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King SN, Kuntz A, Scott N, Smiley B, Portocarrero Bonifaz A, Blackburn M. Chemoradiation to the submental muscles alters hyoid movement during swallowing in a rat model. J Appl Physiol (1985) 2024; 136:1076-1086. [PMID: 38482576 DOI: 10.1152/japplphysiol.00538.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/09/2024] [Accepted: 03/04/2024] [Indexed: 04/30/2024] Open
Abstract
Hyolaryngeal dysfunction is a commonly reported swallowing problem after chemoradiation treatment for head and neck cancer. The displacement of the hyolaryngeal complex during swallowing protects the airway and assists in opening the upper esophageal sphincter. Activation of the submental muscles, specifically the mylohyoid and geniohyoid muscles, is thought to facilitate movement of the hyoid. The purpose of this study was to determine if targeted radiation to the submental muscles given concurrently with chemotherapy alters hyolaryngeal displacement 1 mo after treatment. We hypothesized that chemoradiation treatment would result in abnormal patterns of hyoid movement compared with controls. Furthermore, we propose that these changes are associated with alterations in bolus size and discoordination of the jaw during drinking. Eighteen rats underwent either chemoradiation, radiation, or no treatment. Radiation treatment was targeted to submental muscles using a clinical linear accelerator given in 12 fractions of 4 Gy (3 days per week). Cycles of 1 mg/kg of cisplatin were administered concurrently each week of radiation. One month posttreatment, videofluoroscopy swallow studies (VFSS) were performed in self-drinking rats using a fluoroscope customized with a high-speed camera. The hyoid, jaw, and hard palate were tracked during swallowing from VFSS. Hyoid kinematics were analyzed from the start to the end of hyoid movement, and parameters were compared with bolus size and jaw movement. Significant differences in hyoid retraction parameters were found postchemoradiation. Alterations in the trajectory of hyoid motion during swallowing were observed. The findings demonstrate early changes in hyoid motion during swallowing associated with chemoradiation treatment.NEW & NOTEWORTHY Chemoradiation treatment for head and neck cancer can cause functional impairments in swallowing, which can adversely affect quality of life. This study provides new evidence that chemoradiation targeted to the submental muscles provokes early adaptations in hyoid movement during swallowing, which correlate with changes in bolus size. We also demonstrate a method for tracking the hyoid during swallowing in a rat model of chemoradiation injury.
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Affiliation(s)
- Suzanne N King
- Department of Otolaryngology - Head and Neck Surgery and Communicative Disorders, School of Medicine, University of Louisville, Louisville, Kentucky, United States
| | - Abigail Kuntz
- Department of Otolaryngology - Head and Neck Surgery and Communicative Disorders, School of Medicine, University of Louisville, Louisville, Kentucky, United States
| | - Nathan Scott
- Department of Otolaryngology - Head and Neck Surgery and Communicative Disorders, School of Medicine, University of Louisville, Louisville, Kentucky, United States
| | - Brittany Smiley
- Department of Otolaryngology - Head and Neck Surgery and Communicative Disorders, School of Medicine, University of Louisville, Louisville, Kentucky, United States
| | - Andres Portocarrero Bonifaz
- Department of Radiation Oncology, School of Medicine, University of Louisville, Louisville, Kentucky, United States
| | - Megan Blackburn
- Department of Radiation Oncology, School of Medicine, University of Louisville, Louisville, Kentucky, United States
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Walters RK, Gudipudi R, Gordis T, Davidson K, Nguyen SA, O'Rourke AK. A Systematic Review of Pharyngeal High-Resolution Manometry Normative Data. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2024; 33:1059-1068. [PMID: 38127890 DOI: 10.1044/2023_ajslp-23-00221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE The utilization of high-resolution pharyngeal manometry (HRPM) in the evaluation of pharyngeal dysphagia has been increasing; however, standardization of its use has lagged behind. Without standardization using normative values, it is difficult for clinicians to adopt this emerging technology into meaningful use. Our goal is to map and compare the published normative values for common HRPM metrics in order to help establish consensus reference values. METHOD A systematic review was conducted on prospective and retrospective studies that included HRPM metrics, defined by an international working group consensus, in healthy adult populations. Data on the following variables were extracted when available: contractile integrals of the pharynx (PhCI), velopharynx, mesopharynx, and hypopharynx, as well as the upper esophageal sphincter (UES) integrated relaxation pressure (IRP), relaxation time (RT), maximum admittance, and hypopharyngeal intrabolus pressure. RESULTS Thirty studies were included. Significant variation existed in the technique and equipment used to perform procedures between the different studies. Lower PhCIs and UES IRPs were seen in younger compared to older individuals. Higher UES RTs were found in individuals in the upright position compared to the supine position and in those using larger boluses sizes or smaller catheters. CONCLUSIONS Due to the wide variety of protocols, catheter configurations, manufacturers, and software used in the existing literature, it is difficult to formulate consensus on HPRM normative values using pooled data. Prospective studies adhering to standardized HRPM protocols for specific catheter configurations and manufacturers with larger cohorts of normal individuals are necessary to establish proper reference values for HRPM metrics. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.24843753.
