Creation and Initial Validation of the International Dysphagia Diet Standardisation Initiative Functional Diet Scale

Rheological and Physicochemical Properties of a Functional Apple Drink and Its Clinical Impact on Dysphagia Management

Modification of liquid viscosity using commercial thickeners is a recognized strategy to ensure safe swallowing for patients with oropharyngeal dysphagia. This study investigated the rheological, physicochemical, and sensory properties of functional apple drinks formulated for dysphagia management. Various concentrations of gellan gum (0.042% to 0.050%), inulin (3.5%), maltodextrin (3%), and stevia were tested to optimize the viscosity and sensory characteristics of the drinks. The results indicated that gellan gum concentrations of 0.045%-0.047% and 0.048%-0.050% achieved viscosities corresponding to IDDSI Levels 1 and 2, respectively, making the drinks suitable for dysphagia patients. All samples exhibited time-independent, non-Newtonian, shear-thinning behavior, with the Herschel-Bulkley model providing the best fit for describing flow properties (R2 > 0.93). Higher gellan concentrations enhanced apparent viscosity (ηa,50), consistency index (κ), yield stress (σ0), and viscoelastic moduli (G' and G″). Physicochemical properties such as acidity, pH, Brix, and color remained stable during 15 days of refrigerated storage. Clinical trials demonstrated a significant improvement in swallowing function among patients who consumed the thickened drinks. These findings highlight the potential of low-acyl gellan gum to develop functional beverages tailored for dysphagia management, providing both safety and sensory appeal.

ESSD-ESGAR best practice position statements on the technical performance of videofluoroscopic swallowing studies in adult patients with swallowing disorders

OBJECTIVES

Videofluoroscopic swallowing studies (VFSS) remain the gold standard for the instrumental assessment of oropharyngeal swallowing disorders alongside flexible endoscopic evaluation of swallowing (FEES), requiring a high standard of quality and correct implementation. The current best practice position statements aim to guide the clinical practice of VFSS in individuals experiencing swallowing disorders.

MATERIALS AND METHODS

An international expert consensus panel with expertise in oropharyngeal dysphagia, comprised of radiologists, speech-language therapists, otolaryngologists, and other professionals in the field, convened by the European Society of Swallowing Disorders (ESSD) and the European Society of Gastrointestinal and Abdominal Radiology (ESGAR), developed best practice position statements. They were established using an online Delphi methodology involving an online panel discussion and item preparation and three consecutive rounds. Consensus was reached when ≥ 80% of the participants agreed on a specific recommendation.

RESULTS

Eighteen best practice position statements were formulated, thereby establishing standard recommendations on the technical performance of VFSS. They cover VFSS planning, correct implementation, documentation, radiation protection, equipment and maintenance, and education and training.

CONCLUSION

These position statements summarise the panel's deliberations and recommendations in performing VFSS, representing the agreed consensus of experts from ESSD and ESGAR. They provide a structured framework for optimising and standardising the performance of VFSS in patients with swallowing disorders.

KEY POINTS

Question Significant regional and national differences in clinical practice when performing VFSS highlight the need for interdisciplinary recommendations to optimise patient care. Findings Eighteen statements were developed by representatives of the ESSD and the ESGAR. Clinical relevance These best practice position statements on the technical performance of VFSS may serve as a basis for standardising the procedure and ensuring high-quality service.

Severe Refractory Post-Radiation Strictures: Lessons Learned from Long-term Follow-up after Combined Antegrade Retrograde Dilation

PURPOSE OF REVIEW

Dysphagia with an identifiable stricture occurs frequently following chemoradiation therapy for head/neck cancer patients, some developing complete obliteration of the esophageal lumen. Combined Antegrade Retrograde Dilation (CARD) is designed to restore luminal patency. This paper reports how experience at one institution shaped a more effective strategy for the long-term management of this difficult patient population.

RECENT FINDINGS

Twenty patients, mean age 62.6 years, initially undergoing CARD procedure, subsequently required a total of 278 dilation sessions (average 13.9 sessions/patient) performed on average every 8.2 weeks (range 2.7-12.6). All patients achieved luminal patency. Complications occurred in 7 patients (35.0% of patients, 2.5% of all procedures) and included traumatic bleeding, pneumothorax, overt esophageal perforation, microscopic perforation with cervical osteomyelitis, and perforation at the gastrostomy site. Diet and dysphagia scores were ineffective at directing the schedule for maintenance dilation. The CARD procedure is effective at restoring initial esophageal patency, but must be followed closely with long-term maintenance dilation. Over a large number of dilations, complications are infrequent and difficult to predict. Their incidence may be reduced by use of prophylactic antibiotics, prior removal of a tracheoesophageal prosthesis, avoiding dilation of the gastrostomy tract, modest dilation goal, and scheduled "stricture surveillance" with dilations performed under fluoroscopic guidance.

In Vivo Behavior of Transitional Foods as Compared to Purees: A Videofluoroscopic Analysis

PURPOSE

Medically tailored transitional foods (TFs) may be a clinically viable alternative to pureed consistency for individuals requiring texture-modified foods. However, little remains known about the performance of TFs during the swallow. The purpose of this investigation was to describe oropharyngeal swallowing physiology in patients with dysphagia during consumption of TFs as compared to pureed solids.

METHOD

Retrospective chart reviews were conducted on 31 long-term acute care hospital inpatients (23 males; Mage = 57.5 years), who all had a primary medical diagnosis of acute respiratory failure. All patients received a videofluoroscopic swallow study that included both pureed and transitional solid (Savorease Therapeutic Foods) trials. Swallow function was assessed and described following the Modified Barium Swallow Impairment Profile (MBSImP) interpretation approach.

RESULTS

No statistically significant differences in scores were observed between pureed and transitional solids for any of the MBSImP component scores. Similarly, no statistically significant differences were observed in overall oral or pharyngeal composite scores. Although a majority of the individual patients performed similarly on both consistencies across the components scores, there was some variability across a few scores, with a subset of patients performing better with transitional solids for oral and pharyngeal residue and a subset of patients performing better with pureed solids for bolus preparation and initiation of the pharyngeal swallow. No instances of airway invasion were present across any of the solids trialed.

CONCLUSIONS

The findings of this pilot study revealed that high-dissolving transitional solids did not increase apparent risk as compared to pureed textures, as there were no significant differences in swallowing safety and only some differences were observed in performance between the two textures. These findings may support the use of transitional solids as a "bridge" and safe consistency to facilitate progression to higher, more challenging textures in medically complex persons with dysphagia based on individual performance. This work represents an important initial step toward the integration of transitional solids into evaluation protocols, texture recommendations, and, potentially, into treatment.

Current Technological Advances in Dysphagia Screening: Systematic Scoping Review

BACKGROUND

Dysphagia affects more than half of older adults with dementia and is associated with a 10-fold increase in mortality. The development of accessible, objective, and reliable screening tools is crucial for early detection and management.

OBJECTIVE

This systematic scoping review aimed to (1) examine the current state of the art in artificial intelligence (AI) and sensor-based technologies for dysphagia screening, (2) evaluate the performance of these AI-based screening tools, and (3) assess the methodological quality and rigor of studies on AI-based dysphagia screening tools.

METHODS

We conducted a systematic literature search across CINAHL, Embase, PubMed, and Web of Science from inception to July 4, 2024, following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) framework. In total, 2 independent researchers conducted the search, screening, and data extraction. Eligibility criteria included original studies using sensor-based instruments with AI to identify individuals with dysphagia or unsafe swallow events. We excluded studies on pediatric, infant, or postextubation dysphagia, as well as those using non-sensor-based assessments or diagnostic tools. We used a modified Quality Assessment of Diagnostic Accuracy Studies-2 tool to assess methodological quality, adding a "model" domain for AI-specific evaluation. Data were synthesized narratively.

RESULTS

This review included 24 studies involving 2979 participants (1717 with dysphagia and 1262 controls). In total, 75% (18/24) of the studies focused solely on per-individual classification rather than per-swallow event classification. Acoustic (13/24, 54%) and vibratory (9/24, 38%) signals were the primary modality sources. In total, 25% (6/24) of the studies used multimodal approaches, whereas 75% (18/24) used a single modality. Support vector machine was the most common AI model (15/24, 62%), with deep learning approaches emerging in recent years (3/24, 12%). Performance varied widely-accuracy ranged from 71.2% to 99%, area under the receiver operating characteristic curve ranged from 0.77 to 0.977, and sensitivity ranged from 63.6% to 100%. Multimodal systems generally outperformed unimodal systems. The methodological quality assessment revealed a risk of bias, particularly in patient selection (unclear in 18/24, 75% of the studies), index test (unclear in 23/24, 96% of the studies), and modeling (high risk in 13/24, 54% of the studies). Notably, no studies conducted external validation or domain adaptation testing, raising concerns about real-world applicability.

CONCLUSIONS

This review provides a comprehensive overview of technological advancements in AI and sensor-based dysphagia screening. While these developments show promise for continuous long-term tele-swallowing assessments, significant methodological limitations were identified. Future studies can explore how each modality can target specific anatomical regions and manifestations of dysphagia. This detailed understanding of how different modalities address various aspects of dysphagia can significantly benefit multimodal systems, enabling them to better handle the multifaceted nature of dysphagia conditions.

Dysphagia Symptoms Contribute to Greater Care Partner Burden in Neurodegenerative Disease

PURPOSE

Providing care for family members with neurodegenerative diseases entails significant physical and psychosocial costs, increasing caregiver burden. Limited research exists on the factors contributing to dysphagia-related burden, particularly across disease trajectories. This study aimed to (a) determine if dysphagia-related burden predicts general caregiver burden, (b) identify predictors of dysphagia-related burden, and (c) examine relationships between dysphagia severity, disease severity, and dysphagia-related burden.

METHOD

Care partners (N = 211; 80% female; Mage = 60 ± 14 years) from clinics in Canada, New Zealand, and the United States participated. Care recipients included those with amyotrophic lateral sclerosis (ALS; n = 48), dementia (n = 110), and Parkinson's disease (PD; n = 53). General burden was measured using the Zarit Burden Interview, while dysphagia-related burden was assessed via the Caregiver Assessment of Reported Experiences with Swallowing Difficulties. Multiple regression analyses examined predictors of general and dysphagia-related burden and their relationships to dysphagia and disease severity.

