H Siebens, E Trupe, A Siebens, F Cook, S Anshen, R Hanauer, G Oster
Correlates and consequences of eating dependency in institutionalized elderly.
J Am Geriatr Soc. 1986 Mar;34(3):192-8.
Abstract/Text
Loss of independent eating capacity is a major problem for the institutionalized elderly. Few studies have examined the factors associated with loss of functional eating capacity. The authors cross-sectionally studied 240 residents of a skilled nursing facility, classified their functional eating status, identified correlated deficits, and followed these residents for six months. Information was gathered through questionnaires, chart review, and physical examinations. Residents were stratified into independent (68%, N = 164) and dependent (32%, N = 76) eating status groups according to the need for physical assistance during meals. Dependency status did not correlate with age (P = .88) or weight loss (P = .27). Loss of independence in eating was associated with impaired mobility (P = .0001), impaired cognition (P = .0001), modified consistency diets (P = .0001), upper extremity dysfunction (P = .0001), abnormal oral-motor examinations (P = .0002), absence of teeth and dentures (P = .002), behavioral indicators of abnormal oral and pharyngeal stages of swallowing (P = .0001), and increased mortality within six months (P = .0001). Eating dependency is therefore associated with multiple impairments and early mortality.
D G Smithard, P A O'Neill, R E England, C L Park, R Wyatt, D F Martin, J Morris
The natural history of dysphagia following a stroke.
Dysphagia. 1997 Fall;12(4):188-93.
Abstract/Text
To assess the frequency and natural history of swallowing problems following an acute stroke, 121 consecutive patients admitted within 24 hours of the onset of their stroke were studied prospectively. The ability to swallow was assessed repeatedly by a physician, a speech and language therapist, and by videofluoroscopy. Clinically 51% (61/121) of patients were assessed as being at risk of aspiration on admission. Many swallowing problems resolved over the first 7 days, through 28/110 (27%) were still considered at risk by the physician. Over a 6-month period, most problems had resolved, but some patients had persistent difficulties (6, 8%), and a few (2, 3% at 6 months) had developed swallowing problems. Ninety-five patients underwent videofluoroscopic examination within a median time of 2 days; 21 (22%) were aspirating. At 1 month a repeat examination showed that 12 (15%) were aspirating. Only 4 of these were persistent; the remaining 8 had not been previously identified. This study has confirmed that swallowing problems following acute stroke are common, and it has been documented that the dysphagia may persist, recur in some patients, or develop in others later in the history of their stroke.
J M Chalmers, P L King, A J Spencer, F A C Wright, K D Carter
The oral health assessment tool--validity and reliability.
Aust Dent J. 2005 Sep;50(3):191-9. doi: 10.1111/j.1834-7819.2005.tb00360.x.
Abstract/Text
BACKGROUND: The Oral Health Assessment Tool (OHAT) was a component of the Best Practice Oral Health Model for Australian Residential Care study. The OHAT provided institutional carers with a simple, eight category screening tool to assess residents' oral health, including those with dementia. This analysis presents OHAT reliability and validity results.
METHODS: A convenience sample of 21 residential care facilities (RCFs) in urban and rural Victoria, NSW and South Australia used the OHAT at baseline, three-months and six-months to assess intra- and inter-carer reliability and concurrent validity.
RESULTS: Four hundred and fifty five residents completed all study phases. Intra-carer reliability for OHAT categories: percent agreement ranged from 74.4 per cent for oral cleanliness, to 93.9 per cent for dental pain; Kappa statistics were in moderate range (0.51-0.60) for lips, saliva, oral cleanliness, and for all other categories in range of 0.61-0.80 (substantial agreement) (p < 0.05). Inter-carer reliability for OHAT categories: percent agreement ranged from 72.6 per cent for oral cleanliness to 92.6 per cent for dental pain; Kappa statistics were in moderate range (0.48-0.60) for lips, tongue, gums, saliva, oral cleanliness, and for all other categories in range of 0.61-0.80 (substantial agreement) (p < 0.05). Intraclass correlation coefficients for OHAT total scores were 0.78 for intra-carer and 0.74 for inter-carer reliability. Validity analyses of the OHAT categories and examination findings showed complete agreement for the lips category, with the natural teeth, dentures, and tongue categories having high significant correlations and percent agreements. The gums category had significant moderate correlation and percent agreement. Non-significant and low correlations and percent agreements were evident for the saliva, oral cleanliness and dental pain categories.
CONCLUSION: The Oral Health Assessment Tool was evaluated as being a reliable and valid screening assessment tool for use in residential care facilities, including those with cognitively impaired residents.
松尾浩一郎，中川量晴：口腔アセスメントシート Oral Health Assessment Tool 日本語版（OHAT-J）の作成と信頼性，妥当性の検討，障害者歯科，37：1–7，2016.
小口和代、才藤栄一、馬場 尊、他：機能的嚥下障害スクリーニングテスト「反復唾液嚥下テスト」（the Repetitive Saliva Swallowing Test: RSST）の検討（2）妥当性の検討. リハ医. 37：383–388，2000.
戸原玄、才藤栄一、馬場尊、他: Videofluorographyを用いない摂食・嚥下障害評価フローチャート、日摂食嚥下リハ会誌 6（2）：82－92，2002.
高橋浩二：頸部聴診法. J Clin Rehabil, 27：667–676，2018.
高橋浩二：頸部聴診でわかること. MB Med Reha, No.212：121–129，2017.
Marloes L J Lagarde, Digna M A Kamalski, Lenie van den Engel-Hoek
The reliability and validity of cervical auscultation in the diagnosis of dysphagia: a systematic review.
