Treatment of oral and pharyngeal dysphagia

Oral and Pharyngeal Dysphagia in Adults

Patients with oral and pharyngeal dysphagia have difficulty forming a cohesive bolus and/or transferring food from the mouth into the pharynx and esophagus to initiate the involuntary swallowing process. This may be accompanied by nasopharyngeal regurgitation, aspiration, and a sensation of residual food remaining in the pharynx. Abnormalities affecting the upper esophageal sphincter, pharynx, larynx, or tongue, in isolation or combination, result in oropharyngeal dysphagia affecting either or both transit and airway protection. These issues can be addressed with a combination of management of the underlying systemic disease, with surgical intervention or with swallow therapy.

Clinical Feeding and Swallowing Evaluation for the School-Based Speech-Language Pathologist

PURPOSE

From preschool through high school, eating is part of the school day. Children with feeding and/or swallowing issues are now in our neighborhood schools, our responsibility in our care, and require adequate nutrition and hydration to participate in school and access the curriculum. The whole child is in school, including all of their medical, behavioral, social, and educational needs. This clinical focus article describes a holistic process of evaluating swallowing and feeding in the school setting for the school speech-language pathologist (SLP) leading the team supporting the child.

METHOD

This clinical focus article explores the evaluation process in the educational setting for the school SLP in identification of pediatric feeding disorders (PFDs), which can involve dysphagia. Detailed descriptions of the related U.S. educational law, PFD, assessment processes for the multiple systems relating to eating, and collaboration with an interdisciplinary team are highlighted. Using the four overlapping domains of PFD (medical, psychosocial, feeding skill-based systems and associated nutritional aspects), medical and background history gathering; integration with instrumental results; and the need to consider the complex interaction of developmental, physical, cognitive, social, behavioral, family, and cultural aspects in the evaluation are detailed.

CONCLUSIONS

School-age children require safe and adequate nutrition and hydration for learning and social participation. The SLP has a lead role in the school team in evaluating swallowing and feeding, and developing a plan for team implementation. A holistic school-based SLP clinical evaluation process is described.

Dysphagia and Diets in Skilled Nursing Facilities When Patient's Health Status Changes: The Role of Imaging

OBJECTIVES

Research suggests that clinical decision making for assessing and treating patients with swallowing dysfunction varies significantly, and decisions may harm patients. The study aimed to investigate clinical practice of speech-language pathologists (SLPs) assessing and treating swallowing in skilled nursing facilities (SNFs).

DESIGN

Retrospective review of 120 medical records of patients recommended for a flexible endoscopic evaluation of swallowing (FEES).

SETTING AND PARTICIPANTS

120 SNF patients.

METHODS

Records from 25 SNFs were reviewed to determine which patients were receiving swallowing therapy, their diet level pre- and post-FEES, and if they received prior imaging studies. Recordings of FEES were assigned severity ratings based on the Dynamic Imaging Grade of Swallowing Toxicity-FEES scores to determine the relationship between diet and liquid recommendations before and after FEES, how often patients consume a modified diet in the absence of dysphagia, percentage of patients without dysphagia receiving swallowing treatment, percentage of patients receiving alternative means of nutrition without dysphagia, and the percentage of patients with a feeding tube without an imaging assessment.

RESULTS

Chi-square tests revealed no agreement between pre- and postimaging diet levels. Ordinal regressions indicated preimaging diets did not fit the DIGEST severity rating model; however, investigators found a good fit with postimaging diet recommendations. Descriptive statistics indicated that 67% of the patients receiving a modified solid and/or liquid did not have dysphagia. Treatment was provided to 100% of the patients without dysphagia. Sixty-one percent of patients with feeding tubes had no dysphagia. Forty-five percent of NPO (nothing by mouth) patients had imaging during their acute stay.

CONCLUSIONS AND IMPLICATIONS

The results strongly suggest that the practice of continuing acute care diet recommendations in a SNF increases cost and may negatively impact patient quality of life. The practice may also lead to negative health consequences. A new imaging assessment is required to inform treatment when medical status changes.

Head rotation as an effective compensatory technique for dysphagia caused by unilateral cervical osteophytes

Objective

Dysphagia is common in patients with cervical osteophytes. We aimed to determine whether head rotation as a compensatory technique is effective for dysphagia caused by unilateral cervical osteophytes.

Methods

We retrospectively analyzed videofluoroscopic swallowing study (VFSS) data obtained in one university hospital. Patients whose VFSS showed pharyngeal stasis by mechanical obstruction due to cervical osteophytes were selected. They were divided into a unilateral skewed osteophyte group and a diffuse central osteophyte group as confirmed by laryngoscopy or computed tomography. The effect of head rotation on swallowing was investigated. Fisher’s exact test was used for statistical analysis.

Results

Among 2876 patients who underwent VFSSs, we identified 48 patients with osteophyte-induced dysphagia. The osteophytes were centrally located in 36 patients and unilateral in the remaining 12. Ten of the patients with unilateral osteophytes showed improvement when they swallowed with head rotation toward the osteophyte side, but none of the patients with central osteophytes showed effective swallowing. A statistically significant relationship was found between swallowing with head rotation and skewed cervical osteophytes.

Conclusion

Swallowing with head rotation was safe, easy, and effective for patients with dysphagia caused by unilateral cervical osteophytes. We advise attempting this method prior to considering surgical approaches.

Dysphagia in Alzheimer's disease: a systematic review

Dysphagia is described as a highly relevant comorbidity of Alzheimer's disease (AD). However, there is a scarcity of studies aiming at the characteristics and progression of dysphagia.

OBJECTIVE

The objective of this study was to identify the specific characteristics, progression, and prevalence of dysphagia in AD.

METHODS

Publications were searched in the PubMed (MEDLINE), EBSCO, ScienceDirect, and BASE databases. Critical appraisal and evidence-level analysis were conducted using the Joanna Briggs Institute and Effective Public Health Practice Project's (EPHPP) tools.

RESULTS

A total of 26 studies were reviewed. Symptoms begin in the early stage of AD, as oral phase impairments, and progress to pharyngeal symptoms and swallowing apraxia in the later stages of AD. Dysphagia progresses, as AD, along a continuum, with severity depending on individual variability. There were no studies found on prevalence.