RESULTS

Higher general burden was associated with female caregivers (β = -.19, p = .05), higher education (β = .16, p = .03), caring for someone with dementia (β = .36, p = .01), and greater dysphagia-related burden (β = .33, p = .01). Predictors of dysphagia-related burden included working caregivers (β = .15, p = .01), increased dysphagia symptoms (β = .77, p < .01), and caring for individuals with ALS or dementia (vs. PD; β = -.16, p = .02). Dysphagia burden varied by disease severity and diet tolerance (p < .01).

CONCLUSIONS

Managing dysphagia independently contributes to caregiver burden, potentially increasing burnout and nonadherence to clinical recommendations. Early, proactive inquiry about dysphagia-related care partner burden and provision of support to minimize burden should be considered early in disease management.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.28843055.

Impact of Single-Lumen Versus Double-Lumen Endotracheal Tube on Postoperative Swallowing Function in Lung Transplantation Patients: A Single-Center, Retrospective Cohort Study

Background/Objectives: The role of double-lumen endotracheal tube (DLT) versus single-lumen endotracheal tube (SLT) use during lung transplantation (LTx) and its effects on postoperative dysphagia have not yet been studied. It has been shown that new-onset oropharyngeal dysphagia (OPD) is common after various thoracic surgeries including lung transplantation and that OPD is associated with increased postoperative complications. Methods: A single-center, retrospective cohort study was performed using a data exploration tool in the electronic medical record. Data included demographic characteristics, medical history, postoperative dysphagia measured by Functional Oral Intake Scale (FOIS) via modified barium swallow study (MBSS) within 5 days of surgery, and other secondary outcomes. Results: In univariate analysis, participants who had a DLT (49 patients) had significantly higher FOIS scores (indicating better swallowing function) as compared to those with an SLT (21 patients) (p = 0.035). Lumen type remained significant in a multivariable model, with use of a DLT showing more than a 5-fold increase in the odds of a higher FOIS score after controlling for other factors (p = 0.004; cumulative OR (95% CI): 5.2 (1.7-15.9)). Participants who had a DLT had shorter hospital length of stay (LOS) (p = 0.017; single 18 days (IQR = 13), double 14 days (IQR 7)). Those who had a DLT experienced significantly greater ventilator-free time at postoperative day 30 compared to those who received an SLT (p = 0.018). ICU LOS was similar between those who received a DLT vs. SLT. Conclusions: Overall, DLT seems to confer reduced new-onset OPD after lung transplantation surgery when compared with SLT. The use of DLT instead of SLT for lung isolation for LTx may have the potential to reduce morbidity and mortality in this population.

The Impact of Bolus Rheology on Physiological Swallowing Parameters Derived by Pharyngeal High-Resolution Manometry Impedance

BACKGROUND

The shear rheology of ingested fluids influences their pharyngo-esophageal transit during deglutition. Thus, swallowed fluids elicit differing physiological responses due to their shear-thinning profile.

METHODS

Two hydrocolloid fluids, xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC), were compared in 10 healthy adults (mean age 39 years). Manometry swallowing assessments were performed using an 8-French catheter. Swallows were analyzed using the Swallow Gateway web application (www.swallowgateway.com). Grouped data were analyzed by a mixed statistical model. The coefficient of determination (r2) assessed the relationship between measures and bolus viscosity (SI units, mPa.s) at shear rates of 1-1000 s-1.

KEY RESULTS

Rheology confirmed that the thickened fluids had similar viscosities at 50 s-1 shear rate (XG IDDSI Level-1, 2, and 3 respectively, 74.3, 161.2, and 399.6 mPa.s vs. CMC Level-1, 2, and 3 respectively 78.0, 176.5, and 429.2 mPa.s). However, at 300 s-1 shear, CMC-thickened fluids exhibited approximately double the viscosity (XG Level-1, 2, and 3 respectively 19.5, 34.4, and 84.8 mPa.s vs. CMC Level-1, 2, and 3 respectively, 41.3, 80.8, and 160.2 mPa.s). In vivo swallows of CMC, when compared to XG, showed evidence of greater flow resistance, such as increased intrabolus pressure (p < 0.01) and UES Integrated Relaxation Pressure (UESIRP, p < 0.01) and shorter UES Relaxation Time (p < 0.05) and Bolus Presence Time (p < 0.001). The apparent fluid viscosity (mPa.s) correlated most significantly with increasing UESIRP (r2 0.69 at 50 s-1 and r2 0.97 at 300 s-1, p < 0.05).

CONCLUSION

Fluids with divergent shear viscosities demonstrated differences in pharyngeal function. These physiological responses were linked to the shear viscosity and not the IDDSI level.

Validity and Reliability of Dysphagia Outcome Severity Scale (DOSS) When Used to Rate Flexible Endoscopic Evaluations of Swallowing (FEES)

The Dysphagia Outcome and Severity Scale is used both clinically and within dysphagia research, internationally. Although it was developed using videofluoroscopic swallowing studies, it is frequently used to rate Flexible Endoscopic Evaluations of Swallowing. The validity and reliability of DOSS-use with FEES, however, has not previously been evaluated. This study investigated the validity and rater reliability of clinicians using DOSS to rate FEES. Eleven Speech-Language Pathologists (SLPs) with varied dysphagia experience were recruited to review and DOSS-rate 17 soundless FEES (198 bolus swallows) recorded from 11 heterogenic dysphagic patients (2 cases with repeat FEES) and 4 healthy adults. The SLPs DOSS-ratings were compared against the initial comprehensive dysphagia evaluation (including patient diagnosis, interview, cranial nerve and complete FEES assessment) with Functional Oral Intake Scale (FOIS) and DOSS outcome measures. The SLPs were blinded to patient details and comprehensive dysphagia examination. Re-randomised rating of FEES cases occurred two weeks later (intra rater reliability). Criterion validity for DOSS-ratings (compared against comprehensive dysphagia evaluation with FOIS and DOSS) were strong-very strong (rs = 0.858 and 0.936 respectively; p < 0.001). Inter rater reliability demonstrated high agreement (α = 0.891), also intra rater reliability demonstrated almost perfect agreement (Kw = 0.945). This study's results, with strong-very strong criterion validity and high rater reliability by SLPs, adds to the evidence for DOSS-use with FEES. Future validity research comparing DOSS with both FEES and VFSS simultaneously is recommended.

Manual Therapy for Fibrosis-Related Late Effect Dysphagia in Head and Neck Cancer Survivors: The MANTLE Nonrandomized Clinical Trial

Importance

Late radiation-associated dysphagia (RAD) after head and neck cancer (HNC) treatment is challenging and commonly treatment refractory, with fibrosis stiffening connective tissues and compressing peripheral nerve tracts, contributing to diminished strength and possibly denervation of swallowing muscles. Manual therapy (MT), while common for cancer-related pain and other indications, remains largely unstudied for fibrosis-related late RAD.

Objective

To determine the feasibility and safety of MT, estimate effect size and durability of MT for associated improvements in cervical range of motion (CROM), and examine functional outcomes after MT in survivors of HNC with fibrosis-related late RAD.

Design, Setting, and Participants

This nonrandomized clinical trial, Manual Therapy for Fibrosis-Related Late Effect (MANTLE) Dysphagia in Head and Neck Cancer Survivors, is a prospective, single-institution, pilot, single-arm supportive care trial conducted at a National Comprehensive Cancer Network-designated academic comprehensive cancer center. Participants were adult survivors of HNC who were disease free at 2 or more years after curative-intent radiotherapy with grade 2 or higher fibrosis (per Common Terminology Criteria for Adverse Events version 4.0) and grade 2 or higher dysphagia (per video fluoroscopy Dynamic Imaging Grade of Swallowing Toxicity [DIGEST]). Data were collected June 2018 to July 2021 and analyzed November 2022 to November 2024.

Intervention

MANTLE included 10 hourly MT sessions by lymphedema-certified speech-language pathologists over 6 weeks with a home exercise program. During the subsequent 6-week washout period, participants implemented only the home exercise program, without clinician MT.

Outcomes and Measures

Primary end points were feasibility (per therapy completion rate, with a 75% target) and safety. Secondary end points included functional outcomes per CROM, dysphagia severity (per DIGEST), maximum interincisal opening (MIO), and validated participant-reported outcomes (PROs).

Results

Among 24 survivors of HNC (20 male [83.3%]; median [range] age, 68 [53-80] years), there was a median (range) of 8.9 (2.4-30.2) years after curative-intent radiotherapy. A total of 22 participants (91.7%) completed the 10 prescribed therapy sessions, and 1 participant experienced a severe adverse event. Secondary end points improved among participants who completed the therapy: MIO (r = 0.76; 95% CI, 0.66 to 0.94) and all 6 planes of CROM (eg, cervical extension: r = 0.86; 95% CI, 0.83 to 0.93) improved, with large effect sizes from baseline to after MT. Large to moderate effect sizes were achieved in symptom measures per PROs (eg, lymphedema-fibrosis symptom severity after MT: r = 0.74; 95% CI, 0.63 to 0.99). However, effect sizes were small to moderate or null in uncompensated swallowing outcome measures (eg, MD Anderson Dysphagia Inventory composite score from baseline to after MT: r = 0.38; 95% CI, 0.07 to 0.73).

Conclusions

This study found that MT was safe and feasible in long-term survivors of HNC with late RAD and was associated with several functional, physical, and psychosocial gains. This trial may offer insight into next directions to optimize swallowing outcomes by integrating MT into a comprehensive rehabilitation program.

Trial Registration

ClinicalTrials.gov Identifier: NCT03612531.

Effect of Thickened Fluids on Swallowing Function in Oropharyngeal Dysphagia: Impact of Shear Rheology and Disorder Subtype

INTRODUCTION

Fluid thickeners used in the management of oropharyngeal dysphagia exhibit non-Newtonian shear-thinning rheology, impacting their viscosity during deglutition. This study investigated how the rheological properties of thickened fluids affect pharyngeal swallowing parameters in patients with oropharyngeal motor disorders diagnosed by pharyngeal high-resolution manometry impedance (P-HRM-I).