Clin Rehabil. 2016 Feb;30(2):199-207. doi: 10.1177/0269215515576779. Epub 2015 Mar 19.
Abstract/Text
OBJECTIVE: To systematically review the available evidence for the reliability and validity of cervical auscultation in diagnosing the several aspects of dysphagia in adults and children suffering from dysphagia.
DATA SOURCES: Medline (PubMed), Embase and the Cochrane Library databases.
REVIEW METHODS: The systematic review was carried out applying the steps of the PRISMA-statement. The methodological quality of the included studies were evaluated using the Dutch 'Cochrane checklist for diagnostic accuracy studies'.
RESULTS: A total of 90 articles were identified through the search strategy, and after applying the inclusion and exclusion criteria, six articles were included in this review. In the six studies, 197 patients were assessed with cervical auscultation. Two of the six articles were considered to be of 'good' quality and three studies were of 'moderate' quality. One article was excluded because of a 'poor' methodological quality. Sensitivity ranges from 23%-94% and specificity ranges from 50%-74%. Inter-rater reliability was 'poor' or 'fair' in all studies. The intra-rater reliability shows a wide variance among speech language therapists.
CONCLUSION: In this systematic review, conflicting evidence is found for the validity of cervical auscultation. The reliability of cervical auscultation is insufficient when used as a stand-alone tool in the diagnosis of dysphagia in adults. There is no available evidence for the validity and reliability of cervical auscultation in children. Cervical auscultation should not be used as a stand-alone instrument to diagnose dysphagia.
© The Author(s) 2015.
Yoko Wakasugi, Haruka Tohara, Fumiko Hattori, Yasutomo Motohashi, Ayako Nakane, Shino Goto, Yukari Ouchi, Shinya Mikushi, Syuhei Takeuchi, Hiroshi Uematsu
Screening test for silent aspiration at the bedside.
Dysphagia. 2008 Dec;23(4):364-70. doi: 10.1007/s00455-008-9150-7. Epub 2008 Jul 2.
Abstract/Text
Many screening tests for dysphagia can be given at bedside. However, they cannot accurately screen for silent aspiration (SA). We studied the usefulness of a cough test to screen for SA and combined it with the modified water swallowing test (MWST) to make an accurate screening system. Patients suspected of dysphagia (N = 204) were administered a cough test and underwent videofluorography (VF) or videoendoscopy (VE). Sensitivity of the cough test for detection of SA was 0.87 with specificity of 0.89. Of these 204 patients, 107 were also administered the MWST. Fifty-five were evaluated as normal by the screening system, 49 of whom were evaluated as normal by VF or VE. Sixteen were evaluated as "SA suspected" by the screening system; seven of them were normal, and seven were evaluated as having SA by VF or VE. Nineteen were evaluated as aspirating with cough, 14 of whom had aspiration with cough as shown by VF or VE. Seventeen were evaluated as having SA, 15 of whom had SA shown by VF or VE. The cough test was useful in screening for SA. Moreover, a screening system that included MWST and a cough test could accurately distinguish between the healthy who were safe in swallowing and SA patients who were unsafe.
Mitsuyasu Sato, Haruka Tohara, Takatoshi Iida, Satoko Wada, Motoharu Inoue, Koichiro Ueda
Simplified cough test for screening silent aspiration.
Arch Phys Med Rehabil. 2012 Nov;93(11):1982-6. doi: 10.1016/j.apmr.2012.05.016. Epub 2012 Jun 4.
Abstract/Text
OBJECTIVE: To simplify the cough test to screen silent aspiration without sacrificing accuracy.
DESIGN: Criterion standard.
SETTING: University dental hospital.
PARTICIPANTS: Consecutive patients (N=141; 92 men, 49 women; mean age 71±14y, range 23-94y) who had complained of some dysphagic symptoms between June 2008 and February 2010.
INTERVENTIONS: All patients were administrated a simplified cough test and underwent the fiberoptic endoscopic evaluation of swallowing. Citric acid inhalation was terminated when the first cough occurred, and the time between the start of inhalation and the first cough was measured.
MAIN OUTCOME MEASURES: The time when the first cough was observed by the simplified cough test was compared with the results of the fiberoptic endoscopic evaluation of swallowing, which was used as a criterion standard.
RESULTS: Receiver operating characteristic curve analysis was performed for 53 patients evaluated as having aspiration by fiberoptic endoscopic evaluation of swallowing. We found that 30 seconds or less was an appropriate cutoff value for detecting patients without silent aspiration, where the sensitivity was .92 and the specificity was .94. From the receiver operating characteristic curve analyses for all patients, 60 seconds or less was determined to be an appropriate cutoff, and the sensitivity and specificity were .81 and .65, respectively.
CONCLUSION: The simplified cough test is a useful screening tool for silent aspiration in patients with aspiration.
Copyright © 2012 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Peter C Belafsky, Debbie A Mouadeb, Catherine J Rees, Jan C Pryor, Gregory N Postma, Jacqueline Allen, Rebecca J Leonard
Validity and reliability of the Eating Assessment Tool (EAT-10).
Ann Otol Rhinol Laryngol. 2008 Dec;117(12):919-24. doi: 10.1177/000348940811701210.
Abstract/Text
OBJECTIVES: The Eating Assessment Tool is a self-administered, symptom-specific outcome instrument for dysphagia. The purpose of this study was to assess the validity and reliability of the 10-item Eating Assessment Tool (EAT-10).
