Concordance and discriminatory power of cough measurement devices for individuals with Parkinson disease.

BACKGROUND: Dysphagia and aspiration pneumonia are two causes of morbidity in Parkinson disease (PD). In PD, impaired airway clearance can lead to penetration of foreign material, resulting in a high prevalence of aspiration pneumonia and death. This study examines three different devices for measurement of peak airflow during voluntary cough in healthy control subjects and those with PD. Two simple and low-cost devices for measuring peak cough airflow were compared with the "gold standard" pneumotachograph. METHODS: Thirty-five healthy control subjects and 35 individuals with PD produced voluntary cough at three perceived strengths (weak, moderate, and strong cough) for each of the three devices. RESULTS: A significant difference in mean peak cough airflow was demonstrated for disease (F[1,56] = 4.0, P < .05) and sex (F[1,56] = 9.59, P < .003) across devices. The digital and analog meters were comparable to the gold standard demonstrating no significant difference (statistical) by device (digital vs analog) in receiver operating characteristic curve analysis. Both devices were discriminative of the presence of PD. CONCLUSIONS: The analog and digital peak airflow meters are suitable alternatives to the gold standard pneumotachograph due to their low cost, portability, ease of use, and high sensitivity relative to normative peak cough airflows. Voluntary cough airflow measures may serve as a noninvasive means of screening for aspiration risk in target populations. Additionally, quantification of cough strength through use of predetermined limens for weak, moderate, and strong cough may assist clinicians in better describing and tracking cough strength as a contributing factor to aspiration risk.

Dysphagia, nutrition, and hydration in ischemic stroke patients at admission and discharge from acute care.

Dysphagia may predispose stroke patients toward undernutrition and hydration. These comorbidities increase patient risks for reduced functional outcome and short-term mortality. Despite this impact, available information on relationships among dysphagia, nutrition, and hydration status in acute stroke is limited and conflicted. This study evaluated nutrition and hydration status in ischemic stroke patients with versus without clinically significant dysphagia at admission and at discharge from acute care. Sixty-seven patients admitted to the stroke unit in a tertiary-care hospital provided data for this study. On the day of hospital admission and upon discharge or at 7 days post admission, serum biochemical measures were obtained for nutrition (prealbumin) and hydration status (BUN/Cr). Clinical evaluation for dysphagia, nutrition status, and stroke severity were completed an average of 1.4 days following hospital admission. Dysphagia was identified in 37 % of the cohort. At admission 32 % of patients demonstrated malnutrition based on prealbumin levels and 53 % demonstrated evidence of dehydration based on BUN/Cr levels. No differences in nutrition status were attributed to dysphagia. Patients with dysphagia demonstrated significantly higher BUN/Cr levels (greater dehydration) than patients without dysphagia at admission and at discharge. Dehydration at both admission and discharge was associated with dysphagia, clinical nutrition status, and stroke severity. Results of this study support prior results indicating that dysphagia is not associated with poor nutrition status during the first week post stroke. Dehydration status is associated with dysphagia during this period. The results have implications for future confirmatory research and for clinical management of dysphagia in the acute stroke period.

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

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

The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity.

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

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

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

"Pharyngocise": randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy.

PURPOSE: Dysphagia after chemoradiotherapy is common. The present randomized clinical trial studied the effectiveness of preventative behavioral intervention for dysphagia compared with the "usual care." METHODS AND MATERIALS: A total of 58 head-and-neck cancer patients treated with chemoradiotherapy were randomly assigned to usual care, sham swallowing intervention, or active swallowing exercises (pharyngocise). The intervention arms were treated daily during chemoradiotherapy. The primary outcome measure was muscle size and composition (determined by T(2)-weighted magnetic resonance imaging). The secondary outcomes included functional swallowing ability, dietary intake, chemosensory function, salivation, nutritional status, and the occurrence of dysphagia-related complications. RESULTS: The swallowing musculature (genioglossus, hyoglossuss, and mylohyoid) demonstrated less structural deterioration in the active treatment arm. The functional swallowing, mouth opening, chemosensory acuity, and salivation rate deteriorated less in the pharyngocise group. CONCLUSION: Patients completing a program of swallowing exercises during cancer treatment demonstrated superior muscle maintenance and functional swallowing ability.

McNeill dysphagia therapy program: a case-control study.

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

Treatment of vocal fold bowing using neuromuscular electrical stimulation.

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

Analysis of a physician tool for evaluating dysphagia on an inpatient stroke unit: the modified Mann Assessment of Swallowing Ability.