METHODS

Seventy-two patients (18-89 years) referred for P-HRM-I were diagnostically assessed with a 10 mL thin bolus. In 57 of the patients, 10 mL swallows of two moderately thick formulations-xanthan gum (XG) and sodium carboxymethylcellulose gum (CMC)-were also tested. The XG and CMC fluids had equivalent empirical thickness but different viscosity at pharyngeal phase shear rates: XG 87 mPa.s (83-91) versus CMC mean 157 mPa.s (148-164) at 300 s-1. Standard metrics of pharyngeal and upper esophageal sphincter (UES) function were derived from P-HRM-I recordings and analyzed to characterize patients into one of four disorder subtypes: (i) No Disorder, (ii) UES Disorder, (iii) Pharyngeal Disorder, and (iv) Combination UES/Pharyngeal Disorder. Impedance recordings also assessed pharyngeal bolus transit.

RESULTS

Patients with a Combination UES/Pharyngeal Disorder were most likely to have abnormal bolus transit (82%, p < 0.001). Increasing bolus viscosity significantly influenced UES residual pressure, UES opening area, and post-swallow residue. Patients with UES Disorder exhibited pronounced increases in UES residual pressure with CMC compared to XG. Pharyngeal contractility was unaffected by viscosity changes. Post-swallow residue increased with CMC, particularly in patients with a Combination Disorder. Case-by-case analysis revealed individual variability in response to the different viscosities.

CONCLUSION

The rheological properties of thickened fluids significantly affect swallowing function, with these effects dependent upon the disorder subtype.

Mandarin Chinese Translation and Cultural Adaptation of the Caregiver Analysis of Reported Experiences With Swallowing Disorders Screening Tool

PURPOSE

The caregiver burden of individuals with dysphagia is a major concern. Currently, assessment tools specifically designed for this population are lacking. The present study aimed to translate the Caregiver Analysis of Reported Experiences with Swallowing Disorders (CARES) Questionnaire into Mandarin Chinese and evaluate its psychometric properties.

METHOD

This study analyzed the psychometric properties of the Mandarin Chinese version of the CARES questionnaire using classical measurement theory and Rasch model analysis.

RESULTS

Classical measurement theory: The item-level content validity index of the Mandarin Chinese version of the CARES questionnaire ranged from .83 to 1.00, and the scale-level content validity index ranged from .93 to .95. The correlation coefficient between the total scores, subscale scores of the CARES questionnaire, and Zarit Caregiver Burden Interview scores was between .82 and .87 (p < .01). There were significant relationships between dysphagia-specific burden (CARES) and perceived swallowing impairment (Eating Assessment Tool-10) and diet restrictiveness (International Dysphagia Diet Standardisation Initiative Functional Diet Scale). The overall Cronbach's α coefficient of the Mandarin Chinese version of the CARES questionnaire was .81. Item response theory: The Mandarin Chinese version of the CARES questionnaire was unidimensional. The item difficulty and individual ability were evenly distributed. The total item reliability was .96, the person reliability was .79, the item separation index was 4.95, and the person separation index was 1.93.

CONCLUSION

The Mandarin Chinese version of the CARES questionnaire demonstrates satisfactory reliability and validity and can be utilized as a specific assessment tool for evaluating the informal caregiver burden of individuals with dysphagia.

Validation of the Caregiver Analysis of Reported Experiences with Swallowing Disorders (CARES) Screening Tool for Neurodegenerative Disease

PURPOSE

Swallowing difficulties have a substantial impact on the burden experienced by care partners of individuals with neurodegenerative disease. Given this, there is a clear need to easily identify and quantify the unique aspects of swallowing-related burden. The purpose of this study was to establish the validity and reliability of the Caregiver Analysis of Reported Experiences with Swallowing Disorders (CARES) screening tool in care partners of individuals with neurodegenerative disease.

METHOD

Survey data were collected from an international sample of 212 individuals caring for family members with amyotrophic lateral sclerosis (n = 49), dementia (n = 110), or Parkinson's disease (n = 53). Respondents completed the CARES, Eating Assessment Tool-10, International Dysphagia Diet Standardisation Initiative-Functional Diet Scale, and Zarit Burden Interview. Reliability and validity of the CARES were evaluated via internal consistency alpha coefficients, Spearman's rho correlations, and logistic regression analyses with receiver operating characteristic (ROC) curves.

RESULTS

CARES scores demonstrated excellent internal consistency (α = .90-.95) and high test-retest reliability (r = .86-.91). The CARES was found to be valid, as increased swallowing-related burden was associated with increased severity of swallowing difficulties (r = .79 to .84), diet restrictiveness (r = -.50 to -.54), and general caregiver burden (r = .36 to .40). The CARES had excellent discrimination between care partners with and without self-reported swallowing-related burden, with a score of ≥ 4 suggesting a heightened risk of experiencing this burden.

CONCLUSIONS

Results establish the CARES as a valid and reliable screening tool that can detect burden related to swallowing difficulties among care partners of individuals living with neurodegenerative disease (score ≥ 4). Clinical implementation of the CARES requires the concerted efforts of the larger multidisciplinary team who can collaboratively identify the presence of burden and target the multifaceted sources of burden that a care partner may be experiencing.

Validation of the Polish version of the Functional Oral Intake Scale against flexible endoscopic evaluation of swallowing and the International Dysphagia Diet Standardization Initiative Functional Diet Scale

Introduction

The Functional Oral Intake Scale (FOIS) is a widely used instrument for assessing oral intake in dysphagic patients. Despite its frequent use, a validated version for the Polish population has been lacking.

Methods

This study aimed to validate the Polish adaptation of FOIS (FOIS-PL) by examining its concordance with Fiberoptic Endoscopic Evaluation of Swallowing (FEES) outcomes and the International Dysphagia Diet Standardization Initiative Functional Diet Scale (IDDSI-FDS) scores across patients with diverse clinical profiles. The primary outcome measures included the Penetration-Aspiration Scale (PAS) score from FEES, pharyngeal residue quantification, and IDDSI-FDS scores. A total of 302 participants with varying clinical conditions were recruited. The cohort included individuals with head and neck malignancies, cerebrovascular incidents, neuromuscular disorders, and other dysphagia aetiologies.

Results

Patients with gastroesophageal reflux disease and those post-thyroidectomy consistently exhibited oral food intake with a FOIS-PL score of ≥5. A strong inverse correlation was found between FOIS-PL scores and PAS scores (rho = -0.739; p < 0.001), indicating that reduced oral intake was associated with increased penetration or aspiration risk. Significant differences in FOIS-PL scores were evident across patient subgroups stratified by PAS severity (PAS ≤ 2, PAS 3-5, PAS > 5) and IDDSI levels. Lower FOIS-PL scores corresponded with more impaired swallowing safety (PAS > 5). The median FOISPL score was 5 for individuals with pharyngeal residue and 6 for those without (p < 0.001). Inter-rater reliability between evaluations conducted by a dietitian (FOIS I) and a speech-language pathologist (FOIS II) demonstrated high consistency (tau = 0.995; p < 0.001). Convergent validity was supported by strong correlations between FOIS-PL and IDDSI-FDS scores (FOIS I vs. IDDSI-FDS I: tau = 0.819; p < 0.001; FOIS II vs. IDDSI-FDS II: tau = 0.815; p < 0.001).

Conclusion

The Polish version of the Functional Oral Intake Scale (FOIS-PL) is a valid and reliable tool for assessing oral intake in dysphagia. The findings demonstrate high accuracy, reliability, and validity, supporting its use across diverse clinical conditions.

The development of thickened fermented rice milk formulation for people with dysphagia: A view of multiple in vitro simulation methods

Based on the huge blank of thickened fluid staple food for people with dysphagia, multiple in vitro simulations were utilized to develop the thickened fermented rice milk. Here, the effect of amylase content, hydrolysis time and thickener content were considered. The rheological study and Cambridge throat evaluation revealed that hydrolysis could significantly reduce the viscosity and yield stress of fermented rice milk, accompanied by the decreased swallowing residue. The addition of thickeners increased the viscosity and cohesion of the fermented rice milk due to the entanglement network formation, which facilitated the formation of lubricating film, decreased the coefficient of friction, and improved the sensory score. Increasing thickener content from 0 % to 0.5 % induced the longer oral transition time (0.26 s to 0.45 s), more residue (0.85 g to 2.07 g) and shorter stretching length (850.42 mm to 313.62 mm) shown in the Cambridge throat simulation. Among them, the fermented rice milk with 0.40 % thickener showed the best sensory properties, and its swallowing properties evaluated by computer simulation also suggested concentrated frequency distribution of velocity, shear rate and viscosity without splashing or choking compared with the normal fermented rice milk, showing excellent swallowing safety.

Volume-viscosity swallow test to facilitate individualized dietary modifications for dysphagia following intracerebral hemorrhage

PURPOSE

This study examined the effects of individualized dietary modifications based on the volume-viscosity swallow test (V-VST) on functional oral intake, incidence of pneumonia, and swallowing-related quality of life in individuals with intracerebral hemorrhage.

METHODS

One hundred and seven participants with signs of dysphagia in the acute and early subacute phases of stroke following intracerebral hemorrhage were randomly assigned into an experimental group for individualized dietary modifications based on V-VST plus routine standard care (n = 53), and a control group for routine care alone (n = 54). Incidence of pneumonia, functional oral intake scale (FOIS) ratings and Eating Assessment Tool (EAT-10) scores before and after intervention were evaluated.

RESULTS

A significantly lower incidence of pneumonia was found in the experimental group than in the control group (p < 0.05). Significant group differences were found in functional oral intake and in quality of life, with significantly higher FOIS ratings and significantly lower EAT-10 scores in the experimental group post-intervention (p < 0.001).

CONCLUSION

These findings suggested that despite being a noninstrumental screening tool, V-VST could facilitate individualized dietary modifications and could be an effective clinical option for reducing the risk of pneumonia, improving functional oral intake and enhancing quality of life in individuals with dysphagia following intracerebral hemorrhage. Future studies should explore how dietary modifications could be more precisely implemented based on the International Dysphagia Diet Standardization Initiative framework.