METHODS: The investigation consisted of 4 phases: 1) line-item generation, 2) line-item reduction and reliability, 3) normative data generation, and 4) validity analysis. All data were collected prospectively. Internal consistency was assessed with the Cronbach alpha. Test-retest reliability was evaluated with the Pearson product moment correlation coefficient. Normative data were obtained by administering the instrument to a community cohort of healthy volunteers. Validity was assessed by administering the instrument before and after dysphagia treatment and by evaluating survey differences between normal persons and those with known diagnoses.
RESULTS: A total of 629 surveys were administered to 482 patients. The internal consistency (Cronbach alpha) of the final instrument was 0.960. The test-retest intra-item correlation coefficients ranged from 0.72 to 0.91. The mean (+/- SD) EAT-10 score of the normal cohort was 0.40 +/- 1.01. The mean EAT-10 score was 23.58 +/- 13.18 for patients with esophageal dysphagia, 23.10 +/- 12.22 for those with oropharyngeal dysphagia, 9.19 +/- 12.60 for those with voice disorders, 22.42 +/- 14.06 for those with head and neck cancer, and 11.71 +/- 9.61 for those with reflux. The patients with oropharyngeal and esophageal dysphagia and a history of head and neck cancer had a significantly higher EAT-10 score than did those with reflux or voice disorders (p <0.001). The mean EAT-10 score of the patients with dysphagia improved from 19.87 +/- 10.5 to 5.2 +/- 7.4 after treatment (p <0.001).
CONCLUSIONS: The EAT-10 has displayed excellent internal consistency, test-retest reproducibility, and criterion-based validity. The normative data suggest that an EAT-10 score of 3 or higher is abnormal. The instrument may be utilized to document the initial dysphagia severity and monitor the treatment response in persons with a wide array of swallowing disorders.
若林 秀隆、栢下 淳：摂食嚥下障害スクリーニング質問紙票eat-10の日本語版作成と信頼性・妥当性の検証. 静脈経腸栄養. 2014;29(3):871-876.
渡邉 光子、沖田 啓子、佐藤 新介、瀧本 泰生、岡本 隆嗣、栢下 淳：嚥下スクリーニング質問紙eat-10暫定版の有用性の検討. 日摂食嚥下リハ会誌. 2014;18(1):30-36.
L Rofes, V Arreola, R Mukherjee, P Clavé
Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia.
Neurogastroenterol Motil. 2014 Sep;26(9):1256-65. doi: 10.1111/nmo.12382. Epub 2014 Jun 9.
Abstract/Text
BACKGROUND: Oropharyngeal dysphagia (OD) is an underdiagnosed digestive disorder that causes severe nutritional and respiratory complications. Our aim was to determine the accuracy of the Eating Assessment Tool (EAT-10) and the Volume-Viscosity Swallow Test (V-VST) for clinical evaluation of OD.
METHODS: We studied 120 patients with swallowing difficulties and 14 healthy subjects. OD was evaluated by the 10-item screening questionnaire EAT-10 and the bedside method V-VST, videofluoroscopy (VFS) being the reference standard. The V-VST is an effort test that uses boluses of different volumes and viscosities to identify clinical signs of impaired efficacy (impaired labial seal, piecemeal deglutition, and residue) and impaired safety of swallow (cough, voice changes, and oxygen desaturation ≥3%). Discriminating ability was assessed by the AUC of the ROC curve and sensitivity and specificity values.
KEY RESULTS: According to VFS, prevalence of OD was 87%, 75.6% with impaired efficacy and 80.9% with impaired safety of swallow including 17.6% aspirations. The EAT-10 showed a ROC AUC of 0.89 for OD with an optimal cut-off at 2 (0.89 sensitivity and 0.82 specificity). The V-VST showed 0.94 sensitivity and 0.88 specificity for OD, 0.79 sensitivity and 0.75 specificity for impaired efficacy, 0.87 sensitivity and 0.81 specificity for impaired safety, and 0.91 sensitivity and 0.28 specificity for aspirations.
CONCLUSIONS & INFERENCES: Clinical methods for screening (EAT-10) and assessment (V-VST) of OD offer excellent psychometric proprieties that allow adequate management of OD. Their universal application among at-risk populations will improve the identification of patients with OD at risk for malnutrition and aspiration pneumonia.
© 2014 The Authors. Neurogastroenterology & Motility published by John Wiley & Sons Ltd.
大熊 るり, 藤島 一郎, 小島 千枝子, 北條 京子, 武原 格, 本橋 豊：摂食・嚥下障害スクリーニングのための質問紙の開発. 日摂食嚥下リハ会誌. 2002;6(1):3-8.
中野雅徳 ，藤島一郎，大熊るり，吉岡昌美 他：スコア化による聖隷式嚥下質問紙評価法の検討．日摂食嚥下リハ会誌 2020:24（3）：240–246.
Margareta Bülow
Videofluoroscopic swallow study: techniques, signs and reports.
Nestle Nutr Inst Workshop Ser. 2012;72:43-52. doi: 10.1159/000339980. Epub 2012 Sep 24.
Abstract/Text
Management of oropharyngeal swallowing dysfunction often requires both a clinical and an instrumental examination. A videofluoroscopic swallowing study is an instrumental examination that often could be a good option and a very useful tool for the swallowing clinician. At Skåne University Hospital, Malmö, Sweden, the name of such examination is therapeutic videoradiographic swallowing study (TVSS). A TVSS examination should always be performed in collaboration between a speech language pathologist and a radiologist. During the examination, the patient is seated in an upright position, but the examination can also be performed with the patient lying down. The TVSS examination can be performed both in frontal and lateral projection. Test material with varied consistencies as well as different therapeutic strategies can be tested during the examination. Any oral and/or pharyngeal dysfunction can be defined, for example a delay in the initiation of the pharyngeal swallow or an absent pharyngeal swallow, pharyngeal retention, penetration, and silent aspiration. After the examination, an analysis is performed, and it is studied how different textures affect the physiology of swallowing. A report is then written in which the actual dysfunction is described in detail, and recommendations regarding modified textures and swallowing techniques are given.
