Validation of a Novel Wearable Electromyography Patch for Monitoring Submental Muscle Activity During Swallowing: A Randomized Crossover Trial

Post-Radiotherapy Dysphagia in Head and Neck Cancer: Current Management by Speech-Language Pathologists

OPINION STATEMENT

Dysphagia, difficulty in eating and drinking, remains the most common side effect of radiotherapy treatment for head and neck cancer (HNC) with devastating consequences for function and quality of life (QOL). Over the past decade, 5-year survival has improved due to multiple factors including treatment advances, reduction in smoking, introduction of the human papillomavirus (HPV) vaccine and more favourable prognosis of HPV-related cancers. Increased prevalence of HPV-positive disease, which tends to affect younger individuals, has led to an elevated number of people living for longer with the sequelae of cancer and its treatment. Symptoms are compounded by late effects of radiotherapy which may lead to worsening of dysphagia for some long-term survivors or new-onset dysphagia for others. Speech-language pathology (SLP) input remains core to the assessment and management of dysphagia following HNC treatment. In this article, we present current SLP management of dysphagia post-radiotherapy. We discuss conventional treatment approaches, the emergence of therapy adjuncts and current service delivery models. The impact of adherence on therapy outcomes is highlighted. Despite treatment advancements, patients continue to present with dysphagia which is resistant to existing intervention approaches. There is wide variation in treatment programmes, with a paucity of evidence to support optimal type, timing and intensity of treatment. We discuss the need for further research, including exploration of the impact of radiotherapy on the central nervous system (CNS), the link between sarcopenia and radiotherapy-induced dysphagia and the benefits of visual biofeedback in rehabilitation.

Contribution of Wireless Wi-Fi Intraoral Cameras to the Assessment of Swallowing Safety and Efficiency

BACKGROUND

Clinical evaluation of swallowing provides important clinical information but is limited in detecting penetration, aspiration, and pharyngeal residue in patients with suspected dysphagia. Although this is an old problem, there remains limited access to low-cost methods to evaluate swallowing safety and efficiency.

PURPOSE

The purpose of this technical report is to describe the experience of a single center that recently began using a wireless Wi-Fi intraoral camera for transoral endoscopic procedures as an adjunct to clinical swallowing evaluation. We describe the theoretical structure of this new clinical evaluation proposal. We present descriptive findings on its diagnostic performance in relation to videofluoroscopic swallowing study as the gold standard in a cohort of seven patients with dysphagia following head and neck cancer. We provide quantitative data on intra- and interrater reliability. Furthermore, this report discusses how this technology can be applied in the clinical practice of professionals who treat patients with dysphagia and provides directions for future research.

CONCLUSIONS

This preliminary retrospective study suggests that intraoral cameras can reveal the accumulated oropharyngeal secretions and postswallow pharyngolaryngeal residue in patients with suspected dysphagia. Future large-scale studies focusing on validating and exploring this contemporary low-cost technology as part of a clinical swallowing evaluation are warranted.

Identifying and Overcoming the Barriers to Virtual Electromyography Assessments: A Scoping Review

Introduction: Electromyography (EMG) assessments have been conducted virtually more frequently in recent years, leading researchers to explore the barriers to EMG assessments in a telehealth setting and how to overcome them. Methods: A scoping review was conducted according to the methodology described by Arksey and O'Malley. A comprehensive search using controlled vocabulary and keywords for two concepts, EMG and telehealth, was conducted using Medline and EMBASE on February 7, 2022. Two independent reviewers screened titles, abstracts, and full-text articles. Two reviewers also extracted the data and described the findings in a descriptive analysis. Results: A total of 248 articles were screened during the abstract and title review, of which 64 full texts were screened for eligibility. Of these, 15 publications met the inclusion criteria. Most articles were published in 2018 or later (66.7%). The most frequently mentioned barrier to conducting a virtual EMG assessment was poor data and signal transmission (53.3%). Another frequently mentioned barrier was poor patient usability (33.3%). Solutions most frequently reported related to patient usability (33.3%). These included interactive instructions and video chat to monitor and provide the patient with technical support. Conclusion: The last 4 years have seen an increase in articles published on EMGs' use in telehealth to monitor or diagnose patients. Further research is required to determine if the proposed solutions have improved clinical outcomes for the patient.