Fish Protein Hydrolysate as Protein Enrichment in Texture-Modified Salmon Products

The aim of this study was to develop a chilled, texture-modified salmon product for dysphagia patients, enriched with dairy and fish hydrolysate proteins. The challenge was to create a product with appealing sensory qualities and texture that meets level 5 (minced & moist) of the IDDSI framework. Atlantic salmon (Salmo salar) was heat-treated (95 °C/15 min), blended, and reconstructed by adding texture modifiers, casein and whey protein, and enzymatically derived fish hydrolysate. The products were packaged in oxygen-free plastic trays, heat-treated to a core temperature of 95 °C for 15 min, chilled and stored at 4 °C for 29 days and analyzed for microbiology, instrumental texture, and sensory properties. The texture analyses showed that products with fish protein hydrolysate were softer than those only with casein and whey protein, a result also confirmed by the IDDSI fork pressure test. Quantitative descriptive analysis of salmon products revealed significant differences (p < 0.05) in sensory attributes within flavour (fish flavour), and texture (softness and adhesiveness) but there was no significant change in bitterness. The shelf-life study at 4 °C showed good microbiological quality of the product, and safety after 29 days with appealing sensory and textural properties, i.e., a product at IDDSI level 5 for age care facilities and commercial production was obtained.

The Influence of Strength and Skill Parameters on the Evolution of Dysphagia Post Stroke: A Prospective Study

The role of pathophysiological deficits in the evolution of dysphagia post-stroke is unclear. This observational, longitudinal study aimed to document the evolution and relationship between strength and precision of submental contraction, and swallowing outcomes at six months. Participants were recruited from a tertiary acute hospital after a first acute stroke. Sociodemographic data and stroke typology were documented. Outcome measures were collected five times across six months. These included: oral diet (FOIS, IDDSI), functional ingestion (TOMASS, TWST), self-reported swallowing-related quality of life (SWAL-QOL), and submental muscle strength and precision contraction as assessed using surface electromyography coupled with biofeedback during saliva swallowing and jaw-opening tasks. Mixed effects models and multiple regressions analyses were conducted. Participants (N = 22, mean age 73.9 ± 14.4 years, 9 males) were recruited at a mean time of 2.8 ± 1.5 days after stroke. Strength parameters (effortful swallow hit rate) improved between ten days and one month post-stroke (p = 0.04). Swallowing temporal precision improved significantly between one and six months (p < 0.01). At six months, participants with decreased swallowing precision also had decreased quality of life (p = 0.04) and increased ingestion time of fluids (p = 0.002). This study is a novel step in exploring the nature and evolution of strength and precision parameters of swallowing muscle activation, and their impact on dysphagia recovery. As swallowing precision was associated with poorer functional outcomes, further studies are warranted to improve early differential diagnosis of patients at risk of chronic dysphagia.

Effects of a nutrition education intervention on food-provision managerial decisions in Catalan old age nursing homes

INTRODUCTION

Existing research does not provide definitive conclusions on the most effective initiatives for preventing malnutrition among older adult residents in nursing homes.

OBJECTIVE

We aimed to assess whether a nutrition education intervention provided to nursing home managers can improve dietary managerial decisions within nursing homes.

METHODS

We performed a multicenter study, where each center was randomized to an intervention or a control group. To ensure homogeneous group representation, we stratified the sample based on the facility size and the availability of kitchen equipment. The baseline survey contained questions related to center characteristics, kitchen size and availability of cooking tools, availability of different daily menu options and the staff working in the kitchen. The follow-up survey included questions about the staff responsible for making nutritional decisions, the degree of food handling, the availability of texture-modification tools, and the residents' satisfaction. We use ordered probit regression models to estimate the effect of the educational intervention on decisions around food management.

RESULTS

From the 238 nursing homes that responded to the initial survey, 176 were followed-up; 56 were allocated to the intervention group and 120 to the control group. There were 53.32 residents per center among the treated group and 40.82 residents in the non-treated institutions. The intervention increased by 24% the nursing homes' probability of increasing their stock of texture-modification tools, which rose to 26% after controlling for the effect of receiving specific training on textures or presentation, compared to the control group.

CONCLUSIONS

The intervention improved managerial decisions in nursing homes concerning meal presentation through an increase in the number of cooking tools. Incorporating structured and comprehensive sessions to improve food texture and presentation could help fight the risk of residents' malnutrition.

An Unusual Case of Contralateral Hypoglossal and Recurrent Laryngeal Nerve Palsies Following Endotracheal Intubation

We present an unusual case of a 62-year-old male presenting with contralateral hypoglossal and recurrent laryngeal nerve palsies following endotracheal intubation for emergency cardiac surgery. Postoperative, the patient was referred to Speech and Language Therapy due to concerns regarding the safety of his swallow. Oromotor assessment revealed left-sided tongue weakness and aphonia. Flexible endoscopic evaluation of swallowing (FEES) revealed a right vocal cord palsy and severe oropharyngeal dysphagia. There were no other focal neurological signs. An MRI head did not demonstrate a medial medullary stroke or other intracranial lesion. CT neck showed no abnormality identified in relation to the course of the right vagus nerve or recurrent laryngeal nerve at the skull base or through the neck respectively. The patient required a gastrostomy for nutrition and hydration. He continued to be assessed at several month intervals over the course of a year using FEES to obtain a range of voice, secretion and swallowing outcome measures. The patient commenced intensive dysphagia therapy targeting pharyngeal drive, hyolaryngeal excursion and laryngeal sensation. Swallow manoeuvres were trialled during FEES and a head-turn to the side of the vocal cord palsy during deglutition reduced aspiration risk which expedited return to oral intake. The patient had partial recovery over twelve months. Hypoglossal nerve palsy completely resolved. The right vocal cord remained paralysed however the left vocal cord compensated enabling the patient to produce a normal voice. The patient was able to take thin fluids and regular diet and the gastrostomy was removed.

Understanding user experience and normative data in pharyngeal residue rating scales used in flexible endoscopic evaluation of swallowing (FEES): A scoping review

PURPOSE

Pharyngeal residue rating scales are often used to rate pharyngeal residue observed during flexible endoscopic evaluation of swallowing. Despite the widespread use of pharyngeal residue rating scales, there is no data that has systematically explored user experience. The aim of this scoping review was to investigate specific reporting of user experience, user centred design principles, and normative data in the development of pharyngeal residue rating scales.

METHOD

A scoping review was conducted across four electronic databases inclusive of all dates until June 2024. Grey literature searching occurred in March-April 2023 and was repeated in June 2024. This review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) protocol. Titles/abstracts, full texts, and data extraction were reviewed by two independent reviewers.

RESULT

A total of 22 sources were included, with 18 unique pharyngeal residue rating scales identified. Two studies referred to user experience, seven included at least one user centred design principle, and four studies reported on normative data.

CONCLUSION

The findings of this review highlight few pharyngeal residue rating scales include the experience of the intended user and establish normative data in the initial development phase. User experience, user centred design principles, and normative data may be useful considerations to optimise functionality.

Exercise-Based Dysphagia Treatment: A Proposed Checklist

PURPOSE

Oropharyngeal swallowing exercise-based interventions are frequently utilized to target physiologic mechanisms with the goal of improving swallowing function. However, study replicability and evidence synthesis regarding effects of interventions are limited due to inconsistent reporting on factors known to influence treatment delivery. In order to promote consistency of reporting factors associated with replicability, the authors constructed a set of preferred parameters focused on dysphagia as part of the initial version of the larger tool (Framework for RigOr aNd Transparency In REseaRch on Swallowing or FRONTIERS).

METHOD

Thirty-eight initial questions were assembled by the authors as part of the treatment subsection. Questions were then reviewed by individuals in the FRONTIERS collaborative who have expertise in research, clinical practice, or both.

RESULT

Twenty-four questions were removed following review, reducing the final set of treatment-focused questions to 14 questions.

CONCLUSIONS

The revised set of questions provides users of the exercise-based treatment section of the FRONTIERS checklist with an initial checklist to promote transparency and rigor to improve study replicability and evidence synthesis. We intend for this treatment section of FRONTIERS to undergo further refinement following commentary and feedback.

Impact of Reducing Fluoroscopy Pulse Rate on Adult Modified Barium Swallow Studies

Modified Barium Swallow Studies (MBSS) are a critical part of the evaluation, treatment planning, and outcome assessment for persons with swallowing disorders. Since MBSSs use ionizing radiation with associated cancer risks, many clinicians have reduced radiation exposure by reducing the fluoroscopic pulse rate. However, by reducing pulse rate, we also decrease the temporal resolution of MBSSs which has been shown in pilot studies to significantly reduce diagnostic accuracy. Two hundred MBSSs from patients routinely undergoing MBSS as standard of care conducted at 30 pulses per second (pps) using the Modified Barium Swallow Study Impairment Profile (MBSImP™) standardized administration protocol were selected. A stratified sampling method ensured that a full range of swallowing impairments (etiology, type, and severity) was represented. Recordings were down sampled from 30 pps to 15, 7.5, and 4 pps. MBSSs were rated using the MBSImP components and Penetration-Aspiration Scale (PAS) score for each swallow. Percent agreement was calculated across raters for MBSImP and PAS scores by bolus type and volume. The Least-Squares Method was used for hypothesis testing. Statistically significant and clinically meaningful changes in scores of swallowing physiology and penetration/aspiration occurred when reducing pulse rate below 30pps. These changes were evident across bolus types and volumes. Given the impact on diagnostic accuracy and the low radiation risks to adults undergoing MBSSs, reducing pulse rate to 15pps or below is not aligned with the As Low As Reasonably Achievable (ALARA) principle and should not be used as a viable method to reduce radiation exposure from MBSSs.

Assessment and Rehabilitation Intervention of Feeding and Swallowing Skills in Children with Down Syndrome Using the Global Intensive Feeding Therapy (GIFT)

BACKGROUND

Children with Down syndrome (DS) experience more difficulties with oral motor skills, including chewing, drinking, and swallowing. The present study attempts to measure the preliminary effectiveness of Global Intensive Feeding Therapy (GIFT) in DS. GIFT is a new rehabilitation program addressing the specific difficulties and needs of each child, focusing on sensory and motor oral abilities. It follows an intensive schedule comprising 15 sessions over 5 consecutive days, with 3 sessions per day. The principles of GIFT are applied with specific objectives for DS.

