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Donohue C, Vasilopoulos T, Wymer JP, Plowman EK. Relationship between pulmonary, cough, and swallowing functions in individuals with amyotrophic lateral sclerosis. Muscle Nerve 2024. [PMID: 38742544 DOI: 10.1002/mus.28113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 04/08/2024] [Accepted: 04/28/2024] [Indexed: 05/16/2024]
Abstract
INTRODUCTION/AIMS Evaluations of pulmonary, cough, and swallow function are frequently performed to assess disease progression in amyotrophic lateral sclerosis (ALS), yet the relationship between these functions remains unknown. We therefore aimed to determine relationships between these measures in individuals with ALS. METHODS One hundred individuals with ALS underwent standardized tests: forced vital capacity (FVC), maximum expiratory/inspiratory pressure (MEP, MIP), voluntary cough peak expiratory flow (PEF), and videofluoroscopic swallow evaluation (VF). Duplicate raters completed independent, blinded ratings using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale. Descriptives, Spearman's Rho correlations, Kruskal-Wallis analyses, and Pearson's chi-squared tests were completed. RESULTS Mean and standard deviation across pulmonary and cough measures were FVC: 74.2% predicted (± 22.6), MEP: 91.6 cmH2O (± 46.4), MIP cmH2O: 61.1 (± 28.9), voluntary PEF: 352.7 L/min (± 141.6). DIGEST grades included: 0 (normal swallowing): 31%, 1 (mild dysphagia): 48%, 2 (moderate dysphagia): 10%, 3 (severe dysphagia): 10%, and 4 (life-threatening dysphagia): 1%. Positive correlations were observed: MEP-MIP: r = .76, MIP-PEF: r = .68, MEP-PEF: r = .61, MIP-FVC: r = .60, PEF-FVC: r = .49, and MEP-FVC: r = .46, p < .0001. MEP (p = .009) and PEF (p = .04) differed across DIGEST safety grades. Post hoc analyses revealed significant between group differences in MEP and PEF across DIGEST safety grades 0 versus 1 and grades 0 versus 3, (p < .05). DISCUSSION In this cohort of individuals with ALS, pulmonary function, and voluntary cough were associated. Expiratory metrics (MEP, PEF) were diminished in individuals with unsafe swallowing, increasing their risk for effectively defending the airway.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, The Ohio State University, Columbus, Ohio, USA
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, Tennessee, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Emily K Plowman
- Aerodigestive Research Core Laboratory, The Ohio State University, Columbus, Ohio, USA
- Department of Otolaryngology-Head and Neck Surgery, The Ohio State University, Columbus, Ohio, USA
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Leon-Astudillo C, Brooks O, Salabarria SM, Coker M, Corti M, Lammers J, Plowman EK, Byrne BJ, Smith BK. Longitudinal changes of swallowing safety and efficiency in infants with spinal muscular atrophy who received disease modifying therapies. Pediatr Pulmonol 2024; 59:1364-1371. [PMID: 38358081 DOI: 10.1002/ppul.26919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND Dysphagia is a common feature of the natural history of patients with spinal muscular atrophy (SMA). Literature regarding swallowing safety and efficiency is scarce in patients with SMA, particularly in the era of newborn screening programs and disease-modifying therapies. OBJECTIVE To describe the longitudinal changes of swallowing safety and efficiency in children with SMA who received one or more disease modifying therapies METHODS: Case series of patients with SMA followed at the University of Florida from 1 May 2019 to 31 December 2022 who had two or more videofluoroscopy swallowing studies (VFSS), with the first being within 30 days of their first treatment. Data extracted from the electronic health record included: neuromotor outcomes, VFSS penetration aspiration scores (PAS), presence of abrnormal oral or pharyngeal residue, clinical history, and timing of disease-modifying therapies administration. RESULTS Seven subjects were included (five male); three were diagnosed via newborn screen. Median age at diagnosis was 10 days (range: 4-250). Median age at initial VFSS was 29 days (range: 9-246), and age at the last VFSS was 26.1 months (range: 18.2-36.2). All subjects received onasemnogene-abeparvovec (OA); four received additional therapies. PAS at diagnosis was abnormal in four subjects. Six subjects required feeding modifications after VFSS results. Of these, three had silent aspiration (PAS 8) and three of them improved after treatment. CONCLUSIONS Swallowing safety and efficiency can be impaired in patients with SMA despite early treatment. Larger, prospective studies are needed to define optimal timiing of longitudinal instrumental evaluations.
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Affiliation(s)
- Carmen Leon-Astudillo
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Olivia Brooks
- Department of Speech, Language, and Hearing Sciences, University of Florida College of Medicine, Gainesville, Florida, USA
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA
| | - Stephanie M Salabarria
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Mackenzi Coker
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Manuela Corti
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jenna Lammers
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Emily K Plowman
- Department of Speech, Language, and Hearing Sciences, University of Florida College of Medicine, Gainesville, Florida, USA
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA
| | - Barry J Byrne
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Barbara K Smith
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida, USA
- Department of Physical Therapy, University of Florida, Gainesville, Florida, USA
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Donohue C, Robison R, Steele CM, Wymer JP, Plowman EK. Profiling Number of Swallows per Bolus and Residue in Individuals With Amyotrophic Lateral Sclerosis. J Speech Lang Hear Res 2023; 66:3763-3772. [PMID: 37591233 PMCID: PMC10713014 DOI: 10.1044/2023_jslhr-23-00209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 05/11/2023] [Accepted: 06/13/2023] [Indexed: 08/19/2023]
Abstract
PURPOSE Swallowing efficiency impairments are the most prevalent and earliest manifestation of dysphagia in people with amyotrophic lateral sclerosis (pALS). We aimed to profile number of swallows elicited in pALS across thin liquid, moderately thick liquid, extremely thick liquid, and crackers compared to expected healthy reference data and to determine relationships between degree of pharyngeal residue, number of elicited swallows, and swallowing safety. METHOD pALS underwent standardized videofluoroscopic swallowing studies of 10 bolus trials. Trained raters performed duplicate, independent, and blinded ratings to derive Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) efficiency and safety grades and Analysis of Swallowing Physiology: Events, Kinematics, and Timing (ASPEKT) percent total pharyngeal residue. Number of swallows per bolus was quantified (1 = typical, 2 = atypically high, 3 = extremely high). Kruskal-Wallis, Pearson chi-square, and odds ratio analyses were performed at bolus and participant levels. KEY RESULTS At the bolus level (N = 2,523), number of swallows per bolus was observed to be, in rank order, as follows: atypically high (49.1%), extremely high (28.5%), and typical (22.4%). Mean number of swallows significantly differed by International Dysphagia Diet Standardisation Initiative level (p < .0001), with a higher number of swallows elicited in pALS for moderately thick versus thin liquids, extremely thick liquids, and crackers, p < .0001. Number of swallows per bolus increased with increasing DIGEST efficiency grades (p < .0001). Positive correlations were observed between ASPEKT percent residue and number of swallows for thin (r = .24) and moderately thick (r = .16) liquids, p < .05. DIGEST efficiency and safety grades were not significantly associated (p > .05). CONCLUSION AND INFERENCES pALS demonstrated a higher number of swallows per bolus compared to healthy reference data that may represent a compensation for reductions in swallowing efficiency to clear pharyngeal residue.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN
| | - Raele Robison
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Medicine, University of Wisconsin-Madison
- Center for Health Disparities Research, University of Wisconsin-Madison
| | - Catriona M. Steele
- KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada, Toronto, Ontario, Canada
- Canada Research Chairs, Toronto, Ontario, Canada
| | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville
| | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Neurology, University of Florida, Gainesville
- Department of Surgery, University of Florida, Gainesville
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Donohue C, Wiele L, Terry A, Jeng E, Beaver T, Martin T, Vasilopoulos T, Plowman EK. Preoperative respiratory strength training is feasible and safe and improves pulmonary physiologic capacity in individuals undergoing cardiovascular surgery. JTCVS Open 2023; 15:324-331. [PMID: 37808054 PMCID: PMC10556933 DOI: 10.1016/j.xjon.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 07/06/2023] [Accepted: 07/13/2023] [Indexed: 10/10/2023]
Abstract
Objective To determine the safety, feasibility, and physiologic impact of a preoperative respiratory strength training (RST) program in individuals undergoing elective cardiac surgery (CS). Methods Twenty-five adults undergoing an elective CS at an academic hospital setting enrolled and completed RST 5 days/week (50 repetitions, 50% training load, ≥3 weeks) at home via telehealth in this open-label prospective cohort study. RST adherence, telehealth attendance, and adverse events were tracked. Pre- and post-RST outcomes of maximum expiratory pressure (MEP), maximum inspiratory pressure (MIP), voluntary cough spirometry, and patient-reported dyspnea were collected. Descriptive analyses and Wilcoxon signed rank-tests were performed. Results Two participants (9%) did not complete the prescribed RST program. No significant RST-related adverse events occurred. Treatment adherence for all enrolled participants was 90%, and telehealth attendance was 99%. Of the CS patients who completed the prescribed program (n = 23; 91%), treatment adherence and telehealth attendance were excellent (98% and 100%, respectively). Significant increases in primary outcomes were observed: MEP mean change, +15.4 (95% confidence interval [CI], +3.4 to +27.3, P < .007); MIP mean change, +14.9 (95% CI, +9.4 to +20.4, P < .0001). No statistically significant differences in voluntary cough or perceived dyspnea outcomes were observed (P > .05). Conclusions These preliminary data demonstrate that a preoperative RST program is safe and feasible and can improve short-term respiratory physiologic capacity (MEP and MIP) in CS patients. Future research is warranted to validate the current findings in a larger cohort of CS patients and to determine whether RST improves postoperative extubation outcomes, airway clearance capacity, and aspiration following cardiac surgery.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Fla
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Fla
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, Fla
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, Tenn
| | - Lauren Wiele
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Fla
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Fla
| | - Alyssa Terry
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Fla
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Fla
| | - Eric Jeng
- Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas Beaver
- Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas Martin
- Department of Surgery, University of Florida, Gainesville, Fla
| | | | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Fla
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Fla
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, Fla
- Department of Surgery, University of Florida, Gainesville, Fla
- Department of Neurology, University of Florida, Gainesville, Fla
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Donohue C, Chapin JL, Anderson A, DiBiase L, Gray LT, Wymer JP, Plowman EK. Sensitivity and specificity of the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised to detect dysarthria in individuals with amyotrophic lateral sclerosis. Muscle Nerve 2023; 68:296-302. [PMID: 37345346 PMCID: PMC10529444 DOI: 10.1002/mus.27923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/30/2022] [Accepted: 01/07/2023] [Indexed: 06/23/2023]
Abstract
INTRODUCTION/AIMS Given the widespread use of the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) to measure disease progression in ALS and recent reports demonstrating its poor sensitivity, we aimed to determine the sensitivity and specificity of the ALSFRS-R bulbar subscale and speech item to detect validated clinical ratings of dysarthria in individuals with ALS. METHODS Paired ALSFRS-R and validated Speech Intelligibility Test (SIT) data from individuals with ALS were analyzed. Trained raters completed duplicate, independent, and blinded ratings of audio recordings to obtain speech intelligibility (%) and speaking rate (words per minute, WPM). Binary dysarthria profiles were derived (dysarthria ≤96% intelligible and/or <150 WPM). Data were obtained using the Kruskal-Wallis test, receiver-operating characteristic (ROC) curve, area under the curve (AUC), sensitivity and specificity percentages, and positive/negative predictive values (PPV/NPV). RESULTS A total of 250 paired SIT and ALSFRS-R data points were analyzed. Dysarthria was confirmed in 72.4% (n = 181). Dysarthric speakers demonstrated lower ALSFRS-R bulbar subscale (8.9 vs. 11.2) and speech item (2.7 vs. 3.7) scores (P < .0001). The ALSFRS-R bulbar subscale score had an AUC of 0.81 (95% confidence interval [CI] 0.75 to 0.86). A subscale score of ≤11 yielded a sensitivity of 86%, specificity of 57%, PPV of 84%, and NPV of 60% to correctly identify dysarthria status. The ALSFRS-R speech item score demonstrated an AUC of 0.81 to detect dysarthria (95% CI 0.76 to 0.85), with sensitivity of 79%, specificity of 75%, PPV of 89%, and NPV of 58% for a speech item cutpoint of ≤3. DISCUSSION The ALSFRS-R bulbar and speech item subscale scores may be useful, inexpensive, and quick tools for monitoring dysarthria status in ALS.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, TN, USA
| | - Jennifer L. Chapin
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
| | - Amber Anderson
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
| | - Lauren DiBiase
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
| | - Lauren Tabor Gray
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
- Center of Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL, USA
- Department of Neurology, University of Florida, Gainesville, FL, USA
- Department of Surgery, University of Florida, Gainesville, FL, USA
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Tabor Gray L, Locatelli E, Vasilopoulos T, Wymer J, Plowman EK. Dextromethorphan/quinidine for the treatment of bulbar impairment in amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2023; 10:1296-1304. [PMID: 37265174 PMCID: PMC10424659 DOI: 10.1002/acn3.51821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/10/2023] [Accepted: 05/19/2023] [Indexed: 06/03/2023] Open
Abstract
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.