CONCLUSIONS

Dysphagia is a complex and important comorbidity in AD that impacts the quality of life. No recent publications on prevalence may imply that is not being coded as a potential cause for pneumonia deaths in AD.

Effect of effortful swallow on pharyngeal pressures during swallowing in adults with dysphagia: A pharyngeal high-resolution manometry study

Purpose: Evidence base to support the use of the effortful swallow in clinical populations with dysphagia is currently lacking. This study aims to quantify the effects of effortful swallowing on pharyngeal swallowing biomechanics in adults with dysphagia using pharyngeal high-resolution manometry (PHRM).Method: ManoScan HRM equipment with a 4.2 mm pressure catheter was used. Participants completed duplicate 10ml baseline and 10ml effortful liquid (IDDSI Level 0) swallows in randomised order. PHRM data were analysed using a semi-automated online platform (www.swallowgateway.com).Result: Fifteen adults (8 males; range 45-86 years) with mixed aetiology dysphagia (Functional Oral Intake Scale Level 2-5) were included. Median pharyngeal contractile (156.81 mmHg cm s; IQR 80.62) increased significantly (213.50 mmHg cm s; IQR 117.2) during effortful swallowing. Significant increases were also observed in velopharyngeal pressure, mesopharyngeal pressure, hypopharyngeal pressure and upper oesophageal sphincter (UOS) relaxation duration. UOS integrated relaxation pressure (IRP) was not significantly altered with effortful swallowing.Conclusion: Effortful swallowing induced significant biomechanical changes to swallow in adults with dysphagia. Increases in global pharyngeal rigour, tongue base pressure and UOS opening duration were captured by PHRM during effortful swallowing. Further investigation in larger homogeneous clinical populations is needed to verify the physiological effects of this frequently employed intervention.

Effects of oral exercise on tongue pressure in Taiwanese older adults in community day care centers

Background/purpose

Oral exercise is a training method for swallowing dysfunction in older adults. The study investigated the effect of oral exercise on tongue pressure in older adults in Taiwanese community day care centers over a 3-month period.

Materials and methods

Participants over age 50 who were able to communicate and participating for the duration of the 12-week period were recruited from five community day care centers. A 15-min weekly group oral exercise activity was conducted. The tongue pressures were measured and multivariable linear regression models were used to assess the effect of oral exercise intervention on the participants’ tongue pressures.

Results

A total of 66 older adult participants, among whom the mean age was 78.06 ± 10.74 years. Tongue pressure continued improving during the intervention period, and the mean tongue pressure at the end of the study was 20.63 ± 10.45 kPa, which was significantly higher than the baseline measurement (16.92 ± 10.62 kPa, p < 0.001). Participants exhibited significant improvement in tongue pressure regardless of their age groups. Moreover, participants with one to seven pairs of functional tooth units (FTUs) exhibited significantly more improvement in tongue pressure (16.00 kPa, 95% CI = 2.58–29.43) than those without FTUs (p = 0.021).

Conclusion

Oral exercise over a 3-month period significantly improved tongue pressure among the study participants regardless of their gender or age group. Oral exercise should be integrated into comprehensive health promotion programs to assist in the improvement and maintenance of oral function among older adults.

Barriers and enablers to switching from a solid to a liquid formulation of Parkinson's medication: a theory-based mixed methods investigation

BACKGROUND

Swallowing tablets/capsules can become difficult and dangerous for People with Parkinson's (PwP) who develop oropharyngeal dysphagia. Switching to a liquid delays the need for progressing to last line patches/injections. However, liquids are rarely used therefore a change in prescribing practice is warranted but, as with any change in behaviour, may be met with resistance.

AIM

To characterise PwPs and carers' barriers and enablers (determinants) of switching from solid to liquid Parkinson's medication formulations.

METHOD

Underpinned by the Theoretical Domains Framework, focus groups with PwPs and carers were convened to identify determinants of switching, which were then used to develop a questionnaire distributed across the UK. Determinants were prioritised if ≥ 50% of respondents agreed/strongly agreed that they were important to their decision to switch to a liquid formulation. Percentage precisions were reported as 95% confidence intervals.

RESULTS

From three focus groups and 131 questionnaires responses, PwPs and carers prioritised nine determinants. Three enablers had almost unanimous agreement: liquids' flexibility for incremental dosing (72% ± 8); decline in Parkinson's control (72% ± 8); prescriber's endorsement to switch (70% ± 8). The barriers: perception that tablets/capsules are easier to dose than liquids (72% ± 8); and prescriber's opposition to switching (70% ± 8), attracted similarly high agreement.

CONCLUSION

There is a desire to switch to liquids when Parkinson's progresses and for their use beyond this to offer flexibility in dosing, a previously unrecognised indication for switching. The only notable resistance to switching may be addressed by innovations from the pharmaceutical industry to make liquids easier to measure.

Efficacy of speech therapy in post-intubation patients with oropharyngeal dysphagia: a randomized controlled trial

PURPOSE

to verify the efficacy of speech therapy in the early return of oral intake in patients with post-orotracheal intubation dysphagia.

METHODS

It was a double-blinded randomized controlled trial for two years with patients of intensive care units of a hospital. Study inclusion criteria were orotracheal intubation>48hours, age≥18 years old, clinical stability, and dysphagia. Exclusion criteria were tracheotomy, score 4 to 7 in the Functional Oral Intake Scale (FOIS), neurological disorders. Patients were randomized into speech treatment or control group (ten days of follow-up). The treated group (TG) received guidance, therapeutic techniques, airway protection and maneuvers, orofacial myofunctional and vocal exercises, diet introduction; the control group (CG) received SHAM treatment. Primary outcomes were oral intake progression, dysphagia severity, and tube feeding permanence.

RESULTS

In the initial period of study, 240 patients were assessed and 40 (16.6%) had dysphagia. Of this, 32 patients met the inclusion criteria, and 17 (53%) received speech therapy. Tube feeding permanence was shorter in TG (median of 3 days) compared to CG (median of 10 days) (p=0.004). The size effect of the intervention on tube feeding permanence was statistically significant between groups (Cohen's d=1.21). TG showed progress on FOIS scores compared to CG (p=0.005). TG also had a progression in severity levels of Dysphagia protocol (from moderate to mild dysphagia) (p<0.001).

CONCLUSION

Speech therapy favors an early progression of oral intake in post-intubation patients with dysphagia. Clinical Trial Registration: RBR-9829jk.

