Transcutaneous electrical stimulation as a resistance force in lingual exercise: A preliminary proof-of-concept study.

BACKGROUND: Limited knowledge exists regarding whether transcutaneous electrical stimulation (TES)-based exercise can improve the lingual pressure generation. OBJECTIVES: To compare the effect of submental TES with two different pulse durations (PD) coupled with isometric lingual exercises on lingual pressure measures. METHODS: Twenty-eight healthy volunteers were divided into two submental TES groups: short PD (300 µs) and long PD (700 µs). The Iowa Oral Performance Instrument (IOPI) was used for lingual pressure measurements and exercise. In total, participants attended six exercise sessions 3 days per week for 2 consecutive weeks. Maximum and swallowing lingual pressures were measured 1 h following each exercise session and 3 days after the final session to assess any detraining effect. Data were analysed using repeated measure ANOVA. RESULTS: Mean maximum lingual pressure change was significantly greater in TES with short PD versus the long PD condition following the first week of exercise. Following the 2-week exercise, a significant increase was found in mean maximum lingual pressure for short and long PD conditions compared with the baseline. However, no significant difference was found between PD conditions for maximum lingual pressure. Likewise, no significant differences in swallowing lingual pressure were found compared with the baseline or across the two TES conditions. CONCLUSION: Although short PD induced greater gain in maximum lingual pressure than the long PD after week 1, the enhanced effect faded after week 2, leading to a comparable increase in maximum lingual pressure for both groups. However, increased gain in maximum lingual pressure was not transferred to lingual pressure during swallowing.

Spontaneous Swallowing Frequency, Dysphagia, and Drooling in Children With Cerebral Palsy.

OBJECTIVE: To evaluate relationships between spontaneous swallowing frequency, dysphagia, and drooling in children with cerebral palsy. Spontaneous swallowing frequency was predicted to be inversely related to both dysphagia and drooling among children with cerebral palsy. A secondary objective compared patterns among spontaneous swallowing frequency, drooling, and age in healthy children vs children presenting with cerebral palsy. DESIGN: Cross sectional study. SETTING: Children with cerebral palsy were tested at a Cerebral Palsy Reference Center in a university hospital. Healthy children were tested in their home setting. PARTICIPANTS: Twenty children with cerebral palsy were recruited from the local registry for cerebral palsy children and purposive sampling among parents. A group of 30 healthy children was recruited by purposive sampling among family, friends, and the local community. Children below 1 year of age up to 5 years of age were included in the healthy group. This age range was targeted to maximize the potential for drooling in this group. MAIN OUTCOME MEASURES: Both groups provided data on spontaneous swallowing frequency (swallows per minute, or SPM), dysphagia, and drooling. Motor impairment was documented in the children with cerebral palsy. RESULTS: SPM was significantly lower in children with cerebral palsy. Among children with cerebral palsy, SPM correlated significantly with dysphagia severity and trended toward a significant correlation with drooling at rest. In this subgroup, SPM was not correlated with age or degree of motor impairment. Dysphagia was significantly correlated with drooling at rest and both dysphagia and drooling at rest were correlated with degree of motor impairment. The 2 groups did not differ in the degree of drooling at rest. Among healthy children, age but not SPM demonstrated a significant inverse correlation with drooling quotient at rest. CONCLUSIONS: Spontaneous swallowing frequency is related to dysphagia and drooling in children with cerebral palsy. The pattern of relationships among spontaneous swallowing frequency and drooling is different between children with cerebral palsy and younger healthy children.

Clinical Swallowing Profile Change in HNC Patients Treated with C/RT.