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Affiliation(s)
- Lauren Tabor Gray
- Aerodigestive Research CoreUniversity of FloridaGainesvilleFloridaUSA
- Center for Collaborative ResearchNova Southeastern UniversityFort LauderdaleFloridaUSA
- Dr. Kiran C. Patel College of Allopathic MedicineNova Southeastern UniversityFort LauderdaleFloridaUSA
| | - Eduardo Locatelli
- Center for Collaborative ResearchNova Southeastern UniversityFort LauderdaleFloridaUSA
- Dr. Kiran C. Patel College of Allopathic MedicineNova Southeastern UniversityFort LauderdaleFloridaUSA
| | | | - James Wymer
- Aerodigestive Research CoreUniversity of FloridaGainesvilleFloridaUSA
- Department of NeurologyUniversity of FloridaGainesvilleFloridaUSA
| | - Emily K. Plowman
- Aerodigestive Research CoreUniversity of FloridaGainesvilleFloridaUSA
- Department of NeurologyUniversity of FloridaGainesvilleFloridaUSA
- Department of Speech, Language and Hearing SciencesUniversity of FloridaGainesvilleFloridaUSA
- Department of SurgeryUniversity of FloridaGainesvilleFloridaUSA
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Sharaf OM, Hao KA, Demos DS, Plowman EK, Ahmed MM, Jeng EI. Utility of Fiberoptic Endoscopic Evaluation of Swallowing After Left Ventricular Assist Device Implantation. Cureus 2023; 15:e42291. [PMID: 37609102 PMCID: PMC10441160 DOI: 10.7759/cureus.42291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 08/24/2023] Open
Abstract
Objective Dysphagia following cardiac surgery is common and associated with adverse outcomes. Among patients receiving left ventricular assist devices (LVAD), we evaluated the impact of fiberoptic endoscopic evaluation of swallowing (FEES) on outcomes. Methods A single-center pilot study was conducted in adults (≥18 years of age) undergoing durable LVAD (February 2019 - January 2020). Six patients were prospectively enrolled, evaluated, and underwent FEES within 72 hours of extubation-they were compared to 12 control patients. Demographic, surgical, and postoperative outcomes were collected. Unpaired two-sided t-tests and Fisher's exact tests were performed. Results Baseline characteristics were similar between groups. Intraoperative criteria including duration of transesophageal echo (314 ± 86 min) and surgery (301 ± 74 min) did not differ. The mean time of intubation was comparable (57.3 vs. 68.7 hours, p=0.77). In the entire cohort, 30-day, one-year, two-year, and three-year mortality were 0%, 5.6%, 5.6%, and 16.7%, respectively. Sixty-seven percent of the patients that underwent FEES had inefficient swallowing function. The FEES group trended to a shorter hospital length of stay (LOS) (29.1 vs. 46.6 days, p=0.098), post-implantation LOS (25.3 vs 30.7 days, p=0.46), and lower incidence of postoperative pneumonia (16.7% vs. 50%, p=0.32) and sepsis (0% vs. 33.3%, p=0.25). Conclusion FEES did not impact 30-day, one-year, two-year, or three-year mortality. Though not statistically significant, patients who underwent FEES trended toward shorter LOS and lower postoperative pneumonia and sepsis rates. Additionally, we report a higher incidence of dysphagia among patients undergoing FEES despite comparable baseline risk factors with controls.
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Affiliation(s)
- Omar M Sharaf
- Division of Cardiovascular Surgery, University of Florida Health, Gainesville, USA
| | - Kevin A Hao
- Division of Cardiovascular Surgery, University of Florida Health, Gainesville, USA
| | - Daniel S Demos
- Division of Cardiovascular Surgery, University of Florida Health, Gainesville, USA
| | - Emily K Plowman
- Division of Cardiovascular Surgery, University of Florida Health, Gainesville, USA
| | - Mustafa M Ahmed
- Division of Cardiovascular Medicine, University of Florida Health, Gainesville, USA
| | - Eric I Jeng
- Division of Cardiovascular Surgery, University of Florida Health, Gainesville, USA
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Croft K, Dallal-York J, Miller S, Anderson A, Donohue C, Jeng E, Plowman EK. Provision of Oral Care in the Cardiothoracic Intensive Care Unit: Survey of Nursing Staff Training, Confidence, Methods, Attitudes, and Perceived Barriers. J Contin Educ Nurs 2023; 54:313-321. [PMID: 37390307 DOI: 10.3928/00220124-20230620-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
BACKGROUND Poor oral health is associated with adverse outcomes in critical care settings. Although provision of oral care is a fundamental aspect of nursing practice, both formal training and practice among nursing staff remain unclear. METHOD Cardiothoracic intensive care unit nurses were recruited to complete a 16-item survey regarding training, confidence, methods, prioritization, and barriers to provision of oral care. RESULTS A total of 108 nurses participated (70% response rate). Formal training in oral care was reported by 38%, most frequently reported as less than 1 hour (53%) in duration. Of the respondents, 70% reported confidence in providing oral care. Nine methods and 16 products were identified, with variability in the frequency of provision. Prioritization of oral care was rated most frequently as moderate (53%), with 28% reporting barriers. CONCLUSION Despite limited formal training, surveyed nurses reported confidence in providing oral care. Methods, frequency, and prioritization were variable. Both development of formal curricula and evaluation of adherence to standardized protocols for oral care are warranted. [J Contin Educ Nurs. 2023;54(7):313-321.].
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Tabor Gray L, Donohue C, Vasilopoulos T, Wymer JP, Plowman EK. Maximum Phonation Time as a Surrogate Marker for Airway Clearance Physiologic Capacity and Pulmonary Function in Individuals With Amyotrophic Lateral Sclerosis. J Speech Lang Hear Res 2023; 66:1165-1172. [PMID: 36877985 PMCID: PMC10187964 DOI: 10.1044/2022_jslhr-22-00522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 11/23/2022] [Accepted: 12/12/2022] [Indexed: 05/18/2023]
Abstract
PURPOSE The increased use of telehealth practices has created a critical need for home-based surrogate markers for prognostic respiratory indicators of disease progression in persons with amyotrophic lateral sclerosis (pALS). Given that phonation relies on the respiratory subsystem of speech production, we aimed to examine the relationships between maximum phonation time (MPT), forced vital capacity, and peak cough flow and to determine the discriminant ability of MPT to detect forced vital capacity and peak cough flow impairments in pALS. METHOD MPT, peak cough flow, forced vital capacity, and ALS Functional Rating Scale scores were obtained from 62 pALS (El-Escorial Revised) every 3 months as part of a longitudinal natural history study. Pearson's correlations, linear regressions, and receiver operator characteristic curve analyses with the area under the curve (AUC), sensitivity, specificity, and likelihood ratios were calculated. RESULTS The mean age of pALS was 63.14 ± 10.95 years, 49% were female, and 43% had bulbar onset. MPT predicted forced vital capacity, F(1, 225) = 117.96, p < .0001, and peak cough flow, F(1, 217) = 98.79, p < .0001. A significant interaction was noted between MPT and ALS Functional Rating Scale-Revised respiratory subscore for forced vital capacity, F(1, 222) = 6.7, p = .010, and peak cough flow, F(1, 215) = 4.37, p = .034. The discriminant ability of MPT was excellent for peak cough flow (AUC = 0.88) and acceptable for forced vital capacity (AUC = 0.78). CONCLUSIONS MPT is a simple clinical test that can be measured via telehealth and represents a potential surrogate marker for important respiratory and airway clearance indices. Further larger studies are required to validate these findings with remote data collection. SUPPLEMENTAL MATERIAL https://doi.org/10.23641/asha.22186408.
