Normalization of temporal aspects of swallowing physiology after the McNeill dysphagia therapy program.

OBJECTIVES: We examined the timing of physiological swallowing events in patients before and after completion of an exercise-based dysphagia intervention (McNeill Dysphagia Therapy Program; MDTP) and compared their performance to that of healthy volunteers. METHODS: Eight adults (mean age, 57.5 years) with chronic dysphagia (mean, 45 months) completed 3 weeks of the MDTP. Before and after the MDTP we measured lingual-palatal and pharyngeal manometric pressures during swallows of thin liquid, thick liquid, and pudding material in 5-mL volumes. Using the pressure peak of the pharyngoesophageal segment clearing wave as the anchor point, we measured the relative timing of pressure peaks from the anterior, middle, and posterior parts of the tongue and the manometric peaks from the base of the tongue, the hypopharynx, and the nadir of the pharyngoesophageal segment. We compared these results to identical measures obtained from 34 healthy adults (mean age, 44.0 years). RESULTS: The timing of physiological events before the MDTP was significantly slower than that of the group of healthy volunteers. The timing data from after the MDTP were not significantly different from those of the healthy group. The magnitude change was greatest for thin liquid. CONCLUSIONS: Dysphagia therapy with the MDTP improves the timing of physiological events during swallowing. Temporal coordination of swallowing components after therapy approximates that of healthy adults, suggesting a normalization of swallow timing after the MDTP.

Measurement of hyoid and laryngeal displacement in video fluoroscopic swallowing studies: variability, reliability, and measurement error.

Video fluoroscopy is commonly used in the study of swallowing kinematics. However, various procedures used in linear measurements obtained from video fluoroscopy may contribute to increased variability or measurement error. This study evaluated the influence of calibration referent and image rotation on measurement variability for hyoid and laryngeal displacement during swallowing. Inter- and intrarater reliabilities were also estimated for hyoid and laryngeal displacement measurements across conditions. The use of different calibration referents did not contribute significantly to variability in measures of hyoid and laryngeal displacement but image rotation affected horizontal measures for both structures. Inter- and intrarater reliabilities were high. Using the 95% confidence interval as the error index, measurement error was estimated to range from 2.48 to 3.06 mm. These results address procedural decisions for measuring hyoid and laryngeal displacement in video fluoroscopic swallowing studies.

McNeill dysphagia therapy program: a case-control study.

OBJECTIVE: To compare the effectiveness of the McNeill Dysphagia Therapy Program, a systematic exercise-based rehabilitation framework for swallowing remediation, with traditional swallowing therapy techniques paired with surface electromyography (sEMG) biofeedback. DESIGN: Matched case-control study. SETTING: University medical center. PARTICIPANTS: Dysphagic patients referred to an outpatient swallowing therapy service. INTERVENTIONS: Cases were individually matched to 2 separate controls for age, sex, and primary medical diagnosis (N=24). Cases were patients with dysphagia who entered the McNeill Dysphagia Therapy Program from September 2006 to October 2008. Controls entered a traditional swallowing therapy program augmented with sEMG biofeedback (traditional therapy with biofeedback group) from February 1994 to June 1999. MAIN OUTCOME MEASURES: The primary outcome was the proportion of patients who improved clinical swallowing ability and functional oral intake. The secondary outcomes were the presence (or not) of tube feeding, physiologic change on instrumental swallowing studies, and occurrence of aspiration on posttreatment assessment. RESULTS: Case patients were more likely to demonstrate dysphagia recovery at posttreatment re-evaluation (adjusted odds ratio for dysphagia recovery=13.0 [95% CI, 1.27-63.89]; Mantel-Haenszel chi(2)=6.7; P=.009; relative risk reduction=.69). Dysphagia was reduced by 69% in the McNeill Dysphagia Therapy Program treatment group compared with the traditional therapy with biofeedback group. CONCLUSIONS: Both approaches facilitated improved swallowing function. The McNeill Dysphagia Therapy Program resulted in superior outcomes compared with traditional dysphagia therapy supplemented with sEMG biofeedback.

Adjunctive neuromuscular electrical stimulation for treatment-refractory dysphagia.