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Affiliation(s)
- Rameen K Walters
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Rachana Gudipudi
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Tamar Gordis
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Kate Davidson
- Department of Speech-Language Pathology, Medical University of South Carolina, Charleston
| | - Shaun A Nguyen
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head & Neck Surgery, Medical University of South Carolina, Charleston
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Safi MF, Martin S, Gray L, Ludlow CL. Healthy Volunteers Immediately Adapt to Submental Stimulation During Swallowing. Neuromodulation 2022; 25:1141-1149. [PMID: 34590756 PMCID: PMC8964837 DOI: 10.1111/ner.13537] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 08/16/2021] [Accepted: 08/23/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Transcutaneous stimulation above and below the hyoid is used to assist patients with swallowing disorders (dysphagia) but has shown different effects. Previously, infrahyoid transcutaneous stimulation lowered the hyoid and larynx resisting swallowing movement while suprahyoid stimulation had no effects on hyolaryngeal movement either at rest or during swallowing. More recently, large submental electrodes, covering the submental region, are used for swallowing therapy in combination with resistance therapy. To gain insight into the effects of these electrodes on movement during swallowing, we studied healthy volunteers using videofluoroscopy (VF). We hypothesized that submental electrical stimulation might elevate the hyoid but not the larynx increasing vestibular opening potentially reducing swallowing safety. MATERIALS AND METHODS While undergoing VF, seven healthy volunteers (mean age 51, 5 males) swallowed 5 mL of liquid barium on at least ten trials randomly ordered across three conditions: stimulation at rest, swallowing without stimulation, and swallowing with stimulation. RESULTS During stimulation at rest, significant (one tailed p < 0.05) anterior movement occurred in the hyoid and larynx, no superior hyoid and laryngeal movement and an increase in the distance between the hyoid and larynx. When comparing swallowing with and without submental stimulation, during stimulation volunteers significantly reduced anterior hyoid motion (p = 0.028) and increased hyoid elevation (p = 0.043) without changing anterior or superior laryngeal movement or the distance between the hyoid and larynx. CONCLUSIONS The healthy volunteers immediately corrected for the effects of submental stimulation by reducing hyoid anterior motion and increasing superior hyoid motion without changing laryngeal motion to prevent increased vestibule opening with stimulation. This suggests that healthy volunteers had an internal schema for swallowing movement patterning with feedforward correction for the effects of stimulation.
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Affiliation(s)
- Mohammed F Safi
- Laryngeal and Speech Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA.