METHODS

GIFT was preliminarily implemented among 20 children diagnosed with DS. To measure the efficacy of GIFT, the Karaduman Chewing Performance Scale (KCPS), the International Dysphagia Diet Standardization Initiative (IDDSI), and the Pediatric Screening-Priority Evaluation Dysphagia (PS-PED) were used. Data were analyzed using the Wilcoxon signed-rank test before (T0) and after intervention (T1) and at one-month follow-up (T2). The effect size was also measured for specific outcomes, using Kendall's W.

RESULTS

Our findings revealed that children with DS showed no risk of dysphagia according to the PS-PED (mean score 2.80). Furthermore, statistically significant improvements in chewing performance were observed, as measured by the KCPS (p < 0.01), as well as in texture acceptance and modification, as measured by the IDDSI post-intervention (p < 0.01). For both the KCPS and IDDSI, a large effect size was found (Kendall's W value > 0.8). Parents/caregivers continued using GIFT at home, and this allowed for a positive outcome at the one-month follow-up.

CONCLUSIONS

GIFT proved to be effective in the rehabilitation of feeding and swallowing disorders in children with DS, as well as for food acceptance.

The effect of real versus sham intermittent theta burst transcranial magnetic stimulation combined with conventional treatment on poststroke dysphagia: a randomized controlled trial

Repetitive transcranial magnetic stimulation to the pharyngeal motor cortex has shown beneficial effects on poststroke dysphagia. Previous studies, however, using intermittent theta burst stimulation (iTBS) for dysphagia have targeted the suprahyoid motor cortex. This study aimed to investigate the effects of iTBS to the pharyngeal motor cortex in patients with poststroke dysphagia, using ultrasound and videofluoroscopic swallowing studies (VFSS). A randomized controlled trial was conducted on patients with dysphagia due to a first-time unilateral stroke. Patients who had signs and symptoms of dysphagia and showed aspiration or penetration on VFSS were included. Twenty-eight patients were randomly assigned to either real or sham iTBS groups, and each patient underwent five sessions of iTBS to the ipsilesional pharyngeal motor cortex. Each iTBS session was followed by conventional dysphagia treatment for 30 min. The hyoid-larynx approximation measured by ultrasound, penetration-aspiration scale (PAS) and functional dysphagia scale (FDS) assessed by VFSS were evaluated before and after completion of iTBS. There were no significant differences between the two groups in terms of demographic and clinical characteristics, including age and type of stroke. The hyoid-larynx approximation ratio increased in the real iTBS group and decreased in the sham iTBS group (median values of pre-post differences were 0.27 vs. -0.01, P  < 0.001). The PAS and FDS showed greater improvements in the real iTBS group than in the sham iTBS group (median values of pre-post differences of the PAS were -2.50 vs. 0.00, P  = 0.004; median values of pre-post differences of the FDS were -12.50 vs. -2.50, P  < 0.001). No adverse effects were reported during or after iTBS sessions. Five-session iTBS to the pharyngeal motor cortex combined with conventional treatment led to a significant improvement in poststroke dysphagia in terms of hyoid-larynx approximation which is related to the suprahyoid muscle. Considering the short duration of one iTBS session, this can be an efficient and effective treatment tool for patients with this condition.

Ultrasonographic analysis of the hyoid bone distance in individuals with neurogenic oropharyngeal dysphagia

To compare the ultrasound measurement of distance from the approximation of the hyoid bone during of the maximum deglutition peak between healthy individuals and neurogenic dysphagic individuals and to verify the effect of food consistencies on the displacement of the hyoid bone. Prospective, controlled clinical study. Ultrasound recordings of the oropharyngeal deglutition were conducted in 10 adults diagnosed with oropharyngeal dysphagia and in 10 healthy adults, matched by sex and age group. A portable ultrasound model Micro ultrasound system with a microconvex transducer 5-10 MHz, coupled to a computer as well as the head stabilizer were used. The ultrasound images were recorded using the AAA software (Articulate Assistant Advanced) at a rate of 120 frames/second. Food consistencies level 0 (free volume and 5 mL) and level 4 (5 mL) were used, based on the International Dysphagia Diet Standardisation Initiative (IDSSI). The calculation of the mean and standard deviation was used for the descriptive analysis, while the repeated measures ANOVA test was used for the inferential analysis. Results showed dysphagic individuals had lower elevation of the hyoid bone marked by a longer distance from the approximation of the hyoid bone during of the maximum deglutition peak when compared to healthy individuals, regardless of the food consistency offered. It was concluded that the ultrasound measurement of distance from the approximation of the hyoid bone during of the maximum deglutition peak showed less laryngeal elevation in individuals with neurogenic oropharyngeal dysphagia when compared to healthy individuals for all food consistencies offered.

Apnea behavior in early- and late-stage mouse models of Parkinson's disease: Cineradiographic analysis of spontaneous breathing, acute stress, and swallowing

This study aimed to evaluate the timing and frequency of spontaneous apneas during breathing and swallowing by using cineradiography on mouse models of early/initial or late/advanced Parkinson's disease (PD). C57BL/6 J mice received either 6-OHDA or vehicle injections into their right striatum, followed by respiratory movement recordings during spontaneous breathing and swallowing, and a stress challenge, two weeks later. Experimental group animals showed a significantly lower respiratory rate (158.66 ± 32.88 breaths/minute in late PD, 173.16 ± 25.19 in early PD versus 185.27 ± 25.36 in controls; p<0.001) and a significantly higher frequency of apneas (median 1 apnea/minute in both groups versus 0 in controls; p<0.001). Other changes included reduced food intake and the absence of swallow apneas in experimental mice. 6-OHDA-induced nigrostriatal degeneration in mice disrupted respiratory control, swallowing, stress responsiveness, and feeding behaviors, potentially hindering airway protection and elevating the risk of aspiration.

Tongue Pressure Resistance Training for Post-Stroke Dysphagia: A Case Study

INTRODUCTION

Swallowing outcomes regarding lingual resistance training have been mixed due to variability in methods, leading to ambiguity concerning the utility of this intervention. The purpose of this study was to explore the effect of a lingual resistance training protocol on the swallowing function of an individual presenting with dysphagia and reduced tongue pressure following a supratentorial ischemic stroke.

METHODS

A study involving a lingual resistance training protocol with videofluoroscopy to measure outcomes comparing different parameters to ASPEKT normative reference values at three timepoints: baseline (videofluoroscopic swallowing study [VFSS] A), following a 4-week lead-in period to control for spontaneous recovery (VFSS B), and at the 8-week endpoint of treatment (VFSS C). The study was interrupted due to the COVID-19 pandemic after 1 participant enrollment and is presented as a single case study.

RESULTS

Isometric tongue pressures: Following the 4-week lead-in, a decline in maximum isometric anterior tongue pressure (MAIP) and regular effort saliva swallow pressures (RESS) was noted; however, there was no change in maximum posterior isometric tongue pressures (MPIP). Isometric tongue pressures improved post-treatment, with increases in MAIP, MPIP, and to a lesser degree RESS. Swallowing function: Impairments in swallowing safety continued between the baseline VFSS A (Penetration-Aspiration Scale score [PAS] = 8) and lead-in VFSS B (PAS = 5). Swallowing safety improved following the intervention, with PAS scores = 1 at the endpoint VFSS C. Pixel-based measures of swallowing efficiency revealed a reduced frequency of post-swallow total pharyngeal residue following the treatment. Improvements were found in two other swallowing parameters, laryngeal vestibule closure integrity and pharyngeal area at maximum pharyngeal constriction, at the endpoint VFSS.

CONCLUSION

These pilot data suggest improvements in some swallowing parameters as an outcome of intervention.

Swallowing Rehabilitation: Tracing the Evolution of Assessment and Intervention Approaches for Dysphagia over 30 Years

Dysphagia or difficulty in swallowing is a common condition affecting millions worldwide. It can occur due to structural problems, neurological disorders, cancer treatment, aging, etc. Swallowing rehabilitation aims to help patients regain safe and efficient swallowing function through compensatory strategies and exercises. This literature review examines the recent advancements in swallowing rehabilitation techniques over the past three decades, with a focus on innovations in diagnostics, personalized medicine, and patient care.

Polysaccharide-dextrin thickened fluids for individuals with dysphagia: recent advances in flow behaviors and swallowing assessment methods

The global aging population has brought about a pressing health concern: dysphagia. To effectively address this issue, we must develop specialized diets, such as thickened fluids made with polysaccharide-dextrin (e.g., water, milk, juices, and soups), which are crucial for managing swallowing-related problems like aspiration and choking for people with dysphagia. Understanding the flow behaviors of these thickened fluids is paramount, and it enables us to establish methods for evaluating their suitability for individuals with dysphagia. This review focuses on the shear and extensional flow properties (e.g., viscosity, yield stress, and viscoelasticity) and tribology (e.g., coefficient of friction) of polysaccharide-dextrin-based thickened fluids and highlights how dextrin inclusion influences fluid flow behaviors considering molecular interactions and chain dynamics. The flow behaviors can be integrated into the development of diverse evaluation methods that assess aspects such as flow velocity, risk of aspiration, and remaining fluid volume. In this context, the key in-vivo (e.g., clinical examination and animal model), in-vitro (e.g., the Cambridge Throat), and in-silico (e.g., Hamiltonian moving particles semi-implicit) evaluation methods are summarized. In addition, we explore the potential for establishing realistic assessment methods to evaluate the swallowing performance of thickened fluids, offering promising prospects for the future.

Predictors of Swallowing-Related Quality of Life in United States Veterans with Dysphagia

While both dysphagia and poor health-related quality of life frequently occur in United States (US) Veterans, swallowing-related quality of life in this population has not been systematically examined. This retrospective clinical observation study aimed to determine the independent predictors of swallowing-related quality of life for a sample of US Veterans. We examined the following variables in a multivariate analysis to determine the predictors of Swallowing Quality of Life Questionnaire scores: demographic information, Modified Barium Swallow Impairment Profile (MBSImP) scores, Penetration-Aspiration Scale scores, anterior lingual pressures, and Functional Oral Intake Scale scores. MBSImP oral phase score was the only variable that reached statistical significance (p ≤ 0.01), demonstrating that a more severe physiologic impairment in the oral phase of swallowing was independently predictive of worse swallowing-related quality of life. These findings highlight the need for clinicians to consider how impairments in swallowing physiology may impact the quality of life more broadly for patients with dysphagia.