OBJECTIVES: Neuromuscular electrical stimulation (NMES) has been proposed as an adjunctive modality for the treatment of swallowing disorders. We present data from a prospective case series to define and measure effects of a systematic therapy for chronic pharyngeal dysphagia using adjunctive NMES. METHODS: Six adult patients with pharyngeal dysphagia received 15 sessions of a standardized protocol of swallowing exercises with adjunctive NMES. The patients completed clinical and instrumental baseline, posttreatment, and 6-month follow-up evaluations. Outcome measures included the proportion of patients who improved in clinical swallowing ability, functional oral intake, and change in body weight; patient perception of swallowing ability; and changes in kinematic aspects of swallowing. RESULTS: Significant change was demonstrated for clinical swallowing ability (p < .042), functional oral intake (p < .02), weight gain (p < .026), and patient perception of swallowing ability (p < .043). Hyoid and laryngeal elevation during swallowing demonstrated bolus-specific patterns of change. No patient experienced a treatment-related or swallowing-related complication. Patients (4 of 5) who were followed out to 6 months after treatment maintained functional gains. CONCLUSIONS: A systematic therapy for chronic pharyngeal dysphagia using adjunctive NMES produced improvement in clinical swallowing ability and functional oral intake without significant weight loss or complications.

Effect of comorbid tics on a clinically meaningful response to 8-week open-label trial of fluoxetine in obsessive compulsive disorder.

Currently, there are limited published data evaluating the effects of tics on serotonin reuptake inhibitor (SRI) monotherapy responses in treating obsessive-compulsive disorder (OCD). One retrospective case-controlled analysis of OCD patients treated with SRI monotherapy showed lesser improvement in OCD symptoms in patients with tics than those without. However, more recently there were preliminary reports of OCD subjects treated with SRI monotherapy which did not demonstrate poorer response in subjects with tics or Tourette's Syndrome (TS). The specific aim of this study was to investigate whether the presence of comorbid chronic tics affected "clinically meaningful improvement" [McDougle, C.J., Goodman, W.K., Leckman, J.F., Barr, L.C., Heninger, G.R., Price, L.H., 1993. The efficacy of fluvoxamine in obsessive-compulsive disorder: effects of comorbid chronic tic disorder. Journal of Clinical Psychopharmacology 13, 354-358] of OCD in an 8-week open-label trial of fluoxetine monotherapy. Seventy-four adult subjects (13 patients with comorbid chronic tics and 61 patients without tics) with a primary DSM-IV OCD diagnosis were treated with up to 40mg fluoxetine for 8 weeks and had at least one post-baseline evaluation. The results indicate that there was a significant response by time in both fluoxetine-with-tic subjects and fluoxetine-without-tic subjects. Additionally, there were 3 (23.0%) OCD subjects with tics who had clinically meaningful improvement versus 16 (26.2%) OCD subjects without tics that demonstrated similar levels of improvement. These findings indicate that OCD patients with or without chronic tic disorders did not have a differential response to an 8-week open-label trial of fluoxetine. Limitations include the relatively low number of tic subjects and the open-label nature of the study. Additional data are needed on how comorbid tics may affect SRI treatment response in OCD.

Examining the evidence on neuromuscular electrical stimulation for swallowing: a meta-analysis.

OBJECTIVE: To evaluate the effect of transcutaneous neuromuscular electrical stimulation (NMES) on swallowing rehabilitation. DATA SOURCES: MEDLINE, PubMed, CINAHL, NML, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, doc online, Google, and EMBASE were searched for studies using NMES to treat dysphagia between January 1966 and August 2006. STUDY SELECTION: Included were published or unpublished, English-language, clinical trials with a quantifiable dependent variable. DATA EXTRACTION: Two researchers independently performed data extraction. A random-effects model was used to pool study results. The Cochran Q test was used to evaluate heterogeneity, and a funnel plot and Egger test were used to evaluate publication bias. A best-research synthesis using a methodological quality analysis was conducted. DATA SYNTHESIS: A total of 81 studies were reviewed. Seven were accepted for analysis. A significant summary effect size was identified for the application of NMES for swallowing (Hedges g, 0.66; P<.001). Heterogeneity was significant for the combined trials (P<.10). When 2 outlier trials were removed, heterogeneity was no longer significant (P<.08). Publication bias was not identified on the funnel plot or Egger test (P = .25). Best-evidence synthesis showed indicative findings in favor of NMES for swallowing. CONCLUSIONS: This preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing. Because of the small number of studies and low methodological grading for these studies, caution should be taken in interpreting this finding. These results support the need for more rigorous research in this area.