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Affiliation(s)
- Lauren Tabor Gray
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Center for Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL
| | - Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
| | | | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville
| | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Neurology, University of Florida, Gainesville
- Department of Surgery, University of Florida, Gainesville
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Robison R, DiBiase L, Wymer JP, Plowman EK. Functional Lingual Pressure Thresholds for Swallowing Safety and Efficiency Impairments in Amyotrophic Lateral Sclerosis. Dysphagia 2023; 38:676-685. [PMID: 35907088 PMCID: PMC10228623 DOI: 10.1007/s00455-022-10499-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 07/11/2022] [Indexed: 11/25/2022]
Abstract
Although reductions in lingual strength are reported in individuals with amyotrophic lateral sclerosis (ALS) that are associated with dysphagia; determination of a functional lingual pressure threshold (FLPT) has not yet been established. The present study therefore sought to identify an FLPT for impaired swallowing safety and efficiency in individuals with ALS.Thirty individuals with ALS completed a standardized videofluoroscopic swallowing examination and maximum anterior isometric lingual pressure testing using the Iowa Oral Performance Instrument. Duplicate, blinded ratings of the validated Penetration-Aspiration Scale (PAS) scores and Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) were performed. Binary classifications of safety (unsafe: PAS: ≥ 3) and efficiency (inefficient: ≥ 3% worst total pharyngeal residue) were derived. Descriptives and receiver operating characteristic curve analyses (AUC, sensitivity, specificity) were performed.Unsafe and inefficient swallowing were instrumentally confirmed in 57% and 70% of ALS patients, respectively. Across the entire cohort, the mean maximum lingual physiologic capacity was 32.1 kilopascals ('kPa'; SD: 18.1 kPa). The identified FLPT for radiographically confirmed unsafe swallowing was 43 kPa (sensitivity: 94%, specificity: 62%, AUC 0.82, p = 0.003). FLPT for inefficient swallowing was 46 kPa (sensitivity: 86%, specificity: 56%, AUC = 0.77, p = 0.02).These data provide preliminary FLPT data in a small cohort of individuals with ALS that need to be further investigated in larger cohorts to inform clinical screening practices.
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Affiliation(s)
- Raele Robison
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.
- Department of Medicine, University of Wisconsin-Madison, Madison, WI, USA.
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
- Department of Neurology, University of Florida, Gainesville, FL, USA
- Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA
- Department of Surgery, University of Florida, Gainesville, FL, USA
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Tabor Gray L, McElheny KL, Vasilopoulos T, Wymer J, Smith BK, Plowman EK. Predictors of Peak Expiratory Cough Flow in Individuals with Amyotrophic Lateral Sclerosis. Dysphagia 2023; 38:719-725. [PMID: 35931882 DOI: 10.1007/s00455-022-10503-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Dystussia is prevalent in individuals with amyotrophic lateral sclerosis (ALS), leading to a diminished physiologic capacity to effectively defend the airway. We aimed to identify predictors of peak expiratory cough flow rate in individuals with ALS. One hundred and thirty-four individuals with a confirmed diagnosis of ALS (El-Escorial criteria revised) completed the ALS Functional Rating Scale-Revised (ALSFRS-R) and underwent pulmonary function and cough spirometry testing. Pearson's correlation coefficients and hierarchical multiple regression modeling were conducted to determine predictors of voluntary cough peak expiratory flow rate (p < 0.05). The full model including age, bulbar disease, cough spirometry metrics, and respiratory parameters had a marginal R2 = 0.635, F (7, 126) = 30.241, p < 0.0005, adjusted R2 = 0.61. Maximum expiratory pressure, compression phase, and vital capacity did not contribute and were therefore removed (p < 0.05). The most parsimonious predictive model included age, bulbar disease, peak inspiratory flow rate and duration, peak expiratory rise time, and inspiratory pressure generation with a marginal R2 = 0.543. Although expiratory pressure generation has historically served as the therapeutic target to improve dystussia in ALS, the current dataset highlighted that the inability to quickly and forcefully inspire during the inspiratory phase of voluntary cough places patients at a mechanical disadvantage to generate subsequent high-velocity expiratory airflow to clear the airway. Thus, therapeutic training programs that include both inspiratory and expiratory strength targets may optimize airway clearance capacity in this challenging patient population.
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Affiliation(s)
- Lauren Tabor Gray
- Center for Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL, USA.
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.