Neuromuscular adaptations of swallowing and speech in unilateral cerebral palsy: shared and distinctive traits

Our aims were to 1) examine the neuromuscular control of swallowing and speech in children with unilateral cerebral palsy (UCP) compared with typically developing children (TDC), 2) determine shared and separate neuromuscular underpinnings of the two functions, and 3) explore the relationship between this control and behavioral outcomes in UCP. Surface electromyography (sEMG) was used to record muscle activity from the submental and superior and inferior orbicularis oris muscles during standardized swallowing and speech tasks. The variables examined were normalized mean amplitude, time to peak amplitude, and bilateral synchrony. Swallowing and speech were evaluated using standard clinical measures. Sixteen children with UCP and 16 TDC participated (7-12 yr). Children with UCP demonstrated higher normalized mean amplitude and longer time to peak amplitude across tasks than TDC (P < 0.01; and P < 0.02) and decreased bilateral synchrony than TDC for swallows (P < 0.01). Both shared and distinctive neuromuscular patterns were observed between swallowing and speech. In UCP, higher upper lip amplitude during swallows was associated with shorter normalized mealtime durations, whereas higher submental bilateral synchrony was related to longer mealtime durations. Children with UCP demonstrate neuromuscular adaptations for swallowing and speech, which should be further evaluated for potential treatment targets. Furthermore, both shared and distinctive neuromuscular underpinnings between the two functions are documented.NEW & NOTEWORTHY Systematically studying the swallowing and speech of children with UCP is new and noteworthy. We found that they demonstrate neuromuscular adaptations for swallowing and speech compared with typically developing peers. We examined swallowing and speech using carefully designed tasks, similar in motor complexity, which allowed us to directly compare patterns. We found shared and distinctive neuromuscular patterns between swallowing and speech.

A fully integrated, standalone stretchable device platform with in-sensor adaptive machine learning for rehabilitation

Post-surgical treatments of the human throat often require continuous monitoring of diverse vital and muscle activities. However, wireless, continuous monitoring and analysis of these activities directly from the throat skin have not been developed. Here, we report the design and validation of a fully integrated standalone stretchable device platform that provides wireless measurements and machine learning-based analysis of diverse vibrations and muscle electrical activities from the throat. We demonstrate that the modified composite hydrogel with low contact impedance and reduced adhesion provides high-quality long-term monitoring of local muscle electrical signals. We show that the integrated triaxial broad-band accelerometer also measures large body movements and subtle physiological activities/vibrations. We find that the combined data processed by a 2D-like sequential feature extractor with fully connected neurons facilitates the classification of various motion/speech features at a high accuracy of over 90%, which adapts to the data with noise from motion artifacts or the data from new human subjects. The resulting standalone stretchable device with wireless monitoring and machine learning-based processing capabilities paves the way to design and apply wearable skin-interfaced systems for the remote monitoring and treatment evaluation of various diseases.

Shared and Separate Neuromuscular Underpinnings of Swallowing and Motor Speech Development in the School-Age Years

PURPOSE

Despite co-occurrence of swallowing and speech disorders in childhood, there is limited research on shared and separate neuromuscular underpinnings of these functions. The purpose of this study was to (a) compare neuromuscular control of swallowing and speech between younger and older children and (b) determine similarities and differences in neuromuscular control of swallowing and speech.

METHOD

Twenty-six typically developing children (thirteen 7- to 8-year-olds and thirteen 11- to 12-year-olds) completed this cross-sectional study. Neuromuscular control was evaluated using surface electromyography of submental muscles and superior and inferior orbicularis oris muscles during parallel tasks of swallowing and speech. Outcome measures included normalized mean amplitude, burst duration, time to peak amplitude, and bilateral synchrony, which were examined using mixed-effects models.