OBJECTIVES/HYPOTHESIS: To demonstrate utility of the Mann Assessment of Swallowing Ability-Cancer (MASA-C) to describe change in swallowing ability in a cohort of HNC patients from pre-C/RT to post-C/RT to follow up at 3 months post-C/RT. An exploratory analysis compared patients treated with radiotherapy (RT) only to patients treated with chemoradiation (CRT). STUDY DESIGN: Prospective Cohort. METHODS: The MASA-C and Functional Oral Intake Scale (FOIS) were completed on 85 HNC patients within the first 5 days of CRT initiation, at the completion of C/RT (6 weeks), and 3 months after completion of C/RT. MASA-C total scores and clinical profiles were used to describe change in swallowing performance at each time point. RESULTS: MASA-C and FOIS scores were significantly lower at 6 weeks and 3 months compared to baseline. Patients treated with CRT demonstrated more frequent and more severe dysphagia. Post C/RT items demonstrating the most deterioration included taste, diet level, oral mucosa, saliva, weight loss, and pharyngeal functions. Significant recovery was observed between 6 weeks and 3 months on both the MASA-C and FOIS. MASA-C items revealing the greatest recovery included taste, diet level, oral mucosa, tongue movement, weight loss, oral transit, voice, and pharyngeal phase. Few significant differences were noted between RT and CRT cases at 3 months. CONCLUSIONS: Swallowing functions deteriorate significantly following C/RT with incomplete recovery at 3 months. Few differences were noted between RT and CRT treated patients at 3 months. Clinical profiling with the MASA-C provides a standard, simple method to document swallow function change over time in these patients. LEVEL OF EVIDENCE: 2 Laryngoscope, 131:E1873-E1880, 2021.

Longitudinal Kinematic Evaluation of Pharyngeal Swallowing Impairment in Thyroidectomy Patients.

The aim of this study was to assess pharyngeal swallowing impairments in thyroidectomy patients and to delineate the contributory kinematic components. Forty consecutive patients (mean age = 47.33 years) and fourteen age- and sex-matched heathy adult volunteers (mean age = 42.64 years) participated in this study. A videofluoroscopic swallowing study (VFSS) was performed 1 day prior to surgery, and at 1 week and 3 months post-surgery. VFSS images were evaluated using the Modified Barium Swallowing Impairment Profile (MBSImp). Kinematic and temporal aspects of swallowing were characterized by measurement of maximum hyoid and laryngeal excursion, pharyngeal transit duration, laryngeal response duration (LRD), and laryngeal closure duration at each three time-points. At 1 week post-surgery, only pharyngeal impairment was significantly deteriorated than pre-surgery (p = 0.001). However, at 3 months, a significant improvement was observed to pre-surgery level (p = 0.01). Post-surgery, maximum hyoid excursion was significantly reduced in patients compared controls (p = 0.001). Although the maximal distance of the hyoid and the laryngeal excursion was shorter than before surgery, laryngeal excursion at all three time-points was similar to that of controls. At all three time-points, LRD was significantly longer in patients than in controls (p = 0.01). Following thyroidectomy, pharyngeal aspects of swallowing as measured by the MBSImp and kinematic aspects of swallowing were reduced with incomplete recovery at 3 months. These exploratory data may guide decision regarding management of pharyngeal swallowing impairment with patients undergoing total thyroidectomy.

Derivation and measurement consistency of a novel biofluid dynamics measure of deglutitive bolus-driving function-pharyngeal swallowing power.

