendations for patients with head and neck cancer was the focus in 9/12 studies. The findings of this review identify a large gap in knowledge regarding adherence to dysphagia treatment. Few studies account for adherence within their study designs. When planning dysphagia treatment studies, it is imperative that investigators include information regarding patient adherence to accurately interpret findings. Given the variable adherence rates found in this review, factors influencing patient adherence with dysphagia treatments should be identified to increase adherence in future trials.

Differential impact of tongue exercise on intrinsic lingual muscles.

OBJECTIVES/HYPOTHESIS: Aging is associated with muscle fiber hypotrophy and decreased percentages of rapidly contracting myosin heavy chain (MyHC) type IIb muscle fibers. Tongue exercise programs used to treat dysphagia target age-related decline in tongue muscle function, but the impact of exercise on the intrinsic tongue muscles is unknown. We hypothesized that exercise would induce muscle fiber hypertrophy and increase the percentage of MyHC IIa fibers in the intrinsic tongue. STUDY DESIGN: Animal model. METHODS: Eight old and eight young-adult rats underwent 8 weeks of tongue exercise training, and 8 animals of each age group served as controls. Longitudinal, transverse, and verticalis muscle samples from the anterior, middle, and posterior regions of the tongue were sectioned and stained to determine muscle fiber diameter and MyHC composition. RESULTS: MyHC fiber type distribution was altered by exercise, and the effects differed by muscle and region of the tongue. In the exercise groups, as compared to the control groups, the anterior transverse and middle superior longitudinal muscles had significantly reduced percentages of MyHC IIx positive fibers and higher percentages of rapidly contracting fatigable MyHC IIb positive muscle fibers, whereas the middle transverse and posterior longitudinal muscles had increased percentages of the less rapidly contracting and more fatigue-resistant MyHC IIa fibers. The impact of exercise did not differ with age, as there was no significant interaction between age and exercise. Tongue exercise had no significant effect on muscle fiber diameter. CONCLUSIONS: The impact of exercise varied among the tongue muscles, which may indicate different functional contributions to the tongue exercise task. LEVEL OF EVIDENCE: NA Laryngoscope, 128:2245-2251, 2018.