| | - Sandra Martin
- Laryngeal and Speech Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Lincoln Gray
- Department of Communication Sciences and Disorders, James Madison University, Harrisonburg, VA, USA
| | - Christy L Ludlow
- Laryngeal and Speech Section, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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Nakamura T, Kita Y, Fujimoto J, Ayuzawa K, Ozawa H. Oral support for patients with severe motor and intellectual disabilities. Pediatr Int 2022; 64:e15028. [PMID: 34655262 DOI: 10.1111/ped.15028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 07/15/2021] [Accepted: 09/21/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Oral support during feeding was clinically provided to patients with severe motor and intellectual disabilities (SMID) for the prevention of dysphasia. The present study investigated the advantages of oral support anatomically and functionally. METHODS A videofluoroscopic swallowing study was conducted on nine patients with SMID (age = 5-41 years; mean age = 15.0; four males, five females) and 24 healthy adults (age = 26-67 years; mean age = 44.3; 16 males, eight females). The movements of the hyoid bone and mandible during pharyngeal swallowing were tracked, and the pharyngeal residues were evaluated. The temporal and spatial features of the movements were compared between patients with and without oral support as well as healthy adults. RESULTS The mandible moved downward earlier and showed larger displacement in the patients with SMID. The patients also had insufficient anterior displacement of the hyoid, which was associated with the pharyngeal residue. This displacement was enhanced, and the pharyngeal residue decreased with oral support. CONCLUSIONS Oral support to hold the mandible successfully improved hyoid excursion and reduced pharyngeal residue during swallowing, which is a simple and reliable strategy for the prevention of dysphasia in patients with SMID.
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Affiliation(s)
- Tatsuya Nakamura
- Department of Rehabilitation, Shimada Ryoiku Medical Center Hachioji for Challenged Children, Hachioji, Tokyo, Japan
| | - Yosuke Kita
- Mori Arinori Center for Higher Education and Global Mobility, Hitotsubashi University, Kunitachi, Tokyo, Japan.,Cognitive Brain Research Unit, Department of Psychology and Logopedics, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Junpei Fujimoto
- Department of Rehabilitation, Shimada Ryoiku Medical Center Hachioji for Challenged Children, Hachioji, Tokyo, Japan
| | - Koichi Ayuzawa
- Department of Rehabilitation, Shimada Ryoiku Medical Center Hachioji for Challenged Children, Hachioji, Tokyo, Japan
| | - Hiroshi Ozawa
- Department of Pediatrics, Shimada Ryoiku Medical Center Hachioji for Challenged Children, Hachioji, Tokyo, Japan
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Ogura M, Matsumoto S, Ohama R, Ohama Y, Arima H, Takenaka K, Toyama K, Ikegami T, Shimodozono M. Immediate Effects of Electrical Stimulation on Oropharyngeal Structure and Laryngeal Vestibular Closure: A Pilot Study in Healthy Subjects. Prog Rehabil Med 2022; 7:20220033. [PMID: 35860706 PMCID: PMC9262636 DOI: 10.2490/prm.20220033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 06/07/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Michihiro Ogura
- Department of Rehabilitation, Kagoshima University Hospital, Kagoshima, Japan
| | - Shuji Matsumoto
- Department of Rehabilitation and Physical Medicine, Mito Clinical Education and Training Center, Tsukuba University Hospital, Mito-kyodo Hospital, Mito, Japan
| | - Rintaro Ohama
- Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
| | - Yumi Ohama
- Neurosurgery Center, Ichikikushikino Medical Association, Kagoshima, Japan
| | - Haruka Arima
- Department of Rehabilitation, Kagoshima University Hospital, Kagoshima, Japan
| | - Keita Takenaka
- Department of Rehabilitation, Tarumizu Municipal Medical Center, Tarumizu Chuo Hospital, Kagoshima, Japan
| | - Keiichi Toyama
- Department of Speech Language-Hearing Therapy, Faculty of Allied Health Sciences, Yamato University, Osaka, Japan
| | | | - Megumi Shimodozono
- Department of Rehabilitation and Physical Medicine, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan
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Jones CA, Ciucci MR, Abdelhalim SM, McCulloch TM. Swallowing Pressure Variability as a Function of Pharyngeal Region, Bolus Volume, Age, and Sex. Laryngoscope 2020; 131:E52-E58. [PMID: 32304341 DOI: 10.1002/lary.28667] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 02/14/2020] [Accepted: 03/20/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Within-individual movement variability occurs in most motor domains. However, it is unknown how pharyngeal swallowing pressure varies in healthy individuals. We hypothesized that: 1) variability would differ among pharyngeal regions; 2) variability would decrease with increased bolus volume; 3) variability would increase with age; and 4) there would be no sex differences. STUDY DESIGN Case series. METHODS We used pharyngeal high-resolution manometry to measure swallowing pressure in the following regions: velopharynx, tongue base, hypopharynx, and upper esophageal sphincter. Data were collected from 97 healthy adults (41 male) aged 21 to 89 years during thin liquid swallows: 2 mL, 10 mL, and participant-selected comfortable volume. Pressure variability was measured using coefficient of variation. Repeated measures analysis of variance was used to assess impacts of region, bolus volume, age, and sex on pressure variability. RESULTS There was a significant region × volume interaction (P < .001) and significant main effect of age (P = .005). Pressures in the hypopharynx region were more variable than all other regions (P ≤ .028), and pressures in the tongue base region were less variable than all other regions (P ≤ .002) except at 2 mL volumes (P = .065). Swallowing pressure variability was significantly different in the velopharynx and upper esophageal sphincter regions, with comfortable volume and 2 mL swallows having greater variability than 10 mL swallows (P ≤ .026). Pressure variability significantly increased with increasing age (P = .002). There were no effects of sex on pressure variability (P ≥ .15). CONCLUSION Pharyngeal swallowing pressure variability differs according pharyngeal region, volume, and age but not sex. Abnormal swallowing pressure variability may reflect deviations in motor control in persons with swallowing impairment, and results from this study can be used as normative data for future investigations evaluating swallowing pressure generation. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E52-E58, 2021.