BACKGROUND: The primary function of the pharyngeal swallowing mechanism is to drive ingested materials into the esophagus. Currently, a definitive measure of pharyngeal bolus-driving function that accounts for bolus movement remains lacking. The primary objectives of this study were to describe the derivation of a novel biofluid dynamics measure of deglutition-that is, pharyngeal swallowing power (PSP)-and to demonstrate the consistency of PSP in normal swallowing. METHODS: The pharyngeal swallowing mechanism was conceptualized as a hydraulic power system with the upper esophageal sphincter (UES) as a conduit. PSP was calculated as the product of bolus pressure and flow across the UES. Thirty-four young healthy subjects swallowed materials consisting of two bolus volumes (10, 20 mL) and four bolus viscosities (thin liquid, nectar-thick liquid, honey-thick liquid, pudding). High-resolution impedance manometry was used for data collection. The consistency of PSP across specific bolus conditions was evaluated using standardized Cronbach's coefficient alpha. KEY RESULTS: Standardized Cronbach's coefficient alphas in specific bolus conditions ranged between 0.85 and 0.93. Fisher weighted mean Cronbach's coefficient alphas for swallow trials across bolus volumes and across bolus viscosities ranged from 0.86 to 0.90. Fisher weighted mean Cronbach's coefficient alpha for overall consistency of PSP across all swallow trials was 0.88. CONCLUSIONS AND INFERENCES: PSP estimates the output power of the pharyngeal bolus-driving mechanism during deglutition. PSP's high consistency indicates that it can be a useful biofluid dynamics measure of pharyngeal bolus-driving function. Current results also demonstrate that consistency in pharyngeal bolus propulsion is an important physiological target for the pharyngeal swallowing mechanism.

Bolus volume and viscosity effects on pharyngeal swallowing power-How physiological bolus accommodation affects bolus dynamics.

BACKGROUND: Pharyngeal swallowing power (PSP) is a novel measure of pharyngeal bolus-driving function derived from fluid dynamics principles. This study examined the impact of bolus volume and viscosity on PSP to determine bolus effects on pharyngeal bolus dynamics. The impact of bolus accommodation and physical characteristics of boluses were also explored. METHODS: Thirty-four healthy subjects swallowed materials consisting of two bolus volumes (10 and 20 mL) and four bolus viscosities (thin liquid, nectar-thick liquid, honey-thick liquid and pudding). High-resolution impedance manometry was used for data collection. The pharyngeal swallowing mechanism was conceptualized as a hydraulic power system with the UES as a conduit, and PSP was calculated as the product of bolus pressure and flow across the UES. The impact of bolus characteristics on PSP was evaluated using a mixed model approach. KEY RESULTS: Both bolus volume (F1,32.8  = 412.73, P < 0.0001) and viscosity (F3,84.7  = 28.94, P < 0.0001) were significant predictors of PSP. PSP for 20 mL bolus volume was greater than for 10 mL bolus volume. PSP was lowest in the thin liquid bolus condition and highest in the pudding bolus. All pairwise comparisons among bolus viscosities were significant except between thin liquid and nectar-thick liquid bolus viscosities. Test of linear trend across bolus viscosities was significant (F1,97.2  = 77.25, P < 0.0001). CONCLUSIONS & INFERENCES: Pharyngeal swallowing power variation across bolus conditions illustrates bolus-related changes in bolus dynamics. Bolus effects on PSP likely result from physiological bolus accommodation combined with physical characteristics of boluses.

Dysphagia and Oral Morbidities in Chemoradiation-Treated Head and Neck Cancer Patients.

This study prospectively evaluated relationships between oral morbidities and swallowing ability in head/neck cancer patients following chemoradiation therapy (CRT) and at 3 months following CRT. Thirty patients with confirmed head/neck cancer undergoing chemoradiation were assessed with a battery of swallowing measures and measures of oral morbidities related to chemoradiation (xerostomia, mucositis, pain, taste/smell, oral moisture). All measures were completed at baseline (within the first week of CRT), at 6 weeks (end of treatment), and at 3 months following chemoradiation. Descriptive and univariate statistics were used to depict change over time in swallowing and each oral morbidity. Correlation analyses evaluated relationships between swallowing function and oral morbidities at each time point. Most measures demonstrated significant negative change at 6 weeks with incomplete recovery at 3 months. At 6 weeks, mucositis ratings, xerostomia, and retronasal smell intensity demonstrated significant inverse relationships with swallowing function. In addition, oral moisture levels demonstrated significant positive relationships with swallowing function. At 3 months, mucositis ratings maintained a significant, inverse relationship with swallow function. Taste and both orthonasal and retronasal smell intensity ratings demonstrated inverse relationships with measures of swallow function. Swallow functions and oral morbidities deteriorate significantly following CRT with incomplete recovery at 3 months post treatment. Furthermore, different patterns of relationships between swallow function measures and oral morbidities were obtained at the 6-week versus the 3-month assessment point suggesting that different mechanisms may contribute to the development versus the maintenance of dysphagia over the trajectory of treatment in these patients.