Biomechanical correlates of surface electromyography signals obtained during swallowing by healthy adults.

PURPOSE: The purpose of this study was to describe biomechanical correlates of the surface electromyographic signal obtained during swallowing by healthy adult volunteers. METHOD: Seventeen healthy adults were evaluated with simultaneous videofluoroscopy and surface electromyography (sEMG) while swallowing 5 mL of liquid barium sulfate. Three biomechanical swallowing events were analyzed: hyoid elevation, pharyngeal constriction, and opening-closing of the pharyngoesophageal segment. For each biomechanical event and from the sEMG signal, the authors identified onset, peak, and offset time points. From these points, duration measures were calculated. Means and 95% confidence intervals were calculated for each measure. Subsequently, correlations were evaluated between timing aspects of the sEMG traces and each biomechanical event. RESULTS: Swallow onset in the sEMG signal preceded the onset of all biomechanical events. All biomechanical events demonstrated a strong correspondence to the sEMG signal. The strongest relationship was between hyoid elevation-anterior displacement and the sEMG signal. CONCLUSIONS: These results suggest that the sEMG signal is a useful indicator of major biomechanical events in the swallow. Future studies should address the impact of age and disease processes, as well as bolus characteristics, on the biomechanical correlates of sEMG signals obtained during swallowing.

Dysphagia and nutritional status at the time of hospital admission for ischemic stroke.

BACKGROUND: Dysphagia and poor nutritional status occur frequently after stroke; however, potential associations between them are unknown. We evaluated potential associations between dysphagia and poor nutritional status in patients with acute ischemic stroke. Potential associations between these outcomes and more global stroke severity measures were also assessed. METHODS: In all, 76 patients with acute ischemic stroke were recruited on admission to the dedicated stroke department of an academic medical center. All patients were assessed with a clinical swallowing evaluation, Functional Oral Intake Scale, Mini Nutritional Assessment, body mass index, percent body fat, National Institutes of Health Stroke Scale, modified Rankin Scale, and modified Barthel Index. Associations were evaluated among dysphagia, nutrition, and stroke severity measures. RESULTS: On clinical examination 52.6% of study patients demonstrated dysphagia and 26.3% were identified with poor nutritional status. Dysphagia, based on clinical assessment, was associated with stroke severity (National Institutes of Health Stroke Scale, odds ratio [OR] 4.6, 95% confidence interval [CI] 1.6-13.1; modified Rankin Scale, OR 12.3, 95% CI 3.2-47.4) and with functional oral intake (OR 29.2, 95% CI 8.4-101.8), but not with measures of nutritional status (Mini Nutritional Assessment, OR 1.0, 95% CI 0.4-2.8). Nutritional measures did not correlate with swallowing or stroke severity measures. CONCLUSIONS: Dysphagia and poor nutritional status are prevalent in patients with acute ischemic stroke, however, they are not associated with each other at the time of hospital admission. Furthermore, dysphagia, but not nutritional status, is associated with stroke severity measures.

The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity.

Patients with chronic obstructive pulmonary disease (COPD) may be at increased risk of aspiration secondary to impaired swallow function. One possible cause of this impairment is a reduction in laryngopharyngeal sensitivity. The relationship between COPD and laryngopharyngeal sensitivity has not been previously determined. We conducted a study to investigate the effect of COPD on laryngopharyngeal sensitivity by using laryngopharyngeal sensory discrimination testing (LPSDT). Our study population was made up of 20 adults (mean age: 71.7 yr) with clinically proven COPD and 11 healthy, age-matched controls. All 31 subjects underwent LPSDT with the use of an air-pulse stimulator via a nasendoscope. The threshold of laryngopharyngeal sensation was evaluated by measuring the amount of air pressure required to elicit the laryngeal adductor reflex (LAR). We found that the patients with COPD had a significantly higher LAR threshold than did the controls (p< 0.001). We conclude that patients with COPD have significantly less mechanosensitivity in the laryngopharynx. This sensory change may place patients with COPD at increased risk for aspiration.