Copyright © 2012 S. Karger AG, Basel.
日本摂食・嚥下リハビリテーション学会医療検討委員会：嚥下造影の検査法（詳細版） 日本摂食・嚥下リハビリテーション学会医療検討委員会2011 版案．日摂食嚥下リハ会誌 2011；15（1）：76–95.
日本摂食・嚥下リハビリテーション学会医療検討委員会：嚥下内視鏡検査の手順2012 改訂（修正版）．日摂食嚥下リハ会誌 2013；17（1）：87-91.
N A Leopold, M C Kagel
Prepharyngeal dysphagia in Parkinson's disease.
Dysphagia. 1996 Winter;11(1):14-22.
Abstract/Text
Dysphagia in patients with Parkinson's disease (PD) is most often attributed to pharyngeoesophageal motor abnormalities. In our study of patients with idiopathic PD, attention was focused on prepharyngeal symptoms and motor functions. Using the Hoehn and Yahr disease severity scale, patients were grouped into those with mild/moderate disease [subgroup I (n = 38)] and those with advanced disease [subgroup II (n = 34)]. Dysphagia symptoms were present in 82% of all patients, but subgroup I patients voiced significantly more complaints. Conversely, many prepharyngeal abnormalities of ingestion, including jaw rigidity, impaired head and neck posture during meals, upper extremity dysmotility, impulsive feeding behavior, impaired amount regulation, and lingual transfer movements were statistically more frequent in subgroup II patients. Impaired mastication and oral preparatory lingual movements were the most common aberrations observed during dynamic videofluoroscopy (48/71), with most patients being concordant for both. The motor disturbances of ingestion reported herein reflect the disintegration of volitional and automatic movements caused by PD-related akinesia, bradykinesia, and rigidity.
L Hartelius, P Svensson
Speech and swallowing symptoms associated with Parkinson's disease and multiple sclerosis: a survey.
Folia Phoniatr Logop. 1994;46(1):9-17.
Abstract/Text
A survey of approximately 460 patients with Parkinson's disease (PD) or multiple sclerosis (MS) shows that speech and swallowing difficulties are very frequent within these groups. Seventy percent of the PD patients and 44% of the MS patients had experienced impairment of speech and voice after the onset of their disease. Forty-one percent of the PD patients and 33% of the MS patients indicated impairment of chewing and swallowing abilities. The speech disorder was regarded as one of their greatest problems by 29% of the PD patients and by 16% of the MS patients. Only a small number of patients, 3% of the PD and 2% of the MS group, had received any speech therapy.
S R Fulp, D O Castell
Scleroderma esophagus.
Dysphagia. 1990;5(4):204-10.
Abstract/Text
Scleroderma (systemic sclerosis) is a connective tissue disorder characterized by thickening and fibrosis of the skin and visceral involvement that may include the heart, lungs, kidneys, and gastrointestinal tract. At least 40-50% of patients with scleroderma experience esophageal symptoms such as heartburn and dysphagia, while up to 90% of patients have esophageal dysfunction on objective testing at some point in their disease. The disease results in smooth muscle dysfunction that causes esophageal aperistalsis and reduced lower esophageal sphincter pressures. Gastroesophageal reflux with poor acid clearance results with an increased incidence of complications such as peptic stricture and Barrett's esophagus. Aggressive medical therapy is necessary to prevent these and other complications of gastroesophageal reflux.
A D Hillel, R Miller
Bulbar amyotrophic lateral sclerosis: patterns of progression and clinical management.
Head Neck. 1989 Jan-Feb;11(1):51-9.
Abstract/Text
Patients with bulbar amyotrophic lateral sclerosis (ALS) are often referred to the otolaryngologist/head and neck surgeon and speech pathologist for evaluation and management of dysphagia and dysarthria. These patients comprise an unusual group because of the progressive and multi-system nature of their illness. The neuromuscular disabilities associated with bulbar ALS cause a myriad of related symptoms associated with swallowing, speech, and respiration. Although the rate of progression cannot be predicted, a general pattern of progression is noted. Bulbar disease accounts for the majority of the worst symptoms of ALS. The loss of the ability to swallow changes eating from a pleasurable task to a burden of survival. Loss of communication effectively imprisons the patient in a state of isolation. The progressive weakness of respiration, predominantly a spinal rather than bulbar manifestation, is the cause of death for nearly all ALS patients and is also discussed. The general patterns of progression of bulbar ALS are outlined in this paper. The development of symptoms are correlated with specific treatment recommendations to aid the clinician in devising an orderly plan of management for this progressive disease.
T K Shanahan, J A Logemann, A W Rademaker, B R Pauloski, P J Kahrilas
Chin-down posture effect on aspiration in dysphagic patients.
Arch Phys Med Rehabil. 1993 Jul;74(7):736-9.