Translation, and validation of Dysphagia Outcome and Severity Scale (DOSS): Swedish version

BACKGROUND

Swallowing dysfunction (dysphagia) significantly impacts patient and medical outcomes. In Sweden, there is no comprehensive outcome measure for dysphagia that incorporates holistic assessment and dysphagia impact on a person's impairment, function and participation. The Dysphagia Outcome and Severity Scale (DOSS) was developed and validated (in English) and incorporates the World Health Organisation's (WHO) aforementioned, International Classification of Functioning (ICF) aspects. This study translated then evaluated the validity and reliability of the Swedish version, DOSS-S.

METHOD

Translation occurred based on WHO recommendations. The Content Validity Index (CVI) of the translated version (DOSS-S) was assessed twice by 11 (multi-professional) dysphagia experts. Criterion validity and rater reliability was calculated using 18 Speech Pathologists assessing patient cases from International Dysphagia Diet Standardization Initiative-Functional Diet Scale (IDDS-FDS) research.

RESULTS

Very high CVI values (0.96-0.99) for the linguistic correlation, and high CVI values (0.84-0.94) for applicability correlation were achieved. High criterion validity of DOSS-S with IDDSI-FDS was demonstrated (rs = 0.89, p < 0.01), with very high inter and intra rater reliabilities (ICC > 0.90).

CONCLUSION

The DOSS-S demonstrated very high validity values, and very high inter and intra rater reliability. This research contributes to improved dysphagia management by providing interprofessional dysphagia clinicians with a validated scale to identify patient progression, communicate dysphagia status between regions and countries, and document patient outcomes using an ICF framework.

Pharyngeal Squeeze Maneuver During Endoscopy-What Does it Tell Us?

OBJECTIVES

Diminished pharyngeal constriction is a common biomechanical deficit associated with dysphagia and holds strong predictive value for aspiration. Pharyngeal squeeze manoeuvre (PSM) was previously validated for evaluating pharyngeal constriction on endoscopy. However, PSM is not routinely used in laryngology clinics or flexible endoscopic evaluation of swallowing (FEES) protocols worldwide. This study explored PSM in the acute care setting and its relationship with swallowing safety and efficiency, other swallowing biomechanical functions, and clinical outcomes.

METHODS

This prospective observational study consented 222 consecutive inpatients of mixed aetiology who were receiving FEES as part of their standard care. Established FEES protocols were performed including assessment of secretion accumulation, urge-to-clear ratings, laryngeal motor, and sensory functional tests, PSM, as well as aspiration, and residue during oral trials. Swallow frequency and cough peak flow were also collected as well as clinical outcomes at discharge.

RESULTS

PSM was impaired in 46% of the patients. Accumulated secretions, penetration-aspiration, and post-swallow residue were frequent and correlated with abnormal PSM (p < 0.05). PSM was reliable and agreed with pharyngeal constriction ratio on videofluoroscopy in all 15 patients who had both assessments within 72 h. Abnormal PSM correlated with vocal cord immobility, reduced peak cough flow, and reduced swallow frequency (p < 0.05). Abnormal PSM predicted restricted diet on hospital discharge with an odds ratio of 10.38.

CONCLUSIONS

PSM is a quick and simple addition to an endoscopic evaluation and has the potential to predict likelihood of impaired swallow safety and efficiency as well as clinical outcomes.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3429-3435, 2023.

Accumulated Secretions and Associated Aerodigestive Function in Patients With Dysphagia

PURPOSE

Accumulated pharyngo-laryngeal secretions are associated with dysphagia, aspiration, and poor health outcomes. Despite ongoing developments in the evaluation of pharyngo-laryngeal secretions, understanding of the underlying mechanisms is limited. Pathophysiology associated with accumulated secretions is needed to guide tailored, targeted treatment pathways. This study reports the prevalence of accumulated pharyngo-laryngeal secretions in a large acute care caseload and explores the relationship between secretions and aerodigestive function.

METHOD

Consecutive inpatients (N = 222) referred for flexible endoscopic evaluation of swallow (FEES) with suspected dysphagia following assessment by a speech-language pathologist were recruited (43% neurological, 22% neurosurgical, 20% critical care, 15% other), and 250 standardized FEES were completed (222 first FEES, 28 repeat FEES). The assessment protocol included secretion assessment using the New Zealand Secretion Scale (NZSS), pharyngeal squeeze maneuver, laryngeal motor and sensory assessment, Penetration-Aspiration Scale, and Yale Pharyngeal Residue Severity Rating Scale. Urge-to-clear ratings were collected during endoscopy. Cough peak expiratory flow and swallow frequency measures were also collected, as well as clinical outcomes at time of discharge.

RESULTS

There was a high incidence of accumulated secretions, with 77% of inpatients having elevated NZSS (Mdn = 3, range: 0-7) and 37% with pooled laryngeal secretions. Accumulated secretions were associated with reduced swallow frequency, reduced laryngeal adductor reflex, impaired pharyngeal squeeze maneuver, and peak expiratory flow. NZSS scores also correlated with swallow measures (Penetration-Aspiration Scale and Yale Pharyngeal Residue Severity Rating Scale) and patient outcomes including diet recommendations at discharge and pneumonia during admission.

CONCLUSIONS

This large study contributes to evidence associating both sensory and motor impairments with secretion accumulation and aspiration risk. Further exploration of the key physiological mechanisms contributing to accumulated secretions will serve as markers to provide proof of principle for targets for secretion management protocols.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24101667.

Dysphagia outcomes in COVID-19 patients: experiences in long-term acute care hospital (LTACH)

PURPOSE

Long term acute care hospitals (LTACHs) saw a significant increase in COVID-19 patients with prolonged acute illness recovery. Speech language pathologists (SLP) in LTACHs were integral in assessing swallowing and providing rehabilitation for dysphagia, however, there is limited research on LTACHs and dysphagia. Our aim was to describe this unique dysphagia management experience to improve future patient care.

METHODS

Retrospective chart reviews were conducted for patients admitted to RML Specialty Hospital for respiratory failure secondary to COVID-19 from April 1, 2020 to October 31, 2021. Demographic information, videofluoroscopic swallow study (VFSS) reports with Penetration and Aspiration Scale (PAS) scores and SLP notes were reviewed. Descriptive statistics and chi-square analysis were performed.

RESULTS

A total of 213 patients met inclusion criteria. Most patients presented with tracheostomy (93.9%) and were NPO (92.5%) on admission. A strong correlation (p = 0.029) was noted between dependence on mechanical ventilation and significant airway invasion, as indicated by PAS score of 7 or 8 on VFSS. There was a strong association (p = 0.001) between patients who had tracheostomy placed within 33 days of VFSS and recommendation for thin liquids. Upon discharge, the majority of patients (83.57%) transitioned successfully to oral diets, however, a strong association (p = 0.009) between higher age (≥ 62) and NPO at discharge was demonstrated.

CONCLUSION

Patients admitted post COVID-19 to LTACH, especially those requiring tracheostomy, demonstrated various degrees of dysphagia and benefited from SLP intervention and instrumental swallow assessments. Most patients admitted to LTACH for COVID-19 were successfully rehabilitated for dysphagia.

Dextromethorphan/quinidine for the treatment of bulbar impairment in amyotrophic lateral sclerosis

OBJECTIVE

No efficacious treatments exist to improve or prolong bulbar functions of speech and swallowing in persons with amyotrophic lateral sclerosis (pALS). This study evaluated the short-term impact of dextromethorphan/quinidine (DMQ) treatment on speech and swallowing function in pALS.

METHODS

This was a cohort trial conducted between August 2019 to August 2021 in pALS with a confirmed diagnosis of probable-definite ALS (El-Escorial Criteria-revisited) and bulbar impairment (ALS Functional Rating Scale score ≤ 10 and speaking rate ≤ 140 words per minute) who were DMQ naïve. Efficacy of DMQ was assessed via pre-post change in the ALS Functional Rating Scale-Revised bulbar subscale and validated speech and swallowing outcomes. Paired t-tests, Fisher's exact, and χ2 tests were conducted with alpha at 0.05.

RESULTS

Twenty-eight pALS enrolled, and 24 participants completed the 28-day trial of DMQ. A significant increase in ALSFRS-R bulbar subscale score pre- (7.47 ± 1.98) to post- (8.39 ± 1.79) treatment was observed (mean difference: 0.92, 95% CI: 0.46-1.36, p < 0.001). Functional swallowing outcomes improved, with a reduction in unsafe (75% vs. 44%, p = 0.003) and inefficient swallowing (67% vs. 58%, p = 0.002); the relative speech event duration in a standard reading passage increased, indicating a greater duration of uninterrupted speech (mean difference: 0.33 s, 95% CI: 0.02-0.65, p = 0.035). No differences in diadochokinetic rate or speech intelligibility were observed (p > 0.05).

INTERPRETATION

Results of this study provide preliminary evidence that DMQ pharmacologic intervention may have the potential to improve or maintain bulbar function in pALS.

Swallowing biomechanics in tracheostomised critically ill patients compared to age- and gender-matched healthy controls

Objective

The mechanistic effects of a tracheostomy on swallowing are unclear. Pharyngeal high-resolution manometry with impedance (P-HRM-I) is a novel swallow assessment tool providing quantifiable metrics. This study aimed to characterise swallowing biomechanics in tracheostomised critically ill (non-neurological) patients.

Design

Cohort study.

Setting

Australian tertiary hospital intensive care unit.

Participants

Tracheostomised adults, planned for decannulation.

Main outcome measures

Swallowing assessment using P-HRM-I, compared to healthy age- and gender-matched controls.