Targeting Chemosensory Ion Channels in Peripheral Swallowing-Related Regions for the Management of Oropharyngeal Dysphagia

Oropharyngeal dysphagia, or difficulty in swallowing, is a major health problem that can lead to serious complications, such as pulmonary aspiration, malnutrition, dehydration, and pneumonia. The current clinical management of oropharyngeal dysphagia mainly focuses on compensatory strategies and swallowing exercises/maneuvers; however, studies have suggested their limited effectiveness for recovering swallowing physiology and for promoting neuroplasticity in swallowing-related neuronal networks. Several new and innovative strategies based on neurostimulation in peripheral and cortical swallowing-related regions have been investigated, and appear promising for the management of oropharyngeal dysphagia. The peripheral chemical neurostimulation strategy is one of the innovative strategies, and targets chemosensory ion channels expressed in peripheral swallowing-related regions. A considerable number of animal and human studies, including randomized clinical trials in patients with oropharyngeal dysphagia, have reported improvements in the efficacy, safety, and physiology of swallowing using this strategy. There is also evidence that neuroplasticity is promoted in swallowing-related neuronal networks with this strategy. The targeting of chemosensory ion channels in peripheral swallowing-related regions may therefore be a promising pharmacological treatment strategy for the management of oropharyngeal dysphagia. In this review, we focus on this strategy, including its possible neurophysiological and molecular mechanisms.

MRI Assessment of Swallow Muscle Activation with the Swallow Exercise Aid and with Conventional Exercises in Healthy Volunteers: An Explorative Biomechanical Study

Swallowing muscle strength exercises are effective in restoring swallowing function. In order to perform the exercises with progressive load, the swallow exercise aid (SEA) was developed. Precise knowledge on which muscles are activated with swallowing exercises, especially with the SEA, is lacking. This knowledge would aid in optimizing the training program to target the relevant swallowing muscles, if necessary. Three healthy volunteers performed the three SEA exercises (chin tuck against resistance, jaw opening against resistance and effortful swallow) and three conventional exercises [conventional effortful swallow (cES), Shaker and Masako] in supine position inside an MRI scanner. Fast muscle functional MRI scans (generating quantitative T2-maps) were made immediately before and after the exercises. Median T2 values at rest and after exercise were compared to identify activated muscles. After the three SEA exercises, the suprahyoid, infrahyoid, sternocleidomastoid, and lateral pterygoid muscles showed significant T2 value increase. After the Shaker, the lateral pterygoid muscles did not show such an increase, but the three other muscle groups did. The cES and Masako caused no significant increase in any of these muscle groups. During conventional (Shaker) exercises, the suprahyoid, infrahyoid, and sternocleidomastoid muscles are activated. During the SEA exercises, the suprahyoid, infrahyoid, sternocleidomastoid, and lateral pterygoid muscles are activated. The findings of this explorative study further support the potential of the SEA to improve swallowing rehabilitation.

The effects of head rotation and tilt on oral pressure and muscle activity

We present basic data on head positions that can serve as compensatory interventions for patients with weak tongue and buccinator muscles. We studied 30 Korean adults (15 males, 15 females; mean age, 23 years; range, 20-30 years). A TPS-100 instrument was used to measure tongue and cheek pressures and suprahyoid and buccinator muscle activities at various head rotations and tilts, as independent variables. The data were subjected to one-way analysis of variance and post-hoc (linear contrast) testing. Tongue elevation pressures differed significantly when the head was flexed or extended compared to the neutral position (P<0.01). Suprahyoid muscle activity varied significantly when the head was rotated left or right compared to neutral, or tilted with the tongue elevated (P<0.01). Cheek pressure varied significantly when the head was rotated left or right compared to neutral, or tilted (P<0.01). Both tongue and cheek pressures increased significantly when the head was extended or rotated contralaterally compared to the neutral position. Suprahyoid muscle activity increased when the head was flexed or extended, or contralaterally or ipsilaterally rotated compared to the neutral position. Therefore, we suggest that head rotation or tilting could be used to vary oral pressure and muscle activity.

The role of speech and language therapists in the intensive care unit

National guidance recommends the involvement of speech and language therapists in intensive care particularly for those requiring tracheostomy and ventilation. However, the role of speech and language therapists is poorly understood especially in the context of critical care. This article aims to increase awareness of the background training and skills development of speech and language therapists working in this context to demonstrate their range of specialist abilities. Speech and language therapists support and enhance the process of laryngeal weaning alongside the rehabilitation of speech and swallowing as part of the multidisciplinary team. Examples are provided of the types of interventions that are used and technological innovations that may enhance rehabilitation of oropharyngeal impairments.

Immediate Effect of Dry Swallowing Maneuver in Patients with Neurogenic Dysphagia

BACKGROUND

Compensatory deglutition strategies such as change of posture, swallowing maneuvers, and sensory stimulation have been used by speech-language pathologists (SLPs) to alter oral and pharyngeal biodynamics.

OBJECTIVE

To analyze the immediate effect of the dry swallowing maneuver in patients with neurogenic dysphagia.

METHODOLOGY

The participants were 11 individuals with neurogenic dysphagia who underwent videofluoroscopic swallowing study while performing dry swallow maneuvers for different consistencies. The amount of pre- and post-maneuver residue was measured for the tongue base, vallecula, posterior pharyngeal wall, and pyriform sinus. Two experienced SLPs analyzed the videos blindly as to the timing, pre- or post-maneuver, and information about the videos. In cases of disagreement between the judges, a third judge broke the tie for each structure whose analysis was in disagreement.

RESULTS

There was a significant reduction of residue after dry swallowing maneuvers on the tongue and vallecula. There was no significant difference in the amount of pre- and post-maneuver residue for the posterior pharyngeal wall and pyriform sinus. The amount of pre- and post-maneuver residue showed no significant interference from the different consistencies tested.

CONCLUSION

The dry swallowing maneuver showed an immediate improvement effect for the clearance of residues on the base of tongue and vallecula.