| | - Kasey L McElheny
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology and Orthopedics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - James Wymer
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Barbara K Smith
- Department of Physical Therapy and Center for Respiratory Research and Rehabilitation, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
- Department of Neurology, University of Florida, Gainesville, FL, USA
- Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA
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12
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Robison RD, DiBiase L, Anderson A, Wymer JP, Plowman EK. Maximum lingual pressure impacts both swallowing safety and efficiency in individuals with amyotrophic lateral sclerosis. Neurogastroenterol Motil 2023; 35:e14521. [PMID: 36573040 PMCID: PMC10033350 DOI: 10.1111/nmo.14521] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/05/2022] [Accepted: 12/10/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although reduced lingual strength is a confirmed early manifestation of amyotrophic lateral sclerosis (ALS), its functional impact on swallowing remains unclear. We therefore sought to examine relationships between maximum anterior isometric lingual pressure (MAIP) with swallowing safety, swallowing efficiency, and swallowing timing metrics in a large cohort of individuals with ALS. METHODS Ninety-seven participants with ALS completed a standardized videofluoroscopic swallowing examination (VF) and lingual pressure testing (Iowa Oral Performance Instrument). Duplicate and blinded ratings of the Penetration-Aspiration Scale (PAS) and Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) percent efficiency (%C2-C42 ) and timing (laryngeal vestibule closure (LVC) duration: amount of time (milliseconds, msec) between LVC onset and laryngeal vestibule opening; time-to-LVC: hyoid burst to onset of LVC (msec); and swallow reaction time: interval between bolus passing ramus of mandible and onset of LVC (msec)) were performed across bolus trials. Swallowing safety (safe PAS: 1, 2, 4; unsafe PAS: 3, 5, 6, 7, and 8) and efficiency (inefficient: ≥3% worst total residue) were derived. Statistical analyses including descriptives, binary logistic regressions, and Spearman's rho correlations were performed (α = 0.05). KEY RESULTS Mean MAIP was 36.3 kPa (SD: 18.7). Mean MAIP was higher in those with safe swallowing as compared to those who penetrated (mean difference: 12 kPa) or aspirated (mean difference: 18 kPa). Individuals with efficient swallowing demonstrated higher MAIP than those with inefficient swallowing (mean difference: 11 kPa). Binary logistic regression analyses revealed increasing MAIP was significantly associated with a 1.06 (95% CI: 1.03-1.09) and 1.04 (95% CI: 1.01-1.06) greater odds of safe and efficient swallowing, respectively. No relationships were observed between MAIP and swallow reaction time across all bolus trials. Longer time-to-LVC (5 ml thin liquid: rs = -0.35, p = 0.002; cup sip thin liquid: rs = -0.26, p = 0.02; moderately thick liquid: rs = -0.28, p = 0.01) and prolonged LVC duration (cup sip thin liquid, rs = -0.34, p = 0.003) were associated with lower MAIP. CONCLUSIONS AND INFERENCES Reduced lingual strength was confirmed in this group of 97 individuals with ALS that was associated with a diminished ability to effectively transport boluses and aide in laryngeal vestibule closure to prevent entry of material into the airway.
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Affiliation(s)
- Raele Donetha Robison
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Medicine, University of Wisconsin-Madison, Madison, Wisconsin, USA
- Center for Health Disparities Research, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
| | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Emily K. Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Neurology, University of Florida, Gainesville, Florida, USA
- Speech, Language and Hearing Science Department, University of Florida, Gainesville, Florida, USA
- Department of Surgery, University of Florida, Gainesville, Florida, USA
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Dallal-York J, Croft K, Anderson A, DiBiase L, Donohue C, Vasilopoulos T, Shahmohammadi A, Pelaez A, Pipkin M, Hegland KW, Machuca TN, Plowman EK. A prospective examination of swallow and cough dysfunction after lung transplantation. Neurogastroenterol Motil 2023; 35:e14458. [PMID: 36168190 DOI: 10.1111/nmo.14458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/08/2022] [Accepted: 08/23/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Swallow and cough dysfunction are possible surgical complications of lung transplantation (LT). We examined voluntary cough strength, sensorimotor reflexive cough integrity, and swallow-related respiratory rate (RR) across swallowing safety and aspiration response groups in recovering LT recipients. METHODS Forty-five LT recipients underwent flexible endoscopic evaluation of swallowing indexed by the validated Penetration Aspiration Scale. RR before and after a 3-ounce water drinking task was measured. Voluntary and reflexive cough screening were performed to index motor and sensory outcomes. T-tests, one-way ANOVAs, and chi-square (odds ratios) were used. RESULTS 60% of patients exhibited laryngeal penetration (n = 27) and 40% demonstrated tracheal aspiration (n = 18); 72% (n = 13) demonstrated silent aspiration. Baseline RR was higher in aspirators versus non-aspirators (26.5 vs. 22.6, p = 0.04) and in silent aspirators compared to non-silent aspirators (27.9 vs. 20.7, p = 0.01). RR change post-swallowing did not differ between aspiration response groups; however, it was significantly higher in aspirators compared to non-aspirators (3 vs. -2, p = 0.02). Compared to non-silent aspirators, silent aspirators demonstrated reduced voluntary cough peak expiratory flow (PEF; 166 vs. 324 L/min, p = 0.01). PEF, motor and urge to cough reflex cough ratings did not differ between aspirators and non-aspirators. Silent aspirators demonstrated a 7.5 times higher odds of failing reflex cough screening compared to non-silent aspirators (p = 0.07). CONCLUSIONS During the acute recovery period, all LT participants demonstrated some degree of unsafe swallowing and reduced voluntary cough strength. Silent aspirators exhibited elevated RR, reduced voluntary cough physiologic capacity to defend the airway, and a clinically distinguishable blunted motor response to reflex cough screening.
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Affiliation(s)
- Justine Dallal-York
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, USA
| | - Kayla Croft
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, USA
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, USA
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, USA
| | - Cara Donohue
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, USA
- Department of Surgery, Division of Cardiothoracic Surgery, University of Florida, Gainesville, Florida, USA
| | - Terrie Vasilopoulos
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Departments of Anesthesiology and Orthopedics and Rehabilitation, University of Florida, Gainesville, Florida, USA
| | | | - Andres Pelaez
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Mauricio Pipkin
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Karen W Hegland
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, USA
| | - Tiago N Machuca
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, Florida, USA
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Florida, USA
- Department of Surgery, Division of Cardiothoracic Surgery, University of Florida, Gainesville, Florida, USA
- Departments of Anesthesiology and Orthopedics and Rehabilitation, University of Florida, Gainesville, Florida, USA
- Department of Neurology, University of Florida, Gainesville, Florida, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, USA
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Plowman EK, Gray LT, Chapin J, Anderson A, Vasilopoulos T, Gooch C, Vu T, Wymer JP. Respiratory Strength Training in Amyotrophic Lateral Sclerosis: A Double-Blind, Randomized, Multicenter, Sham-Controlled Trial. Neurology 2023; 100:e1634-e1642. [PMID: 36805435 PMCID: PMC10103108 DOI: 10.1212/wnl.0000000000206830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 12/05/2022] [Indexed: 02/22/2023] Open
Abstract
OBJECTIVE Evaluate the short-term physiologic and one-year functional impact of a 12-week inspiratory and expiratory respiratory strength training (RST) program in individuals with amyotrophic lateral sclerosis (ALS). METHODS A double-blind, randomized, sham-controlled trial was conducted in 45individuals with early-stage ALS. Participants were randomized into 12-weeks of active-RST (30% load, n=23) or sham-RST (0% load, n=22). An intent-to-treat analysis was conducted. Linear regression of pre-post change with group status and pre-test scores as predictors was conducted. Primary outcomes included maximum expiratory and inspiratory pressure (MEP, MIP) and secondary outcomes were cough spirometry and forced vital capacity. Exploratory follow-up outcomes included one-year global and bulbar decline (ALS Functional Rating Scale-Revised- ALSFRS-R total and Bulbar subscale slope), oral-intake status, and time to noninvasive ventilation (NIV). RESULTS RST completion rate was 91% with no RST-related adverse events. A 12-week RST program led to increases in MEP (p=0.004) but not MIP (p=0.33). On average, MEP increased by 20.8 cmH20 following active-RST (95% CI: +7.6, +33.9) and decreased by 1.0 cmH20 (95% CI: -9.1, +7.2) following sham-RST. Mean MIP increased by 8.9 cmH20 (95% CI: +1.5, +16.3) and 4.8 cmH20 (95% CI: -0.6, +10.2) for the active and sham groups respectively. Secondary Outcomes: RST led to significant increases in cough peak inspiratory flow (p=0.02), however, did not impact cough expiratory flow (p = 0.06) or FVC (p=0.60). Twelve-Month Outcomes: A significant difference in ALSFRS-R Bulbar subscale slope was observed across treatment groups, with a more than two-fold faster rate of bulbar decline in the sham versus active-RST groups observed (-0.29 vs. -0.12 points/month, p=0.02). Total ALSFRS-R slope, feeding status, and time to NIV did not differ across treatment groups (p >0.05). CONCLUSIONS RST was well tolerated and led to improvements in some, but not all, short- and long-term outcomes. RST represents a proactive rehabilitative intervention that could increase physiologic capacity of specific breathing and airway clearance functions during the early stages of ALS. Further work is needed to determine optimal training intensity, resistance load specifications, and potential long-term functional outcomes.