RESULTS

For normalized mean amplitude, burst duration, and time to peak amplitude, there were significant two- and three-way interactions between muscle group, task, and age group, indicating that older and younger children demonstrated different muscle activation patterns, and these patterns varied by muscle and task. No differences were noted between groups for bilateral synchrony. For parallel tasks, children demonstrated different magnitudes of normalized mean amplitude and time to peak amplitude of speech and swallowing. However, they demonstrated a similar pattern: increases in magnitude as task complexity increased.

CONCLUSIONS

Children continue to demonstrate refinement of their neuromuscular control of swallowing and speech between 7-8 and 11-12 years of age, and there are both shared and separate elements of neuromuscular control between these two vital functions. To improve generalizability of findings, future research should include longitudinal analysis of swallowing and speech development, as well as measures of central neurophysiology.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.23796258.

ICTs and interventions in telerehabilitation and their effects on stroke recovery

Telerehabilitation (TR) is a new model to provide rehabilitation services to stroke survivors. It is a promising approach to deliver mainstream interventions for movement, cognitive, speech and language, and other disorders. TR has two major components: information and communication technologies (ICTs) and stroke interventions. ICTs provide a platform on which interventions are delivered and subsequently result in stroke recovery. In this mini-review, we went over features of ICTs that facilitate TR, as well as stroke interventions that can be delivered via TR platforms. Then, we reviewed the effects of TR on various stroke disorders. In most studies, TR is a feasible and effective solution in delivering interventions to patients. It is not inferior to usual care and in-clinic therapy with matching dose and intensity. With new technologies, TR may result in better outcomes than usual care for some disorders. One the other hand, TR also have many limitations that could lead to worse outcomes than traditional rehabilitation. In the end, we discussed major concerns and possible solutions related to TR, and also discussed potential directions for TR development.

A Clinician's Guide to Critically Appraising Randomized Controlled Trials in the Field of Speech-Language Pathology

PURPOSE

When considering original research articles, randomized controlled trials (RCTs) provide the highest level of research evidence. Given this, RCTS are often used by clinicians performing evidence-based practice to determine the most effective intervention for a specific patient or patient population. Although RCTs represent a high level of research evidence, it is important for clinicians to critically appraise RCTs to determine the validity of the study methods deployed, the statistical and clinical significance of treatment effects, and whether or not the results generalize to a particular patient, patient population, and/or clinical setting. Therefore, this tutorial will provide clinicians with an overview of what an RCT is, the various types of RCTs, when RCTs are appropriate to conduct and/or use to inform clinical practice, and the advantages and limitations of RCTs. Additionally, this tutorial will provide clinicians with practical tools to employ when reading an RCT, including checklists with questions, definitions of important terminology frequently used in RCTs, and demonstrations of how to critically appraise RCTs using literature examples from the speech-language pathology literature.

CONCLUSIONS

Learning how to interpret and apply the results from RCTs to inform clinical practice for purposes of improving patient care is a critical evidence-based practice skill for clinicians to develop. This tutorial will assist clinicians in the field of speech-language pathology by furthering their fundamental knowledge of RCTs and by providing them with pragmatic tools to critically appraise RCTs to inform their clinical practice.