The Relationship between Texture-Modified Diets, Mealtime Duration, and Dysphagia Risk in Long-Term Care

Many long-term care (LTC) residents have an increased risk for dysphagia and receive texture-modified diets. Dysphagia has been shown to be associated with longer mealtime duration, and the use of texture-modified diets has been associated with reduced nutritional intake. The current study aimed to determine if the degree of diet modification affected mealtime duration and to examine the correlation between texture-modified diets and dysphagia risk. Data were collected from 639 LTC residents, aged 62-102 years. Nine meal observations per resident provided measures of meal duration, consistencies consumed, coughing and choking, and assistance provided. Dysphagia risk was determined by identifying residents who coughed/choked at meals, were prescribed thickened fluids, and/or failed a formal screening protocol. Degree of texture modification was derived using the International Dysphagia Diet Standardization Initiative Functional Diet Scale. There was a significant association between degree of diet modification and dysphagia risk (P < 0.001). However, there was no association between diet modifications and mealtime duration, even when the provision of physical assistance was considered. Some residents who presented with signs of swallowing difficulties were not prescribed a texture-modified diet. Swallowing screening should be performed routinely in LTC to monitor swallowing status and appropriateness of diet prescription. Physical assistance during meals should be increased.

The effect of repetitive transcranial magnetic stimulation combined with traditional dysphagia therapy on poststroke dysphagia: a pilot double-blinded randomized-controlled trial

Dysphagia following stroke is common and can lead to severe complications such as aspiration pneumonia, but there is inconclusive evidence on how poststroke dysphagia should be treated. This study aimed to investigate the effects of repetitive transcranial magnetic stimulation (rTMS) combined with the traditional dysphagia therapy on the swallowing function in patients with poststroke dysphagia. In this pilot double-blind randomized clinical trial, 18 patients with poststroke dysphagia were allocated randomly to three groups: (i) traditional dysphagia therapy, (ii) rTMS, and (iii) combined intervention. Patients received traditional dysphagia therapy for 18 treatment sessions three times per week. The inhibitory rTMS was applied to the intact cerebral hemisphere at 1 Hz with a train of 1200 for 5 consecutive days. The patients in the combined intervention group received traditional dysphagia therapy and rTMS simultaneously. The Mann Assessment of Swallowing Ability (MASA) and Functional Oral Intake Scale were performed before treatment, after the end of the fifth session, after the end of the 10th session, after the end of the 15th session, and after the end of the 18th session. All groups had improved on MASA and Functional Oral Intake Scale scores over time (P<0.01). The improvements achieved in all outcomes were significantly greater in the combined intervention group than those of the traditional dysphagia therapy and rTMS groups. The large effect sizes were found for the MASA score in all groups: traditional dysphagia therapy group (d = 3.57), rTMS group (d = 2.67), and combined intervention group (d = 3.87). This pilot randomized-controlled trial showed that the combination of rTMS and traditional dysphagia therapy significantly improved swallowing function in patients with poststroke dysphagia.

Dysphagia in the intensive care unit: epidemiology, mechanisms, and clinical management

Dysphagia may present in all critically ill patients and large-scale clinical data show that e.g. post-extubation dysphagia (PED) is commonly observed in intensive care unit (ICU) patients. Recent data demonstrate that dysphagia is mostly persisting and that its presence is independently associated with adverse patient-centered clinical outcomes. Although several risk factors possibly contributing to dysphagia development were proposed, the underlying exact mechanisms in ICU patients remain incompletely understood and no current consensus exists on how to best approach ICU patients at risk.From a clinical perspective, dysphagia is well-known to be associated with an increased risk of aspiration and aspiration-induced pneumonia, delayed resumption of oral intake/malnutrition, decreased quality of life, prolonged ICU and hospital length of stay, and increased morbidity and mortality. Moreover, the economic burden on public health care systems is high.In light of high mortality rates associated with the presence of dysphagia and the observation that dysphagia is not systematically screened for on most ICUs, this review describes epidemiology, terminology, and potential mechanisms of dysphagia on the ICU. Furthermore, the impact of dysphagia on affected individuals, health care systems, and society is discussed in addition to current and future potential therapeutic approaches.

Effects of an Oral-Pharyngeal Motor Training Programme on Children with Obstructive Sleep Apnea Syndrome in Hong Kong: A Retrospective Pilot Study

Background

This study aimed to investigate the effects of an oropharyngeal motor training programme on children with Obstructive Sleep Apnea Syndrome (OSAS) in Hong Kong.

Methods

In this retrospective study, we reviewed the outcomes of 10 children with OSAS who had received an oropharyngeal motor training programme in Occupational Therapy Department of an acute hospital in Hong Kong over a 1-year programme. Each participant attended an individual oropharyngeal motor training programme plus a follow-up session after 2 months. The training programme consisted of 10 individual mobilization exercises involving the orofacial and pharyngeal area for 45 minutes. Each exercise had to be repeated for 10 times. Three outcome measures were chosen to study the effectiveness of the training programme including tongue strength, tongue endurance level and orofacial function. Tongue strength and tongue endurance level were assessed using the Iowa Oral Pressure Instrument (IOPI). The Nordic Orofacial Test-Screening (NOT-S) Assessment was used to assess the orofacial function. Seven out of 10 participants completed the training programme and attended the follow-up session after two months.

Results

The tongue strength and the scores of NOT-S of the 7 participants were found to have significant improvement after training. However, there was no significant difference in tongue endurance level.

Conclusion

The findings of this study support the role of occupational therapist in oromotor training modalities to improve the respiratory function for children with OSAS in Hong Kong. Copyright © 2017, Hong Kong Occupational Therapy Association. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Increased levels of substance P in patients taking beta-blockers are linked with a protective effect on oropharyngeal dysphagia

BACKGROUND

We have recently found a potential protective effect of beta-blockers on oropharyngeal dysphagia (OD). The action mechanism by which beta-blockers could wield this protective effect is unknown, but the neurotransmitter substance P (SP) could play a key role. The aim of this study was to analyze serum and saliva SP levels in patients taking beta-blockers (TBB), and to explore its relationship with OD.

METHODS

Adult (>50 year) patients TBB were randomly recruited from the primary care setting and 1:1 matched by age, sex, and Barthel Index (BI) with patients not taking beta-blockers (NTBB). Serum and saliva samples were taken and analyzed for their SP levels using an enzyme-linked immunosorbent assay (ELISA). Socio-demographic and clinical variables were collected. Dysphagia was evaluated in all patients using the clinical volume-viscosity swallow test (V-VST).