Preliminary Development of a Screening Tool for Pre-Clinical Dysphagia in Community Dwelling Older Adults.

Evidence suggests that community dwelling older adults (CDOA) are at risk for dysphagia (swallowing difficulties). Dysphagia is often unidentified until related morbidities like under nutrition or pneumonia occur. These cases of unidentified dysphagia, prior to any clinical intervention, may be termed 'pre-clinical dysphagia'. Identifying pre-clinical dysphagia is challenged by the lack of validated tools appropriate for CDOA. This study addresses preliminary development of a novel patient reported outcome (PRO) screening tool for pre-clinical dysphagia. Initially, 34 questions were developed from literature review and expert opinion. Following pilot testing (n = 53), the questionnaire was revised and tested on 335 additional CDOA. Face validity, content validity, item analysis, reliability (internal consistency), and construct validity (exploratory factor analysis) measures were completed. Psychometric validation resulted in a 17-question PRO tool. Construct analysis identified a three-factor model that explained 67.345% of the variance. Emergent factors represented swallowing effort, physical function, and cognitive function. The results revealed strong construct validity and internal consistency (Cronbach's α = 0.90). A novel, simple PRO incorporating multiple function domains associated with aging demonstrated strong preliminary psychometric properties. This tool is more comprehensive and aging-focused than existing dysphagia screening tools. Inclusion of multiple domains may be key in early identification of pre-clinical dysphagia.

Immediate effects of transcutaneous electrical stimulation on physiological swallowing effort in older versus young adults.

OBJECTIVE: This study compared the immediate impact of different transcutaneous electrical stimulation (TES) amplitudes on physiological swallowing effort in healthy older adults versus young adults. BACKGROUND: Swallowing physiology changes with age. Reduced physiological swallowing effort in older adults including lower lingua-palatal and pharyngeal pressures may increase risk for swallowing dysfunction (i.e. dysphagia). Transcutaneous electrical stimulation (TES) has been advocated as an adjunctive modality to enhance outcomes in exercise-based therapy for individuals with dysphagia. However, significant variation in how TES is applied during therapy remains and the physiological swallowing response to TES is poorly studied, especially in older adults. MATERIALS AND METHODS: Physiological change in swallowing associated with no stimulation, sensory stimulation and motor stimulation was compared in 20 young adults versus 14 older adults. Lingua-palatal and pharyngeal manometric pressures assessed physiological swallowing effort. RESULTS: Multivariate analyses identified interactions between age and stimulation amplitude on lingual and pharyngeal functions. Motor stimulation reduced anterior tongue pressure in both age groups but selectively reduced posterior lingua-palatal pressures in young adults only. Sensory stimulation increased base of tongue (BOT) pressures in older adults but decreased BOT pressures in young adults. Motor stimulation increased hypopharyngeal pressures in both groups. CONCLUSION: Age and TES level interact in determining immediate physiological responses on swallow performance. A one-size-fit-all approach to TES in dysphagia rehabilitation may be misdirected.

Clinical Variables Associated with Hydration Status in Acute Ischemic Stroke Patients with Dysphagia.