BACKGROUND: Although many dysphagia screening protocols have been introduced in recent years, no validated, physician-administered dysphagia screening tool exists for acute stroke that can be performed at the bedside. Based on the psychometrically validated Mann Assessment of Swallowing Ability (MASA), we developed the Modified MASA (MMASA) as a physician-administered screening tool for dysphagia in acute stroke. OBJECTIVE: The purpose of this study was to complete initial validation of this new screening tool for dysphagia in acute ischemic stroke. METHODS: Two stroke neurologists independently performed the MMASA on 150 patients with ischemic stroke. Speech-language pathologists performed the standard MASA on all patients. All examiners were blinded to the results of the other assessments. Interjudge reliability was evaluated between the neurologists. Validity between the screening tool (MMASA) and the clinical evaluation (MASA) was assessed with sensitivity/specificity and predictive value assessment. RESULTS: Interobserver agreement between the neurologists using the MMASA was good (k=0.76; SE=0.082). Based on the comprehensive clinical evaluation (MASA), 36.2% of patients demonstrated dysphagia. Screening results from the neurologists (N1 and N2) identified 38% and 36.7% prevalence of dysphagia, respectively. Sensitivity (N1: 92%, N2: 87%), specificity (N1: 86.3%, N2: 84.2%), positive predictive value (N1: 79.4%, N2: 75.8%), and negative predictive value (N1: 95.3%, N2: 92%) were high between the screen and the comprehensive clinical evaluation. CONCLUSIONS: This preliminary study suggests that the MMASA is a potentially valid and reliable physician-administered screening tool for dysphagia in acute ischemic stroke. Use of this tool may facilitate earlier identification of dysphagia in patients with stroke prompting more rapid comprehensive evaluation and intervention.

The bedside examination in dysphagia.

The evaluation of swallowing disorders currently uses a variety of methods. The most common dichotomy is between instrumental and noninstrumental or clinical examinations. The clinical bedside assessment often is considered the mainstay of dysphagia management. As the first line of assessment, it frequently defines the process and requisites of the task. This article reviews the available methods of noninstrumental bedside swallowing assessment and considers the issues surrounding the use of these approaches today.

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

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

Adjunctive neuromuscular electrical stimulation for treatment-refractory dysphagia.

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

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

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

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

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

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

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

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

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

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

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

The impact of rheologically controlled materials on the identification of airway compromise on the clinical and videofluoroscopic swallowing examinations.

Numerous studies have suggested that the clinical evaluation of swallowing fails to adequately identify those patients who aspirate or do not aspirate on a videofluoroscopic swallowing examination. These conclusions, however, are based on comparisons between swallowed materials that were not rheologically matched. The present study used a battery of rheologically matched test materials, involving thin and thick liquids and cohesive and adhesive semisolids. Using these test items, results from a clinical swallow evaluation were compared to the results of a videofluorographic evaluation using identical test materials. Results suggest that the use of three test materials, including thin and thick liquids given in volumes of 5 and 10 ml, demonstrated the strongest associations between cough on the clinical examination and aspiration on the videofluoroscopic examination.

Pill swallowing by adults with dysphagia.

OBJECTIVE: To evaluate differences in swallowing physiology and safety in patients with dysphagia between conventional tablets and a new method of tablet transportation, orally disintegrating technology (ODT) (RapiTab; Schwarz Pharma Inc, Milwaukee, Wis). DESIGN: The study observed a single group, crossover design. SETTING: Outpatient clinic within an academic teaching hospital. PARTICIPANTS: A total of 36 adult dysphagic patients referred to the clinic. INTERVENTIONS: All subjects underwent simultaneous nasopharyngeal endoscopic evaluation, surface electromyographic (sEMG) measurement, and respiratory monitoring during swallowing. Subjects were evaluated swallowing the ODT and a conventional tablet formulation. Tablets were randomly and blindly presented to each subject. Subjects completed a preference survey subsequent to swallowing both tablets. RESULTS: Significant differences included greater sEMG amplitude and longer apneic duration when swallowing a conventional tablet compared with the ODT (P<.001). Patients with dysphagia demonstrated significantly longer total swallow durations (P<.001), a higher number of swallows per tablet (P<.002), and the need for fluid to assist in the clearance of the conventional tablet (P<.001). No significant difference was noted between the 2 tablet preparations in amount of residue or airway compromise during or following the swallow. On a postevaluation survey, patients reported that they preferred the ODT preparation for most of the parameters assessed. CONCLUSIONS: Patients with dysphagia frequently complain of trouble swallowing medication. In this study, an ODT formulation provided a method of delivery that required less effort to swallow, did not result in increased levels of airway compromise, and was preferred by dysphagic patients. The ODT medication delivery technology may provide benefit to adults with dysphagia in convenience, compliance, and accuracy of dosing.

Functional benefits of dysphagia therapy using adjunctive sEMG biofeedback.

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