KEY RESULTS

We studied 28 patients TBB (64.96 ± 7.31 years, 57.1% women, BI 99.6 ± 1.31, carvedilol-equivalent dose 24.11 ± 18.12 mg) and 28 patients NTBB (65.61 ± 6.43 years, 57.1% women, BI 99.6 ± 1.31). SP serum levels were significantly higher in patients TBB (260.68 ± 144.27 vs 175.46 ± 108.36 pg/mL, P = .009) as were SP saliva levels (170.34 ± 146.48 vs 102.73 ± 52.28 pg/mL, P < .001) compared with patients NTBB. The prevalence of OD was 32.1% in patients TBB and 67.9% in patients NTBB (P = .015). Moreover, patients with OD had significantly lower SP saliva levels in comparison with patients without clinical signs of OD (98.39 ± 43.25 vs 174.69 ± 147.21 pg/mL) P < .001.

CONCLUSIONS & INFERENCES

We have found that serum and saliva SP levels are greater in patients TBB. This increase in SP levels could be the action mechanism by which beta-blockers protect patients from OD.

Validity and reliability of the mixing ability test as masticatory performance outcome in children with spastic cerebral palsy and children with typical development: A pilot study

BACKGROUND

The mixing ability test (MAT) as an outcome measure of masticatory performance is largely used in studies with adults, but not yet with children.

OBJECTIVE

This study aimed to test the construct validity and the test-retest reliability of the MAT in children with spastic cerebral palsy (CP) and children with typical development (TD).

METHOD

The results of the MAT were correlated with tongue movements, mandible movements, relative muscle contraction and clinical observation measured with ultrasound, 3D kinematics, electromyography (EMG) and relevant items of the mastication observation and evaluation (MOE) instrument, respectively. Moreover, the between-groups effect was tested. Test-retest reliability was calculated with an intra-class correlation coefficient (ICC) and standard error of measurement (SEM).

RESULTS

Twenty-one children (seven children with spastic CP and 14 children with TD) participated in this study. The MAT scores showed moderate to good correlations with some variables of the tongue movements, horizontal mandible movements and occlusion duration, relative muscle contraction of the left temporalis and all six MOE items (-0.80 < r < 0.49). The MAT scores were significantly higher for children with CP (mean 22.6; SD 2.4) compared to children with TD (mean 19.9; SD 1.9). The test-retest reliability had an ICC of 0.7 and a SEM of 1.16 (±5% of the mean score).

CONCLUSION

These results indicate that the MAT is suitable and complementary to ultrasound, 3D kinematics, EMG and observation to compare the masticatory performance between children with CP and children with TD, with an acceptable test-retest reliability.

Swallowing disorder following salvage total pharyngo-laryngo-esophagectomy with free jejunum reconstruction

For recurrent cases or residual cases following concomitant chemo-radiation therapy (CCRT), salvage surgery is a frequently used treatment options. A swallowing disorder is one of the major complications of CCRT. The purpose of the present study was to evaluate the effect of CCRT on swallowing function in patients who underwent salvage total pharyngo-laryngo-esophagectomy (TPLE), and to evaluate the importance of pharyngeal constriction in patients who underwent TPLE. Between 2008 January and 2014 May, 54 patients were treated with salvage TPLE following CCRT or TPLE at the National Cancer Center Hospital East, Chiba, Japan and were included in the present study. A total of 14 patients underwent salvage TPLE following CCRT for recurrence or residual tumor (the salvage TPLE group), and 40 patients underwent TPLE as initial treatment (the TPLE group). The pharyngeal constriction score and the post-swallowing oropharyngeal residue rate were evaluated, and inadequate velopharyngeal closure was assessed by videofluorography. The pharyngeal constriction score of the salvage TPLE group was poorer than that of the TPLE group (P<0.05). The bolus residue in the oropharynx was significantly larger in the salvage TPLE group than in the TPLE group (P<0.05). With regards to inadequate velopharyngeal closure, there was no significant difference between the TPLE group and the salvage TPLE group (P>0.99). The results of the present study indicate that the swallowing function of patients who undergo salvage TPLE may be affected by CCRT.

Difficulties in thickened water ingestion in healthy subjects

BACKGROUND

For some patients with dysphagia who have airway aspiration, it is not possible to drink water as a thin liquid, as they need their water to be thickened.

OBJECTIVE

To evaluate in healthy volunteers the difficulties and dynamics of ingestion of thickened water.

METHOD

In 94 healthy volunteers aged 18-67 years, the ingestion of 100 mL of water with consistencies of thin liquid and thickened with 1.2 g (nectar-thick), 2.4 g (honey-thick) and 3.6 g (pudding-thick) of a commercial thickener with maltodextrin, xanthan gum and potassium chloride was evaluated. The volunteers drank in a random sequence 100 mL of each consistency. The duration and the number of swallows to drink the volume were measured. The interval between swallows, the flux of ingestion and the volume of each swallow were calculated. After each test, the individual was asked about the sensation during drinking, with ten as the best sensation and zero as the worst sensation, and about the difficulty to swallow each consistency.

STATISTICAL ANALYSIS

The analysis was done using a linear model with mixed effects.

RESULTS

The time to ingest the volume increased (liquid: 5.8 s; nectar: 7.9 s; honey: 9.5 s; pudding: 12.7 s; p < 0.01), the flux of ingestion decreased (liquid: 20.3 mL/s; nectar: 15.6 mL/s; honey: 13.4 mL/s; pudding: 10.6 mL/s; p < 0.01), the sensation worsened (liquid: 9.7; nectar: 5.7; honey: 4.3; pudding: 2.8), and the difficult of ingestion increase with the increase of the water consistency. Individuals with dental prosthesis (n = 11) had a decrease in the flux of ingestion with 3.6 g of thickener (prosthesis: 11.1 mL/s, no prosthesis: 6.8 mL/s, p = 0.05) and a decrease in the volume in each swallow (prosthesis: 17.6 mL, no prosthesis: 10.5 mL).

CONCLUSIONS

There is some difficulty to drink thickened water. The use of dental prosthesis cause further difficulties.