Acute stroke patients with dysphagia are at increased risk for poor hydration. Dysphagia management practices may directly impact hydration status. This study examined clinical factors that might impact hydration status in acute ischemic stroke patients with dysphagia. A retrospective chart review was completed on 67 ischemic stroke patients who participated in a prior study of nutrition and hydration status during acute care. Prior results indicated that patients with dysphagia demonstrated elevated BUN/Cr compared to non-dysphagia cases during acute care and that BUN/Cr increased selectively in dysphagic patients. This chart review evaluated clinical variables potentially impacting hydration status: diuretics, parenteral fluids, tube feeding, oral diet, and nonoral (NPO) status. Exposure to any variable and number of days of exposure to each variable were examined. Dysphagia cases demonstrated significantly more NPO days, tube fed days, and parenteral fluid days, but not oral fed days, or days on diuretics. BUN/Cr values at discharge were not associated with NPO days, parenteral fluid days, oral fed days, or days on diuretics. Patients on modified solid diets had significantly higher mean BUN/Cr values at discharge (27.12 vs. 17.23) as did tube fed patients (28.94 vs. 18.66). No difference was noted between these subgroups at baseline (regular diet vs. modified solids diets). Any modification of solid diets (31.11 vs. 17.23) or thickened liquids (28.50 vs. 17.81) resulted in significantly elevated BUN/Cr values at discharge. Liquid or diet modifications prescribed for acute stroke patients with dysphagia may impair hydration status in these patients.

'Food Sticking in My Throat': Videofluoroscopic Evaluation of a Common Symptom.

Prevalence of the symptom of food 'sticking' during swallowing has been reported to range from 5 to 50%, depending on the assessment setting. However, limited objective evidence has emerged to clarify factors that contribute to this symptom. Three hundred and fifteen patient records from an outpatient dysphagia clinic were reviewed to identify patients with symptoms of 'food sticking in the throat.' Corresponding videofluoroscopic swallowing studies for patients with this complaint were reviewed for the following variables: accuracy of symptom localization, identification and characteristics (anatomic, physiologic) of an explanatory cause for the symptom, and the specific swallowed material that identified the explanatory cause. One hundred and forty one patients (45%) were identified with a complaint of food 'sticking' in their throat during swallowing. Prevalence of explanatory findings on fluoroscopy was 76% (107/141). Eighty five percent (91/107) of explanatory causes were physiologic in nature, while 15% (16/107) were anatomic. The majority of explanatory causes were identified in the esophagus (71%). Symptom localization was more accurate when the explanatory cause was anatomic versus physiologic (75 vs. 18%). A non-masticated marshmallow presented with the highest diagnostic yield in identification of explanatory causes (71%). Patients complaining of 'food sticking in the throat' are likely to present with esophageal irregularities. Thus, imaging studies of swallowing function should include the esophagus. A range of materials, including a non-masticated marshmallow, is helpful in determining the location and characteristics of swallowing deficits contributing to this symptom.

Spontaneous swallow frequency compared with clinical screening in the identification of dysphagia in acute stroke.

BACKGROUND: The aim of this study was to compare spontaneous swallow frequency analysis (SFA) with clinical screening protocols for identification of dysphagia in acute stroke. METHODS: In all, 62 patients with acute stroke were evaluated for spontaneous swallow frequency rates using a validated acoustic analysis technique. Independent of SFA, these same patients received a routine nurse-administered clinical dysphagia screening as part of standard stroke care. Both screening tools were compared against a validated clinical assessment of dysphagia for acute stroke. In addition, psychometric properties of SFA were compared against published, validated clinical screening protocols. RESULTS: Spontaneous SFA differentiates patients with versus without dysphagia after acute stroke. Using a previously identified cut point based on swallows per minute, spontaneous SFA demonstrated superior ability to identify dysphagia cases compared with a nurse-administered clinical screening tool. In addition, spontaneous SFA demonstrated equal or superior psychometric properties to 4 validated, published clinical dysphagia screening tools. CONCLUSIONS: Spontaneous SFA has high potential to identify dysphagia in acute stroke with psychometric properties equal or superior to clinical screening protocols.

Adoption into clinical practice of two therapies to manage swallowing disorders: exercise-based swallowing rehabilitation and electrical stimulation.