Treatment of vocal fold bowing using neuromuscular electrical stimulation.

OBJECTIVE: To investigate the clinical effectiveness and safety of a novel behavioral voice therapy program combining structured vocal exercise with adjunctive neuromuscular electrical stimulation for rehabilitating dysphonia secondary to vocal fold bowing. DESIGN: Prospective interventional clinical case series with a 3-month follow-up. SETTING: Outpatient speech and hearing clinic in an academic medical center. PATIENTS: Convenience sample of 7 patients diagnosed by an otolaryngologist as having chronic dysphonia for at least 3 months due to bilateral vocal fold bowing. INTERVENTION: A novel voice therapy program incorporating exercise principles and sustained phonations of increasing length, volume, and pitch paired with concurrent transcutaneous neuromuscular electrical stimulation. MAIN OUTCOME MEASURES: Change in maximum phonation time, highest attainable pitch, glottal closure, supraglottic compression, and Voice Handicap Index. RESULTS: Maximum phonation time for /i/ increased significantly (z = -2.201, P < .03), with a modest effect demonstrated (Hedges g, 0.65; 95% confidence interval, -0.56 to 1.75). Voice Handicap Index trended toward significance (z = -1.787, P < .07). Glottal closure during phonation improved, and supraglottic compression decreased. Improvements were maintained or enhanced at the 3-month follow-up. Analysis of highest attainable pitch data was limited owing to aperiodicity in the baseline evaluations. CONCLUSIONS: Behavioral voice therapy with adjunctive neuromuscular electrical stimulation reduced vocal fold bowing, resulting in improved acoustic, laryngeal, and patient-centered outcomes. Maximum phonation time and glottal closure results imply increased vocal fold tension secondary to enhanced thyroarytenoid or cricothyroid muscle function after voice therapy.

Cross-system effects of dysphagia treatment on dysphonia: a case report.

Traditionally, treatment of dysphagia and dysphonia has followed a specificity approach whereby treatment plans have focused on each dysfunction individually. Recently however, a therapeutic cross-system effect has been proposed between these two dysfunctions. At least one study has demonstrated swallowing improvement in subjects who completed a dysphonia treatment program. However, we are unaware of any evidence demonstrating the converse effect. In this paper, we present a case-report of a 74 year old male who demonstrated improvement in selected vocal parameters after completion of a dysphagia therapy program.Dysphagia therapy resulted in improved laryngeal function in this subject. Results implicate improved vocal fold tension with increased glottal closure. Further investigation into the potential for this cross-system effect is warranted.

Identification of swallowing events from sEMG Signals Obtained from Healthy Adults.

Surface electromyography (sEMG) is being used with increasing frequency to identify the occurrence of swallowing, to describe swallow physiology, and to treat impaired swallowing function in dysphagic patients. Despite this increased utilization, limited information is available regarding the validity and reliability of investigators and clinicians to interpret sEMG data in reference to swallowing. This study examines the validity and interjudge reliability of swallow identification using sEMG records obtained from healthy adults. Validity and reliability estimates were compared between experienced and naïve judges in the identification of swallows from graphic sEMG records. Multiple validity estimates were high, indicating a strong degree of accuracy in identification of swallows versus nonswallow movements from sEMG traces. Experienced judges were more accurate than naïve judges (classification accuracy: experienced = 90% vs. naïve = 81%; p = 0.006, kappa: experienced = 0.89 vs. naïve 0.62; p = 0.008). Judges in both groups were more likely to classify swallows as nonswallow movements (false negatives) than to classify nonswallow movements as swallows (false positives). Interjudge reliability estimates indicated a high degree of agreement among judges in the identification of swallows versus nonswallow movements from the sEMG signal, with higher agreement among experienced judges (average kappa coefficient: experienced = 0.75 vs. naïve = 0.51). These results suggest that the sEMG graphic record is a valid and reliable tool for identifying normal swallows and that experience with this technique results in better identification and interjudge agreement.