Abstract/Text
Use of the chin-down posture during swallowing has been reported to reduce the occurrence of aspiration in some dysphagic patients. This study measured four pharyngeal dimensions in 30 neurologically impaired patients who aspirated before the swallow because of a delay in triggering the pharyngeal swallow, 15 for whom the posture eliminated aspiration and 15 who aspirated despite the chin-down position. Patients who did not benefit from the posture were significantly younger and aspirated material from the pyriform sinus rather than the valleculae when the pharyngeal swallow was triggered. Changes in pharyngeal dimensions with the chin down were not significantly different for both patient groups, except for epiglottic angle, which increased significantly more in the group who continued to aspirate. Changes in pharyngeal dimensions with chin-neutral versus chin-down differed somewhat from those reported in a previous publication. Possible reasons for these differences are discussed.
J S Lewin, T M Hebert, J B Putnam, R A DuBrow
Experience with the chin tuck maneuver in postesophagectomy aspirators.
Dysphagia. 2001 Summer;16(3):216-9.
Abstract/Text
Aspiration is a common finding in the postesophagectomy barium swallow that often necessitates premature termination of the study prior to complete evaluation of the gastric conduit. More importantly, aspiration may play a significant role in the high incidence of postoperative pulmonary complications in this population. The chin tuck maneuver is a postural technique that reduces and often eliminates aspiration in swallowing-impaired patients. To evaluate the ability of the chin tuck maneuver to prevent aspiration during radiographic examination of the gastric conduit, the technique was used in 21 esophagectomy patients who aspirated during a swallowing evaluation combining the barium swallow and videofluoroscopy. Aspiration was eliminated in 81% of aspirators using the chin tuck maneuver. The results of this study demonstrate that the chin tuck maneuver is a simple technique that should be attempted in patients who aspirate postesophagectomy during radiographic imaging studies that require multiple swallows of contrast materials. Combining the barium swallow with the videofluoroscopic evaluation of swallowing provides objective documentation of both the structural integrity of the gastric conduit and swallowing function in patients after esophagectomies who are at high risk for postoperative morbidity.
J A Logemann, P J Kahrilas, M Kobara, N B Vakil
The benefit of head rotation on pharyngoesophageal dysphagia.
Arch Phys Med Rehabil. 1989 Oct;70(10):767-71.
Abstract/Text
This study examined the effect of head rotation on the mechanics of swallowing in healthy subjects, as well as the effects of this postural change on the oropharyngeal swallow of five patients with lateral medullary syndrome (LMS). Videofluoroscopic studies of swallowing in the normal subjects revealed that head rotation to either side increased upper esophageal sphincter (UES) opening diameter by an average of 2mm without affecting the period of UES opening or the oropharyngeal transit time. Maximal rotation of the head to the right or left caused the bolus to lateralize away from the direction of rotation, and also caused a significant (18mmHg or 35%) fall in UES pressure. In the face forward position, the LMS patients exhibited barium residue in the pharynx and pyriform sinuses, as well as diminished UES opening diameter. The fraction of the bolus swallowed and the UES opening diameter increased significantly with the head turned toward the paretic side in the LMS patients. We conclude that head rotation can improve swallowing in patients with unilateral oropharyngeal dysphagia. Two potentially beneficial effects were observed: (1) functional exclusion of the relatively flaccid, weakened pharyngeal wall, and (2) reduced UES tone. Which of these mechanisms is operative probably depends on the dominant mechanisms of dysphagia. In individuals with substantial impairment of UES opening, head turning reduces the resistance of the sphincter that must be overcome by pharyngeal contraction. In individuals with a flaccid hemipharynx, which dissipates pharyngeal pressure, head rotation excludes these structures from the bolus path and allows pharyngeal pressure to be directed at the UES.
K V Kuhlemeier, J B Palmer, D Rosenberg
Effect of liquid bolus consistency and delivery method on aspiration and pharyngeal retention in dysphagia patients.
Dysphagia. 2001 Spring;16(2):119-22.
Abstract/Text
There is no empirically derived consensus as to what food consistency types and method of food delivery (spoon, cup, straw) should be included in the videofluoroscopic swallowing (VFSS) studies. In the present study, we examine the rates of aspiration and pharyngeal retention in 190 dysphagic patients given thin (apple juice) and thick (apricot nectar) liquids delivered by teaspoon and cup and ultrathick (pudding-like) liquid delivered by teaspoon. Each patient was tested with each of the bolus/delivery method combinations. The fractions of patients exhibiting aspiration for each bolus/method of delivery combination were (1) thick liquids (cup), 13.2%; (2) thick liquids (spoon), 8.9%; (3) thin liquids (cup), 23.7%; (4) thin liquids (spoon), 15.8%, (5) ultrathick liquids (spoon), 5.8%. In each comparison [thick liquid (cup) vs. thick liquid (spoon), thin liquid (cup) vs. thin liquid (spoon), thick liquid (cup) vs. thin liquid (cup), thick liquid (spoon) vs. thin liquid (spoon), and thick liquid (spoon) vs. ultrathick liquid (spoon)], the p value for chi 2 was < 0.001. These results suggest that utilizing thin, thick, and ultrathick liquids and delivery by cup and spoon during a VFSS of a patient with mild or moderate dysphagia can increase the chances of identifying a consistency that the patient can swallow without aspirating and without pharyngeal retention after swallowing.
Jeri A Logemann, Gary Gensler, Joanne Robbins, Anne S Lindblad, Diane Brandt, Jacqueline A Hind, Steven Kosek, Karen Dikeman, Marta Kazandjian, Gary D Gramigna, Donna Lundy, Susan McGarvey-Toler, Patricia J Miller Gardner
A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson's disease.
J Speech Lang Hear Res. 2008 Feb;51(1):173-83. doi: 10.1044/1092-4388(2008/013).