PURPOSE OF REVIEW: To review recent literature depicting a shift in dysphagia rehabilitation in adults. Distinguishing rehabilitation from compensation in dysphagia management, a review of basic exercise principles is followed by description of recent publications depicting exercise-based therapies. Subsequently, transcutaneous electrical stimulation (TES) is reviewed as it may contribute to exercise-based dysphagia rehabilitation in adults. RECENT FINDINGS: Surveys have documented extensive variability in the clinical application of dysphagia therapy techniques. Despite this variability, two trends are emerging in dysphagia rehabilitation research: documentation of physiologic and functional changes within the swallowing mechanism subsequent to therapy; and prophylactic exercise-based therapies. In addition, extensive efforts have emerged describing the potential application of TES in dysphagia rehabilitation. Though results of these efforts are conflicted, TES may serve a useful role as an adjunct to well developed exercise-based rehabilitation for dysphagia. SUMMARY: The focus of dysphagia rehabilitation in adults is changing. Current efforts indicate that exercise-based therapies should incorporate multiple principles of exercise physiology and document physiologic change within the impaired swallowing mechanism. TES may function as an adjunctive modality; however, current practices should be evaluated to develop additional parameters of stimulation that are focused toward specific dysphagia impairments.

Development and validation of a cancer-specific swallowing assessment tool: MASA-C.

OBJECTIVE: We present data from a sample of patients receiving radiotherapy for head/neck cancer to define and measure the validity of a new clinical assessment measure for swallowing. METHODS: Fifty-eight patients undergoing radiotherapy (±chemotherapy) for head/neck cancer (HNC) supported the development of a physiology-based assessment tool of swallowing (Mann Assessment of Swallowing Ability--Cancer: MASA-C) administered at two time points (baseline and following radiotherapy treatment). The new exam was evaluated for internal consistency of items using Cronbach's alpha. Reliability of measurement was evaluated with intraclass correlation (ICC) and the Kappa statistic between two independent raters. Concurrent validity was established through comparison with the original MASA examination and against the referent standard videofluoroscopic swallowing examination (VFE). Sensitivity, specificity, and likelihood ratios along with 95 % confidence intervals (CIs) were derived for comparison of the two evaluation forms (MASA vs. MASA-C). Accuracy of diagnostic precision was displayed using receiver operator characteristic curves. RESULTS: The new MASA-C tool demonstrated superior validity to the original MASA examination applied to a HNC population. In comparison to the VFE referent exam, the MASA-C revealed strong sensitivity and specificity (Se 83, Sp 96), predictive values (positive predictive value (PPV) 0.95, negative predictive value (NPV) 0.86), and likelihood ratios (21.6). In addition, it demonstrated good reliability (ICC = 0.96) between speech-language pathology raters. CONCLUSIONS: The MASA-C is a reliable and valid scale that is sensitive to differences in swallowing performance in HNC patients with and without dysphagia. Future longitudinal evaluation of this tool in larger samples is suggested. The development and refinement of this swallowing assessment tool for use in multidisciplinary HNC teams will facilitate earlier identification of patients with swallowing difficulties and enable more efficient allocation of resources to the management of dysphagia in this population. The MASA-C may also prove useful in future clinical HNC rehabilitation trials with this population.

Spontaneous swallowing frequency has potential to identify dysphagia in acute stroke.

BACKGROUND AND PURPOSE: Spontaneous swallowing frequency has been described as an index of dysphagia in various health conditions. This study evaluated the potential of spontaneous swallow frequency analysis as a screening protocol for dysphagia in acute stroke. METHODS: In a cohort of 63 acute stroke cases, swallow frequency rates (swallows per minute [SPM]) were compared with stroke and swallow severity indices, age, time from stroke to assessment, and consciousness level. Mean differences in SPM were compared between patients with versus without clinically significant dysphagia. Receiver operating characteristic curve analysis was used to identify the optimal threshold in SPM, which was compared with a validated clinical dysphagia examination for identification of dysphagia cases. Time series analysis was used to identify the minimally adequate time period to complete spontaneous swallow frequency analysis. RESULTS: SPM correlated significantly with stroke and swallow severity indices but not with age, time from stroke onset, or consciousness level. Patients with dysphagia demonstrated significantly lower SPM rates. SPM differed by dysphagia severity. Receiver operating characteristic curve analysis yielded a threshold of SPM≤0.40 that identified dysphagia (per the criterion referent) with 0.96 sensitivity, 0.68 specificity, and 0.96 negative predictive value. Time series analysis indicated that a 5- to 10-minute sampling window was sufficient to calculate spontaneous swallow frequency to identify dysphagia cases in acute stroke. CONCLUSIONS: Spontaneous swallowing frequency presents high potential to screen for dysphagia in acute stroke without the need for trained, available personnel.