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Affiliation(s)
- Corinne A Jones
- Department of Neurology, The University of Texas at Austin, Austin, Texas, U.S.A.,Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A.,Department of Communication Sciences & Disorders, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A.,Neuroscience Training Program, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Michelle R Ciucci
- Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A.,Department of Communication Sciences & Disorders, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A.,Neuroscience Training Program, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Suzan M Abdelhalim
- Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
| | - Timothy M McCulloch
- Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin, U.S.A
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Impaired Movement Scaling and Reduced Synchrony with Vestibule Closure Characterize Swallowing in Severe Dysphagia. Dysphagia 2019; 35:643-656. [PMID: 31630250 DOI: 10.1007/s00455-019-10067-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/27/2019] [Indexed: 10/25/2022]
Abstract
The contribution of hyoid and laryngeal movement deficits to penetration or aspiration in dysphagia is unclear, partly due to large variations in normal hyolaryngeal kinematics for swallowing. In healthy volunteers, laryngeal and hyoid kinematics relate to the requirements for laryngeal vestibule closure suggesting a central schematic control of movement magnitude and patterning for airway protection. Our first aim was to determine if patients with severe dysphagia showed evidence of an impaired swallowing schema, by examining if their kinematic measures were related to their hyolaryngeal space before swallow onset, and if hyolaryngeal movement synchrony for vestibule closure was disrupted. Our second aim was to determine the kinematic measures that predicted bolus penetration and aspiration in dysphagia. The methods included two-dimensional measures of the hyoid and laryngeal anterior and superior displacement and velocity, and the change in laryngeal vestibule area made from videofluoroscopic swallow recordings of 21 healthy volunteers and 21 patients with dysphagia on tube feeding secondary to the stroke or head and neck cancer. The results demonstrated that the patients did not adapt their hyolaryngeal movements during swallowing to their initial hyolaryngeal space. Further, none of the patients' measures of hyoid or laryngeal peak velocity timing were synchronized with vestibule closure, demonstrating a disorganized movement patterning. Laryngeal elevation peak velocity independently predicted penetration and aspiration. In conclusion, the central schema for swallowing patterning was disturbed, impairing the integration of kinematic actions for airway protection in severe dysphagia, while laryngeal peak elevation velocity predicted penetration and aspiration on patient swallows.