Abstract/Text
PURPOSE: This study was designed to identify which of 3 treatments for aspiration on thin liquids-chin-down posture, nectar-thickened liquids, or honey-thickened liquids-results in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study in patients with dementia and/or Parkinson's disease.
METHOD: This randomized clinical trial included 711 patients ages 50 to 95 years who aspirated on thin liquids as assessed videofluorographically. All patients received all 3 interventions in a randomly assigned order during the videofluorographic swallow study.
RESULTS: Immediate elimination of aspiration on thin liquids occurred most often with honey-thickened liquids for patients in each diagnostic category, followed by nectar-thickened liquids and chin-down posture. Patients with most severe dementia exhibited least effectiveness on all interventions. Patient preference was best for chin-down posture followed closely by nectar-thickened liquids.
CONCLUSION: To identify best short-term intervention to prevent aspiration of thin liquid in patients with dementia and/or Parkinson's disease, a videofluorographic swallow assessment is needed. Evidence-based practice requires taking patient preference into account when designing a dysphagic patient's management plan. The longer-term impact of short-term prevention of aspiration requires further study.
J A Logemann, B R Pauloski, L Colangelo, C Lazarus, M Fujiu, P J Kahrilas
Effects of a sour bolus on oropharyngeal swallowing measures in patients with neurogenic dysphagia.
J Speech Hear Res. 1995 Jun;38(3):556-63.
Abstract/Text
This study examines the effects of a sour bolus (50% lemon juice, 50% barium liquid) on pharyngeal swallow measures in two groups of patients with neurogenic dysphagia. Group 1 consisted of 19 patients who had suffered at least one stroke. Group 2 consisted of 8 patients with dysphagia related to other neurogenic etiologies. All patients were selected because they exhibited delays in the onset of the oral swallow and delays in triggering the pharyngeal swallow on boluses of 1 ml and 3 ml liquid barium during videofluoroscopy. Results showed significant improvement in oral onset of the swallow in both groups of patients and a significant reduction in pharyngeal swallow delay in Group 1 patients and in frequency of aspiration in Group 2 patients with the sour as compared to the non-sour boluses. Other selected swallow measures in both subject groups also improved with the sour bolus. Volume effects were present but not as consistently as in prior studies. Implications for swallow therapy are discussed.
Cathy A Pelletier, Harry T Lawless
Effect of citric acid and citric acid-sucrose mixtures on swallowing in neurogenic oropharyngeal dysphagia.
Dysphagia. 2003 Fall;18(4):231-41. doi: 10.1007/s00455-003-0013-y.
Abstract/Text
The ability of sour and sweet-sour mixtures to improve swallowing in 11 nursing home residents with neurogenic oropharyngeal dysphagia was investigated using fiberoptic endoscopic evaluation of swallowing. Citric acid (2.7%) significantly reduced aspiration and penetration compared with water. Teaspoon delivery of liquids significantly reduced aspiration and penetration compared with natural cup drinking. Subjects tended to appropriately self-regulate the cup volume they consumed after the first trial. A significant increase in spontaneous dry swallows was observed after both taste stimuli. The mechanisms for improved swallowing due to citric acid are not understood but may be due to increased gustatory and trigeminal stimulation of acid to the brainstem in neurologically impaired subjects.
Takae Ebihara, Satoru Ebihara, Aya Watando, Tatsuma Okazaki, Masanori Asada, Takashi Ohrui, Mutsuo Yamaya, Hiroyuki Arai
Effects of menthol on the triggering of the swallowing reflex in elderly patients with dysphagia.
Br J Clin Pharmacol. 2006 Sep;62(3):369-71. doi: 10.1111/j.1365-2125.2006.02666.x.
Abstract/Text
AIMS: To investigate the effect of menthol on swallowing reflex sensitivity in elderly patients with dysphagia.
METHODS AND RESULTS: The swallowing reflex sensitivity of institutionalized elderly patients was evaluated as a latent time of swallowing reflex (LTSR), induced by the injection of 1 ml solution into the pharynx. LTSR was significantly shortened in a concentration-dependent manner, from 13.8 s [95% confidence interval (CI) 11.1, 16.5] by distilled water to 9.4 s (95% CI 7.1. 11.8) by 10(-2)m menthol.
CONCLUSION: Using menthol with elderly patients with dysphagia may improve the sensitivity of their swallowing reflex, resulting in prevention of aspiration pneumonia.
Takae Ebihara, Satoru Ebihara, Masahiro Maruyama, Mitsuru Kobayashi, Azusa Itou, Hiroyuki Arai, Hidetada Sasaki
A randomized trial of olfactory stimulation using black pepper oil in older people with swallowing dysfunction.
J Am Geriatr Soc. 2006 Sep;54(9):1401-6. doi: 10.1111/j.1532-5415.2006.00840.x.
Abstract/Text
OBJECTIVES: To determine the effect of olfactory stimulation with volatile black pepper oil (BPO) on risk factors for pneumonia.
DESIGN: A 1-month randomized, controlled study.
SETTING: Nursing homes in Japan that serve as long-term care facilities for older residents who are physically handicapped, mainly because of cerebrovascular disease.
PARTICIPANTS: One hundred five poststroke residents.
MEASUREMENTS: Latency of the swallowing reflex (LTSR), the number of swallowing movements, serum substance P (SP), and regional cerebral blood flow (rCBF).