Results

In this tracheostomised cohort (n = 10), the Swallow Risk Index, a global measure of swallow function, was significantly elevated (p < 0.001). At the upper oesophageal sphincter (UOS), hypopharyngeal intrabolus pressure and UOS integrated relaxation pressure were significantly elevated (control 0.65 mmHg [-1.02, 2.33] v tracheostomy 13.7 mmHg [10.4, 16.9], P < 0.001; control -4.28 mmHg [-5.87, 2.69] v tracheostomy 12.2 mmHg [8.83, 15.6], P < 0.001, respectively). Furthermore, UOS opening extent and relaxation time were reduced (control 4.83 mS [4.60, 5.07] v tracheostomy 4.33 mS [3.97, 4.69], P = 0.002; control 0.52 s [0.49, 0.55] v tracheostomy 0.41 s [0.37, 0.45], P < 0.001, respectively). Total pharyngeal contractility (PhCI) measuring pharyngeal pressure generation was significantly elevated (control 199.5 mmHg cm.s [177.4, 221.6] v tracheostomy 326.5 mmHg cm.s [253.3, 399.7]; P = 0.001).

Conclusion

In a critically ill tracheostomised cohort, UOS dysfunction was the prevalent biomechanical feature, with elevated pharyngeal pressures. Pharyngeal weakness is not contributing to dysphagia in this cohort. Instead, elevated pharyngeal pressures may represent a compensatory mechanism to overcome the UOS dysfunction. Further studies to extend these findings may inform the development of timely and targeted rehabilitation.

Characterizing Swallowing Impairment in a Post-Lung Transplant Population

BACKGROUND

Lung transplant recipients carry significant pre- and post-lung transplant dysphagia risk factors related to altered respiratory-swallow coordination as well as acute injury and decompensation resulting in the acute post-lung transplant recovery period. However, we are only beginning to understand the potential physiological contributors to altered swallowing in this population.

METHOD

A retrospective, cross-sectional, cohort study of post-lung transplant patients was performed. All participants received a modified barium swallow study (MBSS) as part of standard care during their acute hospitalization using the Modified Barium Swallow Impairment Profile (MBSImP) protocol and scoring metric. A combination of MBSImP scores, Penetration-Aspiration Scale (PAS) scores, Functional Oral Intake Scale (FOIS) scores, International Dysphagia Diet Standardization Initiative (IDDSI) scale levels, and the time from lung transplant to MBSS was collected, as well as measures of swallowing impairment and swallowing-related outcomes. Differences in swallowing physiology and swallowing-related outcomes between participants with typical versus atypical PAS were explored.

RESULTS

Forty-two participants met our prespecified inclusion criteria. We identified atypical laryngeal penetration and/or aspiration in 52.4% of our post-lung transplant cohort. Silent aspiration occurred in 75% of those patients who aspirated. Comparing typical versus atypical PAS scores, we found statistically significant associations with laryngeal elevation (Component 8), p < .0001; anterior hyoid excursion (Component 9), p = .0046; epiglottic movement (Component 10), p = .0031; laryngeal vestibule closure (Component 11), p < .0001; pharyngeal stripping (Component 12), p = .0058; pharyngeal total scores, p = .0001; FOIS scores, p = .00264; and IDDSI liquid levels, p = .0009.

CONCLUSIONS

Swallowing impairment resulting in abnormal bolus invasion is prevalent in post-lung transplant patients. Airway invasion in this cohort was related to pharyngeal swallow impairment and resulted in modified oral intake. Our findings help expand upon prior literature, which only reported the incidence of aspiration and pathological laryngeal penetration. Our results suggest that the potential for aerodigestive system impairment and negative sequela should not be underestimated in the post-lung transplant population.

Preliminary Study of the Effects of a Dysphagia Support Group on Quality of Life

PURPOSE

Dysphagia (swallowing difficulties) can greatly decrease quality of life for individuals with dysphagia and can lead to caregiver burden and third-party disability. Support groups have been shown to be effective in improving quality of life in a range of conditions, through allowing individuals to form connections with those with shared experiences and sharing and learning about relevant resources and coping skills. However, no research on the effects of dysphagia support groups on quality of life has been conducted. This preliminary study aimed to determine whether a virtual support group, facilitated by speech-language pathologists, could positively affect quality of life in similar ways for adults with dysphagia and their family caregivers.

METHOD

Pre- and postsupport group surveys were sent to participants to gain information about their dysphagia, demographics, and support group feedback (e.g., access to resources). Questions were mainly multiple choice, with three open-ended questions related to the support group.

RESULTS

Eight individuals participated in the surveys, with four completing both pre- and postsession surveys. Seven of eight individuals reported that they felt a support group could improve their quality of life, with the eighth being unsure. Qualitative data found the support group offered both informational (e.g., resource access) and psychosocial support (e.g., knowledge that they were not alone, emotional support).

CONCLUSION

These initial results suggest that a dysphagia support group could fill a gap in the health care system to offer more holistic support to individuals with dysphagia and their family caregivers.

How Valid and Reliable Is the International Dysphagia Diet Standardisation Initiative (IDDSI) When Translated into Another Language?

Swallowing difficulties are estimated to affect 590 million people worldwide and the modification of food and fluids is considered the cornerstone of dysphagia management. Contemporary practice uses the International Dysphagia Diet Standardisation Initiative (IDDSI), however, the validity and reliability of IDDSI when translated into another language has not been investigated. This study describes the translation process and confirms the validity and reliability of IDDSI when translated into another language (Swedish). The translation used a 12-step process based on the World Health Organization recommendations. Validity was tested using Content Validity Index (CVI) based on three ratings by a panel of 10-12 experts (Dietitians and Speech-Language Pathologists [SLPs]). The translation was rated for linguistic correlation as well as understandability and applicability in a Swedish context. Inter-rater reliability was calculated using Intraclass Correlation Coefficient (ICC) from 20 SLP assessments of 10 previously published patient cases. Significant improvement (p < 0.05) of CVI between Expert Panel assessments was shown for linguistic correlation (improvement from 0.74-0.98) and understandability/applicability (improvement from 0.79-0.93 across ratings). Excellent validity (Item-CVI > 0.78 and Scale-CVI/Average > 0.8) and very high inter-rater reliability (ICC > 0.9) were demonstrated. Results show that, when using a multi-step translation process, a translated version of IDDSI (into Swedish) demonstrates high validity and reliability. This further contributes to the evidence for use of IDDSI.

RELATIONSHIP BETWEEN NUTRITIONAL STATUS, DYSPHAGIA, AND FUNCTIONAL EATING LEVEL IN ADULT PATIENTS WITH CEREBRAL PALSY IN LONG INSTITUTIONAL STAYS

BACKGROUND

Diets with modified consistencies for patients with dysphagia in long term care health institutions may be associated with malnutrition.

OBJECTIVE

: To assess the nutritional status of adult patients with cerebral palsy and dysphagia hospitalized in a health institution for more than 10 years.

METHODS

: This prospective investigation was performed in 56 patients with cerebral palsy (ages 25 to 71 years, mean: 44±12 years) and no other neurological diagnosis in hospital stay for more than 10 years had their nutritional status, dysphagia, and food ingestion capacity assessed in two moments with a 12-month interval in between them, respectively using the body mass index, the dysphagia risk assessment protocol (PARD), and the functional oral ingestion scale (FOIS).

RESULTS

: There were no differences between December 2015 and December 2016 in the patients' weight, nutritional status, diet consistency classification, PARD, and FOIS. The limits of prescribed diet consistency (IDDSI-FDS) and the assessments of dysphagia and functional eating level influenced the nutritional status. More intense dysphagia and greater eating restrictions were associated with a worse nutritional status.

CONCLUSION

: The nutritional status of adult patients with cerebral palsy hospitalized in a health long term institution who had modified diets according to their swallowing and mastication capacity did not worsen between assessments with a 12-month interval in between them. The severity of dysphagia and diet restrictions interfere with the patients' nutritional status: dysphagia and more intense eating restrictions are associated with a worse nutritional status.

Reliability and Validity of Non-Instrumental Clinical Assessments for Adults with Oropharyngeal Dysphagia: A Systematic Review

This systematic review on non-instrumental clinical assessment in adult oropharyngeal dysphagia (OD) provides an overview of published measures with reported reliability and validity. In alignment with PRISMA, four databases (CINAHL, Embase, PsycINFO, and PubMed) were searched, resulting in a total of 16 measures and 32 psychometric studies included. The included measures assessed any aspect of swallowing, consisted of at least one specific subscale relating to swallowing, were developed by clinical observation, targeted adults, and were developed in English. The included psychometric studies focused on adults, reported on measures for OD-related conditions, described non-instrumental clinical assessments, reported on validity or reliability, and were published in English. Methodological quality was assessed using the standard quality assessment QualSyst. Most measures targeted only restricted subdomains within the conceptual framework of non-instrumental clinical assessments. Across the 16 measures, hypothesis testing and reliability were the most reported psychometrics, whilst structural validity and content validity were the least reported. Overall, data on the reliability and validity of the included measures proved incomplete and frequently did not meet current psychometric standards. Future research should focus on the development of comprehensive non-instrumental clinical assessments for adults with OD using contemporary psychometric research methods.

Dysphagia in Solid Tumors Outside the Head, Neck or Upper GI Tract: Clinical Characteristics

CONTEXT

Dysphagia is common in cancer, but underlying pathophysiology and manifestations within patients are unknown.

OBJECTIVES

To examine dysphagia characteristics in those with solid malignancies outside the head, neck and upper gastrointestinal tract.

METHODS

Seventy-three individuals with dysphagia (46 male, 27 female, aged 37-91) were recruited from a parent trial conducted in two acute hospitals and one hospice. Cranial nerve function, Oral Health Assessment Tool (OHAT), Mann Assessment of Swallowing Ability (MASA) and Functional Oral Intake Scale (FOIS) evaluated swallow profile.

RESULTS

Only 9/73 (12%) had documented dysphagia prior to study enrollment. MASA risk ratings found n=61/73 (84%) with dysphagia risk and n=22/73 (30%) with aspiration risk. Food texture modification was required for n=34/73 (47%), fluid texture modification for n=1/73 (1%). Compensatory strategies for food were needed by n=13/73 (18%) and for fluids by n=24/73 (33%). Cranial nerve deficits were present in n=43/73 (59%). Oral health problems were common, with xerostomia in two-thirds. Worse dysphagia on MASA was associated with disease progression, affecting hospice, and palliative care the most. Worse performance status was indicative of poorer MASA raw score (P<0.001, OR 2.2, 95% CI 1.5-3.4), greater risk of aspiration (P=0.005, OR 2.1, 95% CI 1.3-3.6) and lower FOIS (P=0.004, OR 2.0, 95% CI 1.2-3.2).