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A review of the approaches to predict the ease of swallowing and post-swallow residues. Trends Food Sci Technol 2019. [DOI: 10.1016/j.tifs.2019.02.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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DeLozier KR, Gould FDH, Ohlemacher J, Thexton AJ, German RZ. Impact of recurrent laryngeal nerve lesion on oropharyngeal muscle activity and sensorimotor integration in an infant pig model. J Appl Physiol (1985) 2018; 125:159-166. [PMID: 29648522 DOI: 10.1152/japplphysiol.00963.2017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
The successful performance of a swallow requires dynamic integration between a wide range of sensory inputs and muscle activities to produce the coordinated kinematics of oropharyngeal structures. Damage to the recurrent laryngeal nerve (RLN) produces dysphagia in infants, with food or liquid entering the airway despite this nerve having minimal direct sensory or motor connections to the act of swallowing, apart from vocal fold closure. Previous results have demonstrated that a complete RLN lesion disrupts both performance and kinematics before initiation of the pharyngeal swallow in infants. We tested the hypothesis that a RLN lesion produces changes in the normal activity of oral floor, tongue, and infrahyoid muscles during a swallow. We recorded swallowing in our validated infant pig model, with synchronous high-speed imaging and fine-wire, chronic electromyography. We found changes in the timing, duration, and amplitude of the motor pattern in an array of muscles that are supplied by several different cranial and cervical nerves. Some of these changes in muscle activity are associated with the preparatory aspects of bolus aggregation or movement and so occur before the pharyngeal swallow. Taken with previous biomechanical results, these patterns suggest an intricate brain stem sensorimotor integration that occurs as part of a swallow. In particular, the execution of oral motor function is changed as a result of this simple lesion. NEW & NOTEWORTHY Damage to the recurrent laryngeal nerve compromises swallowing despite an absent or minimal contribution to either the motor or sensory aspects of this function. This study documents EMG changes, following RLN lesion, to non-RLN innervated muscles that are active during swallowing in an infant model. Some of these muscles fire before the pharyngeal swallow and are associated with the preparatory aspects of bolus aggregation and movement, suggesting important sensorimotor integration at a brain stem level.
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Affiliation(s)
- Katherine R DeLozier
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
| | - Francois D H Gould
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
| | - Jocelyn Ohlemacher
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
| | - Allan J Thexton
- Department of Physiology, King's College , London , United Kingdom
| | - Rebecca Z German
- Department of Anatomy and Neurobiology, Northeast Ohio Medical University, Rootstown, Ohio
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Guedes R, Azola A, Macrae P, Sunday K, Mejia V, Vose A, Humbert IA. Examination of swallowing maneuver training and transfer of practiced behaviors to laryngeal vestibule kinematics in functional swallowing of healthy adults. Physiol Behav 2017; 174:155-161. [PMID: 28322908 DOI: 10.1016/j.physbeh.2017.03.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/14/2017] [Accepted: 03/14/2017] [Indexed: 02/06/2023]
Abstract
Swallowing maneuvers are routinely trained in dysphagia rehabilitation with the assumption that practiced behaviors transfer to functional swallowing, however transfer is rarely examined in the deglutition literature. The goal of this study was to train the volitional laryngeal vestibule closure (vLVC) maneuver, which is a swallowing maneuver that targets prolonged laryngeal vestibule closure (LVC). In two different training experiments, 69 healthy adults underwent Long-hold (hold vLVC as long as possible) or Short-hold vLVC training (hold vLVC for 2s). Before and after vLVC training, natural swallows (swallowing without a therapeutic technique) were completed. The outcome variables included laryngeal vestibule closure reaction time and the duration of laryngeal vestibule closure. Results indicate that during both Long-hold and Short-hold vLVC trainings, vLVC swallows had faster laryngeal vestibule closure reaction times and longer durations of laryngeal vestibule closure than in pre-training 5ml liquid swallows. However, only faster laryngeal vestibule closure reaction times transferred to post-training 5ml liquid swallows (20-24% faster), but not prolonged durations of laryngeal vestibule closure. Our findings suggest that swallowing maneuver training has the potential to induce transfer of what was practiced to functional swallowing behavior, although not all practiced behaviors may generalize. These findings are significant for bolstering the effectiveness of dysphagia management in medical settings and should be tested in individuals with dysphagia.
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Affiliation(s)
- Renata Guedes
- Swallowing Systems Core, Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States; AC Camargo Cancer Center, Brazil
| | - Alba Azola
- Department of Physical Medicine and Rehabilitation, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Phoebe Macrae
- Department of Communication Disorders, University of Canterbury, Christchurch, New Zealand
| | - Kirstyn Sunday
- Swallowing Systems Core, Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States
| | - Veerley Mejia
- Swallowing Systems Core, Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States
| | - Alicia Vose
- Swallowing Systems Core, Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States
| | - Ianessa A Humbert
- Swallowing Systems Core, Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States.
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