RESULTS: Nasal inhalation of BPO for 1 minute shortened LTSR, compared with that of lavender oil and distilled water (P < .03). Compared with the period before the study, the 1-month intervention using BPO improved LTSR with an increase of serum SP (P < .01). The number of swallowing movements for 1 minute during the nasal inhalation of BPO increased (P < .001). Multiple comparisons showed a poststudy increase in rCBF within the insular cortex (P < .001). Compared with the prestudy rCBF, BPO intervention increased rCBF in the right orbitofrontal and left insular cortex (P < .001).
CONCLUSION: Inhalation of BPO, which can activate the insular or orbitofrontal cortex, resulting in improvement of the reflexive swallowing movement, might benefit older poststroke patients with dysphagia regardless of their level of consciousness or physical and mental status.
J C Rosenbek, E B Roecker, J L Wood, J Robbins
Thermal application reduces the duration of stage transition in dysphagia after stroke.
Dysphagia. 1996 Fall;11(4):225-33.
Abstract/Text
The present study had two purposes. The first was to provide variability data on objectively measured durational parameters of swallowing as accomplished by dysphagic patients secondary to stroke. The second was to examine the short-term effects of thermal application on these same durational measures. The study employed a cross-over design with each dysphagic stroke subject swallowing 10 times in both untreated and treated conditions. Two findings emerged: (1) swallowing durations in the 22 dysphagic stroke subjects were highly variable within and across subjects and have distributions that were nonnormal with nonhomogeneous variances; (2) thermal application reduced duration of stage transition (DST) and total swallow duration (TSD). Implications of these findings are discussed.
Cathy Lazarus, Jeri A Logemann, Chi Wook Song, Alfred W Rademaker, Peter J Kahrilas
Effects of voluntary maneuvers on tongue base function for swallowing.
Folia Phoniatr Logop. 2002 Jul-Aug;54(4):171-6. doi: 63192.
Abstract/Text
Concurrent manometry and videofluoroscopy were utilized to examine tongue base function during swallowing in 3 patients with head and neck cancer. Subjects were instructed in four voluntary swallow maneuvers, including the supersupraglottic swallow, effortful swallow, Mendelsohn maneuver, and tongue-hold maneuver. Peak catheter pressures (mm Hg) at the tongue base-pharyngeal wall level were recorded and duration of tongue base to pharyngeal wall contact was measured for each swallow. This pilot study revealed that tongue base-pharyngeal wall pressures and contact duration increased with use of maneuvers. Preliminary data are provided to support the use of swallow maneuvers to improve tongue base posterior motion and pressures generated at the tongue base-pharyngeal wall level during swallowing in patients who exhibit this disorder.
Copyright 2002 S. Karger AG, Basel
J A Logemann, B R Pauloski, A W Rademaker, L A Colangelo
Super-supraglottic swallow in irradiated head and neck cancer patients.
Head Neck. 1997 Sep;19(6):535-40.
Abstract/Text
BACKGROUND: After radiotherapy to the head and neck, many patients experience swallowing difficulties. Preliminary work indicates that these patients benefit from the super-supraglottic swallow maneuver.
METHODS: Lateral videofluoroscopic studies examined oropharyngeal swallowing in 9 patients who suffered from dysphagia after radiation to the head and neck. Each patient completed two swallows each of 1 mL or 3 mL liquid barium without a voluntary swallow maneuver and with the super-supraglottic swallow designed to close the entrance to the airway early. The videotape of each swallow was digitized and the location of pharyngeal structures marked throughout the swallow. Movement over time plots were generated to measure changes in structural movement resulting from the maneuver.
RESULTS: The super-supraglottic swallow resulted in changes in airway entrance closure and hyolaryngeal movement. One patient who aspirated without the maneuver stopped aspirating with the maneuver. Two others had aspiration reduced to a trace with the maneuver. Fewer swallowing disorders were observed with the maneuver.
CONCLUSION: The super-supraglottic swallow results in improved biomechanics of swallow in irradiated head and neck cancer patients.
Mary Hägg, Matti Anniko
Lip muscle training in stroke patients with dysphagia.
Acta Otolaryngol. 2008 Sep;128(9):1027-33. doi: 10.1080/00016480701813814.
Abstract/Text
CONCLUSION: Training with an oral screen can improve lip force (LF) and swallowing capacity (SC) in stroke patients with oropharyngeal dysphagia, irrespective of the duration of pretreatment of dysphagia, and irrespective of the presence or absence of central facial paresis. It is more plausible that treatment results are attributable to sensory motor stimulation and the plasticity of the central nervous system than to the training of the lip muscles per se.
OBJECTIVES: A close relationship has been demonstrated between LF and SC in stroke patients whether or not they are affected by facial paresis. It is not known how training of lip function can improve swallowing capacity. The present study was therefore designed to ascertain: (i) if training with an oral screen can improve the LF and SC of stroke patients with oropharyngeal dysphagia; to establish (ii) if improvement in LF and SC is connected with the presence or absence of central facial palsy, (iii) on the interval between stroke onset and initiation of treatment, (iv) on age, or (v) on sex.
SUBJECTS AND METHODS: This was a retrospective study of 30 stroke patients, 49-88 years old, who were investigated with a Lip Force Meter, LF100 (LF100) and a swallowing capacity test (SCT) before and after a period of self-training lasting at least 5-8 weeks, using an oral screen. Initial central facial paresis was present in 24 patients.
RESULTS: The median LF was 7 Newtons (N) (range 0-27) before treatment and 18.5 N (range 7-44) after treatment (p < 0.001). The median SC was 0 ml/s (range 0-9.1) before treatment and 12.1 ml/s (range 0-36.7) at follow-up (p < 0.001). There was no significant difference in swallowing improvement between patients with versus those without facial paresis. The interval between stroke attack and start of treatment, ranging from a few days up to 10 years, had no significant influence on the treatment results, nor did age or sex. The facial paresis was improved or at least ameliorated in all patients after the lip training period.