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Affiliation(s)
| | - Lauren Tabor Gray
- Aerodigestive Research Core, University of Florida, Gainesville, FL.,Center for Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL
| | - Jennifer Chapin
- Aerodigestive Research Core, University of Florida, Gainesville, FL
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, FL
| | | | - Clifton Gooch
- Department of Neurology, University of South Florida, Tampa, FL
| | - Tuan Vu
- Department of Neurology, University of South Florida, Tampa, FL
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, FL
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Gandhi P, Plowman EK, Steele CM. Differences in pharyngeal swallow event timing: Healthy aging, Parkinson disease, and amyotrophic lateral sclerosis. Laryngoscope Investig Otolaryngol 2023; 8:466-477. [PMID: 37090868 PMCID: PMC10116960 DOI: 10.1002/lio2.1019] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/01/2022] [Accepted: 12/29/2022] [Indexed: 02/05/2023] Open
Abstract
Objective The pharyngeal phase of swallowing involves a coordinated sequence of events. Event durations may be prolonged in people with Parkinson disease (PwPD), and amyotrophic lateral sclerosis (PwALS); however, the cumulative effect of these changes is unexplored. We compared event latencies relative to hyoid burst (HYB) (time zero) to understand differences in deglutatory event timing. We hypothesized PwPD and PwALS would display similarly prolonged cumulative pharyngeal phase durations compared to healthy controls, with greater prolongations with increasing bolus viscosity. Method We retrospectively evaluated videofluoroscopic data of healthy adults (n = 78), PwPD (n = 17), and PwALS (n = 20). Participants swallowed 15 boluses of 20% (w/v) barium across five liquid consistencies. Paired raters evaluated nine deglutitive events using the ASPEKT method. Latencies were plotted by consistency relative to HYB and compared across cohorts using Mann-Whitney U tests (p ≤ .05). Cohen's d was calculated for all statistically significant results to determine effect size. Results In PwPD, significantly prolonged latencies were observed on thin liquid boluses compared to healthy controls. Latencies to all post-HYB events were significantly prolonged except for maximum upper esophageal sphincter distension. In PwALS, significantly prolonged latencies for events preceding and following HYB were noted on all consistencies compared to healthy controls and PwPD. Conclusion In PwPD, event latencies for multiple components of the swallowing sequence were prolonged culminating in overall prolongation of the pharyngeal phase on thin liquid. A similar pattern, but with significantly greater prolongation, was seen in the PwALS, and extended to swallows of all liquid consistencies.
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Affiliation(s)
- Pooja Gandhi
- Swallowing Rehabilitation Research Laboratory KITE Research Institute—University Health Network Toronto Ontario Canada
- Rehabilitation Sciences Institute University of Toronto Toronto Ontario Canada
| | - Emily K. Plowman
- Aerodigestive Research Core—University of Florida Gainesville Florida United States
| | - Catriona M. Steele
- Swallowing Rehabilitation Research Laboratory KITE Research Institute—University Health Network Toronto Ontario Canada
- Rehabilitation Sciences Institute University of Toronto Toronto Ontario Canada
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Plowman EK, Anderson A, York JD, DiBiase L, Vasilopoulos T, Arnaoutakis G, Beaver T, Martin T, Jeng EI. Dysphagia after cardiac surgery: Prevalence, risk factors, and associated outcomes. J Thorac Cardiovasc Surg 2023; 165:737-746.e3. [PMID: 33814177 DOI: 10.1016/j.jtcvs.2021.02.087] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 02/17/2021] [Accepted: 02/17/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES The study objectives were to determine the prevalence of swallowing impairment in adults after cardiac surgery and examine associated risk factors and health-related outcomes. METHODS A prospective single-center study was conducted in postoperative adult cardiac surgery patients with no history of dysphagia. A standardized fiberoptic endoscopic evaluation of swallowing was performed within 72 hours of extubation. Blinded raters completed validated outcomes of swallowing safety and efficiency. Demographic, surgical, and postoperative health-related outcomes were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs). RESULTS In 182 patients examined, imaging confirmed inefficient swallowing (residue) in 52% of patients and unsafe swallowing in 94% (65% penetrators, 29% aspirators). Silent aspiration was observed in 53% of aspirators, and 32% did not clear aspirate material. Independent risk factors for aspiration included New York Heart Association III and IV (OR, 2.9; CI, 1.2-7.0); reoperation (OR, 2.0; CI, 0.7-5.5); transesophageal echocardiogram images greater than 110 (OR, 2.6; CI, 1.1-6.3); intubation greater than 27 hours (OR, 2.1; CI, 0.8-5.3); and endotracheal tube size 8.0 or greater (OR, 3.1; CI, 1.1-8.6). Patients with 3 or 4 identified risk factors had a 16.4 (CI, 3.2-148.4) and 22.4 (CI, 3.7-244.7) increased odds of aspiration, respectively. Compared with nonaspirators, aspirators waited an additional 85 hours to resume oral intake, incurred $49,372 increased costs, and experienced a 43% longer hospital stay (P < .05). Aspiration was associated with pneumonia (OR, 2.6; CI, 1.1-6.5), reintubation (OR, 5.7; CI, 2.1-14.0), and death (OR, 2.8; CI, 1.2-9.0). CONCLUSIONS Tracheal aspiration was prevalent, covert, and associated with increased morbidity and mortality.