Electrical stimulation therapy for dysphagia: descriptive results of two surveys.

Given the paucity of objective information on neuromuscular electrical stimulation approaches to dysphagia therapy, and the expanding utilization of this clinical approach, we designed and conducted two surveys to gather large-scale information regarding reported practice patterns, outcomes, complications, and professional perceptions associated with electrical stimulation approaches to dysphagia therapy. Self-administered questionnaires were mailed to 1000 randomly selected speech-language pathologists in each of two groups: (1) clinicians who had completed a formal electrical stimulation training course and were actively using these techniques, and (2) clinicians who were members of Special Interest Division 13 of the American Speech-Language and Hearing Association. Survey responses were anonymous and no incentive to respond was included. Acceptable response rates were achieved for both surveys (47% and 48%). Both groups of respondents were demographically similar and reported similar practice patterns. Stroke was the most common etiology of dysphagia treated with this approach. The majority of respondents identified no specific dysphagia criteria for application of electrical stimulation, used varied behavioral treatment methods, and did not follow patients beyond therapy. Clinicians reported positive outcomes with no treatment-related complications. Satisfaction with this approach was reported to be high among patients and professionals. Clinicians who did not report using these techniques indicated that they were waiting for more objective information on clinical outcomes and safety. Results of these surveys form an initial description of practice patterns and outcomes associated with electrical stimulation approaches to dysphagia therapy.

Initial psychometric assessment of a functional oral intake scale for dysphagia in stroke patients.

OBJECTIVE: To report on the development and psychometric evaluation of a clinical scale to document change in functional oral intake of food and liquid in stroke patients. DESIGN: Validity and reliability study. SETTING: Tertiary care, academic medical center, metropolitan stroke unit. PARTICIPANTS: Acute stroke patients (N=302). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Interrater reliability, validity, and sensitivity to change assessments were completed on a 7-point ordinal scale-the Functional Oral Intake Scale (FOIS)-developed to document the functional level of oral intake of food and liquid in stroke patients. Interrater reliability was drawn from FOIS ratings applied to dietary information from patient medical charts. Consensual validity was estimated by rankings from judges against predefined scale scores. Criterion validity was evaluated by comparison to the Modified Rankin Scale, the Modified Barthel Index, and Mann Assessment of Swallowing Ability. Cross-validation was assessed via comparison to 2 physiologic measures of swallowing function. Change in functional oral intake over time was assessed descriptively by applying the scale to dietary information from a cohort of 302 acute stroke patients followed up for 6 months. RESULTS: Interrater reliability was high, with perfect agreement on 85% of ratings. Kappa statistics ranged from .86 to .91. Consensual validity was high (.90). Criterion validity was high at onset and 1 month poststroke. Significant associations were identified between the FOIS and stroke handicap scales. The FOIS was significantly associated with 2 physiologic measures of swallowing. Scores on the FOIS from the cohort of stroke patients showed a shift toward increased oral intake over a 6-month period. CONCLUSIONS: The FOIS had adequate reliability, validity, and sensitivity to change in functional oral intake. These findings suggest that the FOIS may be appropriate for estimating and documenting change in the functional eating abilities of stroke patients over time.

Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback.

This article describes a retrospective analysis of functional outcome, time in therapy, and cost per unit of functional change in patients who received therapy for pharyngeal dysphagia. Twenty-five patients presenting dysphagia following stroke and 20 patients with dysphagia following treatment for head/neck cancer completed a systematic therapy program supplemented with surface electromyographic (sEMG) biofeedback. Eighty-seven percent (39/45) of all patients increased their functional oral intake of food/liquid including 92% of stroke patients and 80% of head/neck cancer patients. Patients with dysphagia following stroke demonstrated greater improvement than those in the head/neck cancer group. Patients in the stroke group completed more therapy sessions thus increasing the total cost of therapy, but they made more functional progress resulting in lower costs per unit of functional change than patients in the head/neck cancer group. Limitations of this study are described in reference to implications for future clinical research on the efficacy of this therapy approach.