JoAnne Robbins, Ronald E Gangnon, Shannon M Theis, Stephanie A Kays, Angela L Hewitt, Jacqueline A Hind
The effects of lingual exercise on swallowing in older adults.
J Am Geriatr Soc. 2005 Sep;53(9):1483-9. doi: 10.1111/j.1532-5415.2005.53467.x.
Abstract/Text
OBJECTIVES: To determine the effects of an 8-week progressive lingual resistance exercise program on swallowing in older individuals, the most "at risk" group for dysphagia.
DESIGN: Prospective cohort intervention study.
SETTING: Subjects were recruited from the community at large.
PARTICIPANTS: Ten healthy men and women aged 70 to 89.
INTERVENTION: Each subject performed an 8-week lingual resistance exercise program consisting of compressing an air-filled bulb between the tongue and hard palate.
MEASUREMENTS: At baseline and Week 8, each subject completed a videofluoroscopic swallowing evaluation for kinematic and bolus flow assessment of swallowing. Swallowing pressures and isometric pressures were collected at baseline and Weeks 2, 4, and 6. Four of the subjects also underwent oral magnetic resonance imaging (MRI) to measure lingual volume.
RESULTS: All subjects significantly increased their isometric and swallowing pressures. All subjects who had the MRI demonstrated increased lingual volume of an average of 5.1%.
CONCLUSION: The findings indicate that lingual resistance exercise is promising not only for preventing dysphagia due to sarcopenia, but also as a treatment strategy for patients with lingual weakness and swallowing disability due to frailty or other age-related conditions. The potential effect of lingual exercise on reducing dysphagia-related comorbidities (pneumonia, malnutrition, and dehydration) and healthcare costs while improving quality of life is encouraging.
JoAnne Robbins, Stephanie A Kays, Ronald E Gangnon, Jacqueline A Hind, Angela L Hewitt, Lindell R Gentry, Andrew J Taylor
The effects of lingual exercise in stroke patients with dysphagia.
Arch Phys Med Rehabil. 2007 Feb;88(2):150-8. doi: 10.1016/j.apmr.2006.11.002.
Abstract/Text
OBJECTIVE: To examine the effects of lingual exercise on swallowing recovery poststroke.
DESIGN: Prospective cohort intervention study, with 4- and 8-week follow-ups.
SETTING: Dysphagia clinic, tertiary care center.
PARTICIPANTS: Ten stroke patients (n=6, acute: < or =3mo poststroke; n=4, chronic: >3mo poststroke), age 51 to 90 years (mean, 69.7y).
INTERVENTION: Subjects performed an 8-week isometric lingual exercise program by compressing an air-filled bulb between the tongue and the hard palate.
MAIN OUTCOME MEASURES: Isometric and swallowing lingual pressures, bolus flow parameters, diet, and a dysphagia-specific quality of life questionnaire were collected at baseline, week 4, and week 8. Three of the 10 subjects underwent magnetic resonance imaging at each time interval to measure lingual volume.
RESULTS: All subjects significantly increased isometric and swallowing pressures. Airway invasion was reduced for liquids. Two subjects increased lingual volume.
CONCLUSIONS: The findings indicate that lingual exercise enables acute and chronic dysphagic stroke patients to increase lingual strength with associated improvements in swallowing pressures, airway protection, and lingual volume.
Reza Shaker, Caryn Easterling, Mark Kern, Terilynn Nitschke, Benson Massey, Stephanie Daniels, Barbara Grande, Marta Kazandjian, Karen Dikeman
Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening.
Gastroenterology. 2002 May;122(5):1314-21.
Abstract/Text
BACKGROUND & AIMS: We evaluated the effect of a novel rehabilitative exercise on restoration of deglutition in a group of patients with deglutitive failure caused by abnormal upper esophageal sphincter (UES) opening manifested by postswallow residue and aspiration necessitating percutaneous tube feeding.
METHODS: We studied a total of 27 patients by videofluoroscopy and functional assessment of swallowing scores before and after 6 weeks of a head-raising exercise program. Seven of 27 patients, assigned randomly, participated in a sham exercise before entering the tested exercise program. Eleven of 27 were randomized to the real exercise program.
RESULTS: Although there was no change in swallow function and biomechanics after the sham exercise, following 6 weeks of real exercise, all 11 patients exhibited a significant improvement in their UES opening, anterior laryngeal excursion (P < 0.01), as well as resolution of postdeglutitive aspiration and were able to resume oral feeding. Similar results were found when the 7 patients in the sham group were crossed over to the real exercise group. Comparison of before and after exercise values for anteroposterior UES opening (P < 0.01) and laryngeal anterior excursion (P < 0.05), as well as functional outcome assessment of swallowing (P < 0.05) in the entire group of 27 patients also showed significant improvement. Etiology and duration of dysphagia did not affect the outcome.
CONCLUSIONS: The proposed suprahyoid muscle strengthening exercise program is effective in restoring oral feeding in some patients with deglutitive failure because of abnormal UES opening.
T Yoneyama, M Yoshida, T Matsui, H Sasaki
Oral care and pneumonia. Oral Care Working Group.
Lancet. 1999 Aug 7;354(9177):515.
Abstract/Text
D Simons, E A Kidd, D Beighton
Oral health of elderly occupants in residential homes.
Lancet. 1999 May 22;353(9166):1761. doi: 10.1016/s0140-6736(99)01343-4.
Abstract/Text