CONCLUSION

Dysphagia management in those with cancer requires robust assessment to uncover clinically important needs like food texture modification and safe swallowing advice. Better assessment tools should be developed for this purpose. Oral health problems should be routinely screened in this population since they exacerbate dysphagia.

An International Commentary on Dysphagia and Dysphonia During the COVID-19 Pandemic

COVID-19 has had an impact globally with millions infected, high mortality, significant economic ramifications, travel restrictions, national lockdowns, overloaded healthcare systems, effects on healthcare workers' health and well-being, and large amounts of funding diverted into rapid vaccine development and implementation. Patients with COVID-19, especially those who become severely ill, have frequently developed dysphagia and dysphonia. Health professionals working in the field have needed to learn about this new disease while managing these patients with enhanced personal protective equipment. Emerging research suggests differences in the clinical symptoms and journey to recovery for patients with COVID-19 in comparison to other intensive care populations. New insights from outpatient clinics also suggest distinct presentations of dysphagia and dysphonia in people after COVID-19 who were not hospitalized or severely ill. This international expert panel provides commentary on the impact of the pandemic on speech pathologists and our current understanding of dysphagia and dysphonia in patients with COVID-19, from acute illness to long-term recovery. This narrative review provides a unique, comprehensive critical appraisal of published peer-reviewed primary data as well as emerging previously unpublished, original primary data from across the globe, including clinical symptoms, trajectory, and prognosis. We conclude with our international expert opinion on what we have learnt and where we need to go next as this pandemic continues across the globe.

Abnormal Esophageal Clearance Identified During Modified Barium Swallow Study in an Acute Poststroke Cohort

PURPOSE

Dysphagia impacts many poststroke survivors with wide-ranging prevalence in the acute and chronic phases. One relatively unexplored manifestation of poststroke swallowing impairment is that of primary or co-occurring esophageal dysphagia. The incidence of esophageal dysphagia in this population is unknown despite the shared neuroanatomy and physiology with the oropharynx. We aimed to determine the presence of abnormal esophageal clearance in an acute poststroke sample using the Modified Barium Swallow Impairment Profile (MBSImP) Component 17 (esophageal clearance) as our outcome measure.

METHOD

We performed a retrospective, cross-sectional, cohort study of 57 poststroke patients with acute, first-ever, ischemic strokes. All participants received a modified barium swallow study (MBSS) using the MBSImP protocol and scoring metrics. Swallowing impairment was determined using a combination of MBSImP scores and Penetration-Aspiration Scale scores. Swallowing outcome measures were collected including Functional Oral Intake Scale and International Dysphagia Diet Standardization Initiative (IDDSI) scores. We performed tests of association and logistic regression analysis to determine if statistically significant associations exist between judgments of esophageal clearance and other swallowing impairments and/or swallowing outcome measures.

RESULTS

In our study of poststroke patients who received an MBSS as part of their care, 57.9% had abnormal esophageal clearance. Statistically significant associations were also identified in measures of pharyngeal physiology (MBSImP scores) and swallowing outcome measures (IDDSI scores and alternate means of nutrition).

CONCLUSIONS

Abnormal esophageal clearance was identified in greater than half of our poststroke patients. There is a dearth of scientific research regarding esophageal function poststroke. While esophageal visualization during the MBSS is not diagnostic of esophageal impairment, it may serve as an indicator for those poststroke patients who require dedicated esophageal testing to best determine the full nature of their swallowing pathophysiology and make the most effective treatment recommendations.

Assessment of Chewing in Children With Down Syndrome

In the present study a comprehensive protocol to assess chewing in four children with Down syndrome is provided and described. One baseline and four assessment meals were conducted across four textures of foods to investigate the presence or absence of components of chewing (bite down, chew and tongue lateralization), as well as movements associated with the development of chewing. Results showed that at baseline all participants ate their typical diet (i.e., pureed food) but no chewing components or movements were observed. The findings of the assessment protocol indicated that it offers a prescriptive assessment of chewing and its components across different food textures. The results of the assessment provided useful information for clinicians by identifying a potential starting point for interventions to address chewing deficits. Furthermore, the findings add to the existing literature on the role of tongue lateralization and specific tongue movements in chewing. Implications of the findings for chewing interventions and future research are discussed.

Home-based intensive treatment of chronic radiation-associated dysphagia in head and neck cancer survivors (HIT-CRAD trial)

Background

Chronic radiation-associated dysphagia (C-RAD) is considered to be one of the most severe functional impairments in head and neck cancer survivors treated with radiation (RT) or chemoradiation (CRT). Given the major impact of these late toxicities on patients’ health and quality of life, there is a strong need for evidence-based dysphagia management. Although studies report the benefit of strengthening exercises, transference of changes in muscle strength to changes in swallowing function often remains limited. Therefore, combining isolated strengthening exercises with functional training in patients with C-RAD may lead to greater functional gains.

Methods

This 3-arm multicenter randomized trial aims to compare the efficacy and possible detraining effects of mere strengthening exercises (group 1) with a combination of strengthening exercises and functional swallowing therapy (group 2) and non-invasive brain stimulation added to that combination (group 3) in 105 patients with C-RAD. Patients will be evaluated before and during therapy and 4 weeks after the last therapy session by means of swallowing-related and strength measures and quality of life questionnaires.

Discussion

Overall, this innovative RCT is expected to provide new insights into the rehabilitation of C-RAD to optimize post-treatment swallowing function.

Trial registration

International Standard Randomized Controlled Trials Number (ISRCTN) registry ID ISRCTN57028065. Registration was accepted on 15 July 2021.

Adapting the International Dysphagia Diet Standardisation Initiative in East Asia: Feasibility study

In dysphagia, food or water cannot be delivered safely through the oral cavity to the stomach; both are treated using texture-modified food and thickened fluid. Before, each country had its own diet modifications and texture measurement standards. In 2012, the International Dysphagia Diet Standardisation Initiative (IDDSI) was developed by several countries. Owing to cultural differences, it was necessary to determine whether the IDDSI could well be applied to clinicians and patients without difficulties in East Asia countries. To evaluate the IDDSI scale to find out the difficulties applying this scale in East Asia countries to educate the clinicians and patients. In May 2021, we enrolled physicians, nurses, nutritionists, and swallowing therapists involved in dysphagia treatment at a single center in Seoul. To evaluate the degree of understanding and difficulties of adapting IDDSI to clinicians in East Asia countries, we used the 17-item questionnaire with IDDSI sample foods and foods in Asian countries. In first 7 items, we compared IDDSI with the previously used scale based on the National Dysphagia Diet (NDD). In the next 10 questions, only the IDDSI levels were answered, and the absolute values of the answer-response differences were calculated. The IDDSI showed a significantly high intraclass correlation with the previously used NDD-based scale; the coefficient was higher for the nutritionists (0.988) and swallowing therapists (0.991). When evaluating whether the IDDSI could applied well in East Asia countries, the absolute values of the answer-response differences were lower than 0.5 in majority of levels, except for Level 4. Because the IDDSI framework might successfully be applied universally regardless of food culture, a worldwide standard for food rheology in dysphagia treatment might be possible.

Risk Factors for Dysphagia in Patients Hospitalized with COVID-19

Patients hospitalized with COVID-19 may be at risk for dysphagia and vulnerable to associated consequences. We investigated predictors for dysphagia and its severity in a cohort of patients hospitalized with COVID-19 at a single hospital center. A large level I trauma center database was queried for all patients hospitalized with COVID-19. Demographics, medical information associated with COVID-19, specific to dysphagia, and interventions were collected. 947 patients with confirmed COVID-19 met the criteria. 118 (12%) were seen for a swallow evaluation. Individuals referred for evaluation were significantly older, had a lower BMI, more severe COVID-19, and higher rates of intubation, pneumonia, mechanical ventilation, tracheostomy placements, prone positioning, and ARDS. Pneumonia (OR 3.57, p = 0.004), ARDS (OR 3.57, p = 0.029), prone positioning (OR 3.99, p = 0.036), ventilation (OR 4.01, p = 0.006), and intubation (OR 4.75, p = 0.007) were significant risk factors for dysphagia. Older patients were more likely to have more severe dysphagia such that for every 1-year increase in age, the odds of severe dysphagia were 1.04 times greater (OR 1.04, p = 0.028). Patients hospitalized with COVID-19 are at risk for dysphagia. We show predictive variables that should be considered when referring COVID-19 patients for dysphagia services to reduce time to intervention/evaluation.

Clinical Focus: Findings and Clinical Implications for Thickening Formula With Infant Cereal Using the International Dysphagia Diet Standardisation Initiative Flow Test

PURPOSE

The International Dysphagia Diet Standardisation Initiative (IDDSI) framework was established to provide standardized terminology and objective measures to assess foods and liquids for persons with swallowing difficulties. This clinical focus article reports the findings and clinical implications of the flow testing of infant formulas thickened with infant cereal completed as part of the transition process to IDDSI for one large pediatric quaternary care hospital.

METHOD

To determine a common recipe that could be used to thicken formulas with infant cereal to the appropriate IDDSI levels, three clinicians completed flow testing on 94 infant formulas. To examine intra- and interclinician variability in the process, they repeated flow testing with three commonly used formulas and infant cereal.

RESULTS

Clinicians were unable to identify a standard recipe (infant formula + infant cereal combination) that consistently thickened different formula brands to a desired IDDSI thickness level, as there was pronounced variability across and within infant formulas. Reliability testing revealed that, overall, clinician mixers were consistent in replicating similar results to themselves and to each other and that, instead, greater variability lies within the formula (and infant formula + infant cereal combination).

CONCLUSIONS

Based on findings of pronounced variability within and across infant formulas, our institution determined that the creation of a standard recipe for achieving IDDSI thickness levels of formula mixed with infant cereal was not feasible or clinically appropriate. We offer recommendations for similar institutions for advancing clinical management of infant dysphagia using the IDDSI flow test and directions for future research.