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Affiliation(s)
- Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, Fla; Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Fla; Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Fla.
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, Fla; Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Fla
| | - Justine Dallal York
- Aerodigestive Research Core, University of Florida, Gainesville, Fla; Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Fla
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, Fla; Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, Fla
| | - Terrie Vasilopoulos
- Aerodigestive Research Core, University of Florida, Gainesville, Fla; Departments of Anesthesiology and Orthopedics and Rehabilitation, University of Florida, Gainesville, Fla
| | - George Arnaoutakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Thomas Beaver
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Tomas Martin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Fla
| | - Eric I Jeng
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Fla
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Donohue C, Gray LT, Anderson A, DiBiase L, Wymer JP, Plowman EK. Profiles of Dysarthria and Dysphagia in Individuals With Amyotrophic Lateral Sclerosis. J Speech Lang Hear Res 2023; 66:154-162. [PMID: 36525626 PMCID: PMC10023186 DOI: 10.1044/2022_jslhr-22-00312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 07/22/2022] [Accepted: 09/21/2022] [Indexed: 06/17/2023]
Abstract
PURPOSE While dysarthria and dysphagia are known bulbar manifestations of amyotrophic lateral sclerosis (ALS), the relative prevalence of speech and swallowing impairments and whether these bulbar symptoms emerge at the same time point or progress at similar rates is not yet clear. We, therefore, sought to determine the relative prevalence of speech and swallowing impairments in a cohort of individuals with ALS and to determine the impact of disease duration, severity, and onset type on bulbar impairments. METHOD Eighty-eight individuals with a confirmed diagnosis of ALS completed the ALS Functional Rating Scale-Revised (ALSFRS-R), underwent videofluoroscopy (VF), and completed the Sentence Intelligibility Test (SIT) during a single visit. Demographic variables including disease duration and onset type were also obtained from participants. Duplicate, independent, and blinded ratings were completed using the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale and SIT to index dysphagia (DIGEST ≥ 1) and dysarthria (< 96% intelligible and/or < 150 words per minute) status. Descriptive statistics, Pearson chi-squared tests, independent-samples t tests, and odds ratios were performed. RESULTS Dysphagia and dysarthria were instrumentally confirmed in 68% and 78% of individuals with ALS, respectively. Dysarthria and dysphagia were associated (p = .01), and bulbar impairment profile distributions in rank order included (a) dysphagia - dysarthria (59%, n = 52), (b) no dysphagia - dysarthria (19%, n = 17), (c) no dysphagia - no dysarthria (13%, n = 11), and (d) dysphagia - no dysarthria (9%, n = 8). Participants with dysphagia or dysarthria demonstrated 4.2 higher odds of exhibiting a bulbar impairment in the other domain than participants with normal speech and swallowing (95% CI [1.5, 12.2]). There were no differences in ALSFRS-R total scores or disease duration across bulbar impairment profiles (p > .05). ALSFRS-R bulbar subscale scores were significantly lower in individuals with dysphagia versus no dysphagia (8.4 vs. 10.4, p < .0001) and dysarthria versus no dysarthria (8.5 vs. 10.9, p < .0001). Dysphagia and onset type (p = .003) and dysarthria and onset type were associated (p < .0001). CONCLUSIONS Over half of the individuals with ALS in this study demonstrated both dysphagia and dysarthria. Of those with only one bulbar impairment, speech was twice as likely to be the first bulbar symptom to degrade. Future studies are needed to confirm these findings and determine the longitudinal progression of bulbar impairments in this patient population.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
| | - Lauren Tabor Gray
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Center of Collaborative Research, NOVA Southeastern University, Fort Lauderdale, FL
| | - Amber Anderson
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
| | - Lauren DiBiase
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
| | - James P. Wymer
- Department of Neurology, University of Florida, Gainesville
| | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Neurology, University of Florida, Gainesville
- Department of Surgery, University of Florida, Gainesville
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Donohue C, Tabor Gray L, Anderson A, DiBiase L, Chapin J, Wymer JP, Plowman EK. Discriminant Ability of the Eating Assessment Tool-10 to Detect Swallowing Safety and Efficiency Impairments. Laryngoscope 2022; 132:2319-2326. [PMID: 35137963 DOI: 10.1002/lary.30043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/07/2022] [Accepted: 01/21/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVES/HYPOTHESIS Quick, sensitive dysphagia screening tools are necessary to identify high-risk patients for further evaluation in busy multidisciplinary amyotrophic lateral sclerosis (ALS) clinics. We examined the relationship between self-perceived dysphagia using the validated Eating Assessment Tool-10 (EAT-10) and videofluoroscopic analysis of swallowing safety and efficiency. STUDY DESIGN Prospective, observational, longitudinal study. METHODS Individuals with ALS completed the EAT-10 and a videofluoroscopic swallowing study. Duplicate, independent, blinded analyses of the validated Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale were performed to index swallowing safety and efficiency (mild dysphagia: DIGEST ≥ 1, moderate dysphagia: DIGEST ≥ 2). A between-groups analysis of variance with Games-Howell test for post-hoc pairwise comparisons was performed to examine EAT-10 scores across dysphagia severity levels. Receiver operator characteristic curve analysis, area under the curve (AUC), sensitivity, specificity, positive-negative predictive values (PPV, NPV), and odds ratios (OR) were derived. RESULTS Four hundred and thirty five paired EAT-10 and DIGEST scores were analyzed. Mean EAT-10 score was 8.48 (95% confidence interval [CI]: 7.63-9.33). Individuals with dysphagia demonstrated higher EAT-10 scores (mild: 4.1 vs. 11.3, moderate: 6.0 vs. 17.5, P < .001). Mean EAT-10 scores increased across DIGEST levels (D0: 4.1, D1: 7.9, D2: 15.1, D3: 20.4, D4: 39.0). For mild dysphagia, an EAT-10 cut score of 3 was optimal: AUC 0.74 (95% CI: 0.69-0.78; sensitivity: 77%; specificity: 53%; PPV: 71%; NPV: 60%; OR: 3.5). An EAT-10 cut score of 7 optimized detection of moderate dysphagia: AUC 0.83 (95% CI: 0.78-0.87; sensitivity: 81%; specificity: 66%; PPV: 39%; NPV: 93%; OR: 8.1). CONCLUSION The EAT-10 is an easy-to-administer dysphagia screening tool with good discriminant ability for use in ALS clinics. LEVEL OF EVIDENCE 2 Laryngoscope, 132:2319-2326, 2022.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, U.S.A.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, U.S.A.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, U.S.A
| | - Lauren Tabor Gray
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, U.S.A.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, U.S.A.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, U.S.A
| | - Amber Anderson
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, U.S.A.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, U.S.A