Head and Neck Virtual Coach: A Randomized Control Trial of Mobile Health as an Adjunct to Swallowing Therapy During Head and Neck Radiation

Dysphagia is a common consequence of head and neck radiation and may be mitigated by performance of swallowing exercises during radiation treatment. Given historically poor adherence to such exercise protocols, we created a mobile health application, HNC Virtual Coach as an adjunct to standard clinical care. This randomized control trial investigated the impact of HNC Virtual Coach on adherence as well as swallowing outcomes by comparing those using the mobile app to those receiving only standard clinical care and paper logs. Both treatment groups were provided with the same exercise protocol as well as the same baseline educational information. Outcome measures included adherence rates, physiologic measures obtained during a Modified Barium Swallow Study (PAS, MBS-ImP, DIGEST), patient-reported outcomes (MDADI), diet levels (FOIS, PSS-HN), and quality of information received (INFO-25). Patients using the HNC Virtual Coach tended to have better adherence to treatment recommendations during radiation therapy. Increased adherence was associated with better patient-reported quality of life, but not physiologic function 2-3 months following completion of radiation. Results suggest that a mobile health application may provide benefit for some patients undergoing head and neck radiation.

A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans

Swallowing impairment is a highly prevalent and clinically significant problem affecting people and dogs. There are myriad causes of swallowing impairment of which gastroesophageal reflux is the most common in both species. Similarities in anatomy and physiology between humans and canines results in analogous swallowing disorders including cricopharyngeus muscle achalasia, esophageal achalasia, hiatal herniation, and gastroesophageal reflux with secondary esophagitis and esophageal dysmotility. Accordingly, the diagnostic approach to human and canine patients with swallowing impairment is similar. Diagnostic procedures such as swallowing fluoroscopy, high-resolution manometry, pH/impedance monitoring, and endolumenal functional luminal imaging probe can be performed in both species; however, nasofacial conformation, increased esophageal length, and the difficulty of completing several of these procedures in awake dogs are inherent challenges that need to be considered. Human patients can convey their symptoms and respond to verbal cues, whereas veterinarians must rely on clinical histories narrated by pet owners followed by comprehensive physical examination and observation of the animal eating different food consistencies and drinking water. Dogs may also be unwilling to drink or eat in the hospital setting and may be resistant to physical restraint during diagnostic procedures. Despite the species differences and diagnostic challenges, dogs are a natural animal model for many oropharyngeal and esophageal disorders affecting people, which presents a tremendous opportunity for shared learnings. This manuscript reviews the comparative aspects of esophageal anatomy and physiology between humans and canines, summarizes the diagnostic assessment of swallowing impairment in both species, and discusses future considerations for collaborative medicine and translational research.

Characterizing Effortful Swallows from Healthy Community Dwelling Adults Across the Lifespan Using High-Resolution Cervical Auscultation Signals and MBSImP Scores: A Preliminary Study

There is growing enthusiasm to develop inexpensive, non-invasive, and portable methods that accurately assess swallowing and provide biofeedback during dysphagia treatment. High-resolution cervical auscultation (HRCA), which uses acoustic and vibratory signals from non-invasive sensors attached to the anterior laryngeal framework during swallowing, is a novel method for quantifying swallowing physiology via advanced signal processing and machine learning techniques. HRCA has demonstrated potential as a dysphagia screening method and diagnostic adjunct to VFSSs by determining swallowing safety, annotating swallow kinematic events, and classifying swallows between healthy participants and patients with a high degree of accuracy. However, its feasibility as a non-invasive biofeedback system has not been explored. This study investigated 1. Whether HRCA can accurately differentiate between non-effortful and effortful swallows; 2. Whether differences exist in Modified Barium Swallow Impairment Profile (MBSImP) scores (#9, #11, #14) between non-effortful and effortful swallows. We hypothesized that HRCA would accurately classify non-effortful and effortful swallows and that differences in MBSImP scores would exist between the types of swallows. We analyzed 247 thin liquid 3 mL command swallows (71 effortful) to minimize variation from 36 healthy adults who underwent standardized VFSSs with concurrent HRCA. Results revealed differences (p < 0.05) in 9 HRCA signal features between non-effortful and effortful swallows. Using HRCA signal features as input, decision trees classified swallows with 76% accuracy, 76% sensitivity, and 77% specificity. There were no differences in MBSImP component scores between non-effortful and effortful swallows. While preliminary in nature, this study demonstrates the feasibility/promise of HRCA as a biofeedback method for dysphagia treatment.