Clinical inter-rater reliability of postural control techniques

Effectiveness of postural control techniques to compensate for oropharyngeal dysphagia have been recommended and used by several clinicians. However, the inter-rater reliability of these techniques is not well understood. The purpose of this study was to clarify the ambiguity of postural control techniques using statistical analyses. A total of 50 clinicians involved in dysphagia treatment participated in this study, where a healthy male served as the simulated patient. The following clinically used postures were measured by two investigators on two separate days: chin down, right/left incline, and right/left rotation. Postural angles were measured twice by two investigators on each day. Data obtained for the angle of each posture were visually displayed. Data from both investigators were assessed for each posture using the Youden plot, which analyzes data variability for systematic errors and accidental errors separately. The correlation coefficient for examining the measurement error between investigators was calculated. The results showed considerable variation between clinicians regarding the postures used, and significant differences were noted each day. The correlation coefficient for a total of four measurements was more often lower on Day 2 than that on Day 1. The details of the instructions provided by clinicians were not fixed, and the same specified posture was not reproduced even when instructions were provided to the same subject. These findings suggest poor inter-rater reliability because of the variability of selected postures when using statistical analyses. Therefore, standardized postures need to be developed that can be easily measured and reproduced.

Effect of the Masako maneuver and neuromuscular electrical stimulation on the improvement of swallowing function in patients with dysphagia caused by stroke

[Purpose] The aim of this study was to compare improvements in swallowing function by the intervention of the Masako maneuver and neuromuscular electrical stimulation in patients with dysphagia caused by stroke. [Subjects and Methods] The Masako maneuver (n=23) and neuromuscular electrical stimulation (n=24) were conducted in 47 patients with dysphagia caused by stroke over a period of 4 weeks. Swallowing recovery was recorded using the functional dysphagia scale based on videofluoroscopic studies. [Results] Mean functional dysphagia scale values for the Masako maneuver and neuromuscular electrical stimulation groups decreased after the treatments. However, the pre-post functional dysphagia scale values showed no statistically significant differences between the groups. [Conclusion] The Masako maneuver and neuromuscular electrical stimulation each showed significant effects on the improvement of swallowing function for the patients with dysphagia caused by stroke, but no significant difference was observed between the two treatment methods.

Dysphagia in Alzheimer's disease

OBJECTIVE

To investigate electrophysiological parameters of swallowing in all stages of Alzheimer's disease.

METHODS

Forty Alzheimer's disease patients, 20 age-matched normal controls and 20 young normal controls were included. Dysphagia limit (DL) and sequential water swallowing (SWS) tests were performed. Cardiac rhythm, respiration and sympathetic skin responses were concomitantly recorded.

RESULTS

Dysphagia was found in 30/40 (75%) of Alzheimer's disease patients. Mean volume at the DL test was significantly reduced (16.5±1.0mL) in the Alzheimer's disease group. Swallowing and apnea times in the SWS test were significantly prolonged in elderly controls, but even longer in Alzheimer's disease patients.

CONCLUSIONS

Alzheimer's disease patients had electrophysiological features of dysphagia, even in the early period of disease. The cortical involvement and severity of cognitive disorder can increase swallowing problems, but subclinical signs of dysphagia may be observed even in patients with mild or moderate Alzheimer's disease.

Effectiveness of Chin-tuck Maneuver to Facilitate Swallowing in Neurologic Dysphagia

Introduction The chin-tuck maneuver is the most frequently employed postural maneuver in the treatment of neurogenic oropharyngeal dysphagia caused by encephalic vascular strokes and degenerative diseases.

Objective The purpose of this study was to investigate the effectiveness of this maneuver in patients with neurogenic dysphagia and factors that could interfere in it.

Methods In this retrospective cohort, we analyzed the medical files and videofluoroscopy exams of 35 patients (19 male – 54% and 16 female – 46%; age range between 20 and 89 years old; mean = 69 years).

Results The results suggest that the effectiveness of chin-tuck maneuver is related to the overall degree of dysphagia: the more severe the dysphagia, the less effective the maneuver.

Conclusion Chin-tuck maneuver should benefit dysphagic patients with delay in the swallowing trigger, reduced laryngeal elevation, and difficulties to swallow liquids, but is not the best compensatory strategy for patients with severe dysphagia.

Dysphagia associated with cervical spine and postural disorders

Difficulties with swallowing may be both persistent and life threatening for the majority of those who experience it irrespective of age, gender, and race. The purpose of this review is to define oropharyngeal dysphagia and describe its relationship to cervical spine disorders and postural disturbances due to either congenital or acquired disorders. The etiology and diagnosis of dysphagia are analyzed, focusing on cervical spine pathology associated with dysphagia as severe cervical spine disorders and postural disturbances largely have been held accountable for deglutition disorders. Scoliosis, kyphosis–lordosis, and osteophytes are the primary focus of this review in an attempt to elucidate the link between cervical spine disorders and dysphagia. It is important for physicians to be knowledgeable about what triggers oropharyngeal dysphagia in cases of cervical spine and postural disorders. Moreover, the optimum treatment for dysphagia, including the use of therapeutic maneuvers during deglutition, neck exercises, and surgical treatment, is discussed.

Transcranial direct current stimulation enhances sucking of a liquid bolus in healthy humans

BACKGROUND

Transcranial direct current stimulation (tDCS) is a non-invasive technique used for modulating cortical excitability in vivo in humans. Here we evaluated the effect of tDCS on behavioral and electrophysiological aspects of physiological sucking and swallowing.

METHODS

Twelve healthy subjects underwent three tDCS sessions (anodal, cathodal and sham stimulation) on separate days in a double-blind randomized order. The active electrode was placed over the right swallowing motor cortex. Repeated sucking and swallowing acts were performed at baseline and at 15 and 60 min after each tDCS session and the mean liquid bolus volume ingested at each time point was measured. We also calculated average values of the following electrophysiological parameters: 1) area and 2) duration of the rectified EMG signal from the suprahyoid/submental muscles related to the sucking and swallowing phases; 3) EMG peak amplitude for the sucking and swallowing phases; 4) area and peak amplitude of the laryngeal-pharyngeal mechanogram; 5) oropharyngeal delay.

RESULTS

The volume of the ingested bolus significantly increased (by an average of about 30% compared with the baseline value) both at 15 and at 60 min after the end of anodal tDCS. The electrophysiological evaluation after anodal tDCS showed a significant increase in area and duration of the sucking phase-related EMG signal.