Acoustic discrimination of healthy swallows from upper airway movements.

Spontaneous swallowing in dysphagic individuals has been shown to occur at a lower rate compared to healthy controls, and passive swallowing detection may function as a valid screening test to identify dysphagia in at-risk populations. To automate swallow identification, acoustic source and vocal tract features were extracted from two types of swallows and eight upper airway movements from nine healthy subjects. Swallow vs non-swallow classification accuracy was 96.3 ± 1.1%. The results provide useful methods for further development of automated tools for identification of patients with swallowing impairment.

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.

Validation and demonstration of an isolated acoustic recording technique to estimate spontaneous swallow frequency.

Spontaneous swallowing is considered a reflexive, pharyngeal clearance mechanism. Reductions in spontaneous swallow frequency may be a sensitive index for dysphagia and related morbidities. This study evaluated an acoustic recording technique as a measure to estimate spontaneous swallow frequency. Initially, a multichannel physiologic (surface electromyography, swallow apnea, cervical auscultation) recording technique was validated and subsequently compared to an isolated acoustic (microphone) recording technique on a sample of younger (25 ± 2.8 years) and older (68 ± 5.3 years) healthy adult participants. Sensitivity (94 %), specificity (99 %), and classification accuracy (98 %) were high for swallow identification from the multichannel physiologic recording technique. Interjudge reliability was high (k = 0.94, 95 % CI = 0.92-0.96). No significant differences in spontaneous swallow frequency were observed between the multichannel physiologic recordings and the acoustic recordings (0.85 vs. 0.81 swallows per minute). Furthermore, these two techniques were highly correlated (r = 0.95). Interjudge reliability for swallow identification via acoustic recordings was high (k = 0.96, 95 % CI = 0.94-0.99). Preliminary evaluation of the temporal stability of spontaneous swallow frequency measured from acoustic recordings indicated that time samples as short as 5 min produce viable results. Age differences were identified in spontaneous swallow frequency rates, with older participants swallowing less frequently than younger participants (0.47 vs. 1.02 swallows per minute). Collectively, these results indicate that an isolated acoustic recording technique is a valid approach to estimate spontaneous swallow frequency.

Dysphagia in the elderly: management and nutritional considerations.

Dysphagia is a prevalent difficulty among aging adults. Though increasing age facilitates subtle physiologic changes in swallow function, age-related diseases are significant factors in the presence and severity of dysphagia. Among elderly diseases and health complications, stroke and dementia reflect high rates of dysphagia. In both conditions, dysphagia is associated with nutritional deficits and increased risk of pneumonia. Recent efforts have suggested that elderly community dwellers are also at risk for dysphagia and associated deficits in nutritional status and increased pneumonia risk. Swallowing rehabilitation is an effective approach to increase safe oral intake in these populations and recent research has demonstrated extended benefits related to improved nutritional status and reduced pneumonia rates. In this manuscript, we review data describing age related changes in swallowing and discuss the relationship of dysphagia in patients following stroke, those with dementia, and in community dwelling elderly. Subsequently, we review basic approaches to dysphagia intervention including both compensatory and rehabilitative approaches. We conclude with a discussion on the positive impact of swallowing rehabilitation on malnutrition and pneumonia in elderly who either present with dysphagia or are at risk for dysphagia.

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.