CONCLUSIONS

Anodal tDCS leads to stronger sucking of a liquid bolus in healthy subjects, likely by increasing recruitment of cortical areas of the swallowing network. This finding might open up interesting perspectives for the treatment of patients suffering from dysphagia due to various pathological conditions.

Aspiration pneumonia after chemo-intensity-modulated radiation therapy of oropharyngeal carcinoma and its clinical and dysphagia-related predictors

BACKGROUND

The purpose of this study was to assess aspiration pneumonia (AsPn) rates and predictors after chemo-irradiation for head and neck cancer.

METHODS

The was a prospective study of 72 patients with stage III to IV oropharyngeal cancer treated definitively with intensity-modulated radiotherapy (IMRT) concurrent with weekly carboplatin and paclitaxel. AsPn was recorded prospectively and dysphagia was evaluated longitudinally through 2 years posttherapy by observer-rated (Common Toxicity Criteria version [CTCAE]) scores, patient-reported scores, and videofluoroscopy.

RESULTS

Sixteen patients (20%) developed AsPn. Predictive factors included T classification (p = .01), aspiration detected on videofluoroscopy (videofluoroscopy-asp; p = .0007), and patient-reported dysphagia (p = .02-.0003), but not observer-rated dysphagia (p = .4). Combining T classification, patient reported dysphagia, and videofluoroscopy-asp, provided the best predictive model.

CONCLUSION

AsPn continues to be an under-reported consequence of chemo-irradiation for head and neck cancer. These data support using patient-reported dysphagia to identify high-risk patients requiring videofluoroscopy evaluation for preventive measures. Reducing videofluoroscopy-asp rates, by reducing swallowing structures radiation doses and by trials reducing treatment intensity in patients predicted to do well, are likely to reduce AsPn rates.

[Dysphagia management of acute and long-term critically ill intensive care patients]

Dysphagia is a severe complication in critically ill patients and affects more than half the patients in an intensive care unit. Dysphagia also has a strong impact on morbidity and mortality. Risk factors for the development of dysphagia are neurological diseases, age >55-70 years, intubation >7 days and sepsis. With increasing numbers of long-term survivors chronic dysphagia is becoming an increasing problem. There is not much knowledge on the influence of specific diseases, including the direct impact of sepsis on the development of dysphagia. Fiberoptic evaluation of swallowing is a standardized tool for bedside evaluation, helping to plan swallowing training during the acute phase and to decrease the rate of chronic dysphagia. For evaluation of chronic dysphagia even more extensive diagnostic tools as well as several options of stepwise rehabilitation using restitution, compensation and adaption strategies for swallowing exist. Currently it seems that these options are not being sufficiently utilized. In general, there is a need for controlled clinical trials analyzing specific swallowing rehabilitation concepts for former critically ill patients and long-term survivors.

Rehabilitative management of swallowing and oral-motor movements in patients with tetanus of a public service in Brazil

When looking at developing countries, the prolonged intensive medical and nursing care required by many patients places extra demands on an already stretched healthcare budget. The purpose of this study was to verify the effectiveness of a systematic rehabilitative program for swallowing and oral-motor movements in intensive care unit patients with the diagnosis of tetanus. Forty-five patients who were clinically diagnosed with tetanus were included in the study. Participants were divided in two groups: GI - consisted of 18 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2002 to December 2005, prior to the existence of a systematic swallowing and oral-motor intervention; GII - consisted of 27 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2006 to December 2009 and were submitted to a specific rehabilitative management of swallowing and of the oral-motor movements. Results indicate that the proposed rehabilitative program reduced by approximately 50% the time patients remained in the ICU. The significant improvement observed in patients with tetanus who were submitted to the rehabilitative program for swallowing and oral-motor movements occurred in conjunction with a reduction in the amount of time necessary to reintroduce oral feeding, to decannulate and to remove the feeding tubes. In conclusion, swallowing/muscle exercise, in patients with severe/very severe tetanus, seem to promote the remission of muscle tension and seem to maximize functional swallowing.

Speech and myofunctional exercise physiology: a critical review of the literature

PURPOSE

To analyze the scientific literature about the physiology and effects of exercises used in the treatment of oral myofunctional disorders.

RESEARCH STRATEGY

The methodology used followed the concepts of the Cochrane Handbook and involved question formulation related to the topic of investigation, identification and selection of the studies, and a critical evaluation of the selected articles.

SELECTION CRITERIA

Papers were selected on PubMed database using the following keyword combinations: "physiology exercise AND speech, language and hearing science", "exercise physiology AND speech therapy", "exercise physiology AND myofunctional therapy", and "physiology exercise AND swallowing therapy". Only papers written in English and published between the years of 2000 and 2010 were included in the analysis.

DATA ANALYSIS

Manuscripts were analyzed according to their objectives, research design, participants, inclusion of a control group, assessment criteria, therapeutic proposal, results and existence about physiology of the chosen exercises.

RESULTS

One hundred and eight studies were identified, out of which 38 had access to the full text and were directly related to the investigated topic. The articles were classified as clinical trials and experimental research, case studies, literature reviews and theoretical articles, letters to the editor and critical analyses.

CONCLUSION

This review concluded that there is a lack of knowledge about the effects of the myofunctional exercises used by clinicians. Also there is a lack of scientific evidence to determine the frequency at which they should be performed. Generally, the articles investigate the efficacy of treatment programs without inquiring whether the included exercises are individually effective.

Paralisia cerebral: análise dos padrões da deglutição antes e após intervenção fonoaudiológica

OBJETIVO: analisar os padrões da deglutição antes e após intervenção fonoaudiológica em um grupo de crianças com Paralisia Cerebral que apresentam quadro de Disfagia. MÉTODO: estudo longitudinal, constituído por vinte crianças portadoras de Paralisia Cerebral, com idades entre um e oito anos, de ambos os sexos. Foi utilizada anamnese com os responsáveis e os pacientes foram submetidos à avaliação funcional da deglutição antes e após intervenção fonoaudiológica num período de três meses. RESULTADOS: percebeu-se discreta melhora no padrão de deglutição o que consequentemente trouxe um melhor padrão de alimentação aos pacientes avaliados e orientados. CONCLUSÃO: o presente estudo mostrou que a intervenção fonoaudiológica aos pacientes portadores de Paralisia Cerebral traz como resultado melhorias em seu padrão de alimentação, apesar do curto período de atendimento (três meses).

Effects of oral intake of water in patients with oropharyngeal dysphagia

Background

Dysphagia is associated with numerous medical conditions and the major intervention to avoid aspiration in people with dysphagia involves modifying the diet to thickened fluids. This is associated with issues related to patient quality of life and in many cases non-compliance leading to dehydration. Given these concerns and in the absence of conclusive scientific evidence, we designed a study, to further investigate the effects of oral intake of water in people with dysphagia.

Methods

We monitored lung related complications, hydration levels and assessed quality of life in two groups of people with dysphagia. The control group was allowed only thickened fluids and patients in the intervention group were allowed access to water for a period of five days.

Results

Our findings indicate a significantly increased risk in the development lung complications in patients given access to water (6/42; 14.3%) compared to the control group (0/34; no cases). We have further defined patients at highest risk, namely those with degenerative neurologic dysfunction who are immobile or have low mobility. Our results indicate increased total fluid intake in the patients allowed access to water, and the quality of life surveys, albeit from a limited number of patients (24% of patients), suggest the dissatisfaction of patients to diets composed of only thickened fluids.

Conclusions

On the basis of these findings we recommend that acute patients, patients with severe neurological dysfunction and immobility should be strongly encouraged to adhere to a thickened fluid or modified solid consistency diet. We recommend that subacute patients with relatively good mobility should have choice after being well-informed of the relative risk.

Trial registration

Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12608000107325

A randomized prospective study of rehabilitation therapy in the treatment of radiation-induced dysphagia and trismus

PURPOSE

To evaluate the therapeutic effect of rehabilitation therapy on radiation-induced dysphagia and trismus in nasopharyngeal carcinoma (NPC) patients after radiotherapy.

PATIENTS AND METHODS

43 NPC patients after radiotherapy were included. Patients were randomly assigned to either the rehabilitation group or a control group. Both groups were subjected to routine treatment, while the rehabilitation group also received rehabilitation therapy for 3 months. The severity of dysphagia was assessed using the water swallow test, while trismus was evaluated with the LENT/SOMA score and the interincisor distance (IID). The water swallow test, the LENT/SOMA score, as well as IID for both groups before and after treatment were analyzed and compared.

RESULTS

After treatment, the rehabilitation group displayed a significant improvement in swallowing function, while the control group did not. The efficacy rate (percentage of patients with excellent or effective results) of rehabilitation group was higher than that of control group (77% vs. 43%), and the difference was statistically significant (ϰ(2) = 5.32, p = 0.02). IID pretreatment and posttreatment did not show much difference in the rehabilitation group, while in the control group IID significantly decreased posttreatment (1.1 ± 0.36 cm vs.1.8 ± 0.56 cm, p = 0.001). Although the mean IID in patients of both groups decreased after the 3 month follow-up, the decrease in the rehabilitation group was less than that of the control group (0.19 ± 0.5 cm vs. 0.69 ± 0.56 cm, p = 0.004 ). The efficacy rate of trismus in the rehabilitation group was significantly higher than that of the control group (64% vs. 28%, ϰ(2) = 5.31, p = 0.02).

CONCLUSIONS

Rehabilitation training can improve swallow function and slow down the progress of trismus in NPC patients following radiotherapy.

Protocolo para controle de eficácia terapêutica em disfagia orofaríngea neurogênica (PROCEDON)

OBJETIVO: apresentar uma proposta para o controle de eficácia terapêutica em disfagia orofaríngea neurogênica. MÉTODOS: o protocolo foi proposto em concordância com a literatura atual e aplicado em um indivíduo pós-acidente vascular encefálico (AVE) isquêmico à direita, comprovado por tomografia computadorizada, com disfagia orofaríngea grave crônica, gênero masculino, 66 anos, apresentando aspiração laringotraqueal e em uso de sonda nasoentérica exclusiva pré-fonoterapia. Para controle da eficácia terapêutica do programa de reabilitação fonoaudiológica foi aplicado, pré e pós-fonoterapia, a classificação do grau de comprometimento da disfagia orofaríngea, Functional Oral Intake Scale (FOIS), a avaliação videofluoroscópica da deglutição com medida do tempo de trânsito faríngeo (TTF) da deglutição por meio de software e da percepção do indivíduo. RESULTADOS: na pré-fonoterapia verificou-se disfagia orofaríngea grave, FOIS nível 1, presença de aspiração laringotraqueal para mais de uma consistência e tempo de trânsito faríngeo de 13 segundos. Após fonoterapia verificou-se disfagia orofaríngea moderada, FOIS nível 5, ausência de aspiração laringotraqueal e TTF de 4 segundos. CONCLUSÃO: o protocolo proposto foi capaz de avaliar a eficácia da reabilitação na disfagia orofaríngea neurogênica neste indivíduo pós-acidente vascular encefálico, tanto para mensurar as mudanças ocorridas na fisiopatologia da deglutição quanto na ingestão oral e na percepção do indivíduo. Outros estudos com populações distintas são necessários, sendo que novas propostas devem ainda refletir a inclusão da condição nutricional e pulmonar do indivíduo no controle de eficácia em disfagia orofaríngea.

Functional dysphagia therapy and PEG treatment in a clinical geriatric setting

Functional dysphagia therapy (FDT) is a noninvasive procedure that can accompany percutaneous endoscopic gastrostomy (PEG) treatment and supports transitioning from tube to oral feeding. In this retrospective study, we investigated the outcome of FDT with or without PEG feeding. Patients with dysphagia were divided into two groups: those with PEG feeding (N = 117) and those with exclusively oral feeding (N = 105). Both groups received functional training (oral motor skills/sensation, compensatory swallowing techniques) from speech-language therapists. Functional oral intake, weight, Barthel index, and speech and language abilities were evaluated pre- and post-training. The non-PEG group showed a significant post-treatment improvement in functional oral intake, with diet improvement from pasty consistency to firm meals in most cases. However, even severely disordered patients (with PEG feeding) showed a significant increase in functional oral intake, still requiring PEG feeding post-treatment but able to take some food orally. The sooner a PEG was placed, the more functional oral intake improved. Significantly more complications and higher mortality occurred in the PEG group compared to the group with exclusively oral feeding. Dysphagia treatment in the elderly requires a multiprofessional setting, differentiated assessment, and functional training of oral motor skills and sensation and swallowing techniques.