| | - Lauren DiBiase
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, U.S.A.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, U.S.A
| | - Jennifer Chapin
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, U.S.A.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, U.S.A
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, Florida, U.S.A
| | - Emily K Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, U.S.A.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, U.S.A.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, U.S.A.,Department of Neurology, University of Florida, Gainesville, Florida, U.S.A.,Department of Surgery, University of Florida, Gainesville, Florida, U.S.A
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Donohue C, Robison R, DiBiase L, Anderson A, Vasilopoulos T, Plowman EK. Comparison of Validated Videofluoroscopic Outcomes of Pharyngeal Residue: Concordance Between a Perceptual, Ordinal, and Bolus-Based Rating Scale and a Normalized Pixel-Based Quantitative Outcome. J Speech Lang Hear Res 2022; 65:2510-2517. [PMID: 35749660 PMCID: PMC9584126 DOI: 10.1044/2022_jslhr-21-00659] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 03/09/2022] [Accepted: 04/11/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE This study compared the concordance between two validated videofluoroscopic pharyngeal residue outcome scales used in clinical and research settings: the Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) and the Analysis of Swallowing Physiology: Events, Kinematics and Timing (ASPEKT) percent residue metric. METHOD Two trained raters completed independent and blinded videofluoroscopic ratings of both DIGEST efficiency and ASPEKT percent pharyngeal residue outcomes for bolus trials of 5 cc Varibar thin liquid (n = 223), thin liquid comfortable cup sips (n = 223), and 5 cc Varibar thin honey (n = 223). Spearman's rho and Kruskal-Wallis analyses were performed for each bolus type. RESULTS Significant associations between DIGEST and ASPEKT pharyngeal residue outcomes were noted for 5 cc thin (r = .54, p < .001), cup sip thin (r = .41, p < .001), and 5 cc thin honey (r = .60, p < .001) bolus trials. ASPEKT percent residue increased across worsening DIGEST efficiency ordinal scale levels, with a main effect for each bolus type. Post hoc analysis revealed significant differences in the ASPEKT percent residue values between each DIGEST pairwise comparison for the thin cup sip bolus trial and for each pairwise comparison except between the moderate-to-severe (less than half vs. majority) ordinal levels for the 5 cc thin and 5 cc honey bolus trials, p < .05. CONCLUSIONS Perceptual, ordinal (DIGEST) and quantitative, pixel-based (ASPEKT) videofluoroscopic pharyngeal residue outcomes were associated in this data set of 669 bolus trials. Future research is warranted to confirm these results.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
| | - Raele Robison
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Department of Medicine, University of Wisconsin–Madison
| | - Lauren DiBiase
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
| | - Amber Anderson
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
| | | | - Emily K. Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville
- Breathing Research and Therapeutics Center, University of Florida, Gainesville
- Department of Neurology, University of Florida, Gainesville
- Department of Surgery, University of Florida, Gainesville
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20
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Gandhi P, Plowman EK, Steele CM. Comparison of Lingual Pressure Generation Capacity in Parkinson Disease, Amyotrophic Lateral Sclerosis, and Healthy Aging. Am J Speech Lang Pathol 2022; 31:1845-1853. [PMID: 35858265 PMCID: PMC9907496 DOI: 10.1044/2022_ajslp-21-00385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 03/01/2022] [Accepted: 04/25/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE The tongue plays a key role in bolus propulsion during swallowing, with reduced lingual pressure generation representing a risk factor for impaired swallowing safety and efficiency. We compared lingual pressure generation capacity in people with Parkinson disease (PwPD), people with amyotrophic lateral sclerosis (PwALS), and healthy older adults. We hypothesized that both patient cohorts would demonstrate reduced maximum anterior isometric pressure (MAIP) and regular effort saliva swallow (RESS) pressures compared with healthy controls, with the greatest reductions expected in the ALS cohort. METHOD We enrolled 20 PwPD, 18 PwALS, and 20 healthy adults over 60 years of age. The Iowa Oral Performance Instrument was used to measure MAIP, RESS, and lingual functional reserve (LFR, i.e., MAIP - RESS). Descriptive statistics were calculated; between-groups differences were explored using univariate analyses of variance and post hoc Sidak tests with alpha set at .05. RESULTS Mean MAIPs for the PD, ALS, and heathy cohorts were 54.7, 33.5, and 47.4 kPa, respectively. Significantly lower MAIP was found in PwALS compared with PwPD and healthy controls. RESS values did not differ significantly across groups. LFR was significantly higher in PwPD versus PwALS and healthy controls. CONCLUSIONS Lingual pressure generation capacity and functional reserve were reduced in PwALS, but not in PwPD, beyond changes seen with healthy aging. Both patient cohorts displayed preserved lingual pressure during saliva swallows. Future studies exploring longitudinal changes in tongue pressure generation on isometric and saliva swallowing tasks will be needed to confirm whether tongue pressure measures serve as noninvasive clinical biomarkers of swallowing impairment.
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Affiliation(s)
- Pooja Gandhi
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
| | | | - Catriona M. Steele
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute, University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
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21
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Donohue C, Tabor Gray L, Chapin J, Anderson A, DiBiase L, Wymer JP, Plowman EK. Discriminant ability of the 3-ounce water swallow test to detect aspiration in amyotrophic lateral sclerosis. Neurogastroenterol Motil 2022; 34:e14310. [PMID: 34936158 DOI: 10.1111/nmo.14310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/18/2021] [Accepted: 12/10/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND Given the need for quick and accurate dysphagia screening tools to optimize referral workflows and resource utilization in fast-paced multidisciplinary amyotrophic lateral sclerosis (ALS) clinics, we evaluated the discriminant ability of the 3 oz. water swallow test (WST) to detect aspiration in individuals with ALS. METHODS A total of 212 paired 3 oz. WST (index test) and standardized videofluoroscopic swallow studies (reference test) were completed in individuals with a confirmed diagnosis of ALS. Blinded raters analyzed swallowing safety using the validated penetration-aspiration scale (PAS; non-aspirator: PAS < 6; aspirator: PAS ≥ 6). Receiver operating characteristic curve analysis, area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated. KEY RESULTS Index test: 78 (36.8%) WSTs were scored as a fail and 134 (63.2%) as a pass. REFERENCE TEST Aspiration was confirmed in 67 (31.6%) reference tests with 145 (68.4%) reference tests verified as having no aspiration. Sensitivity and specificity of the 3 oz. WST to detect radiographically confirmed aspiration was 55.2% and 71.7%, respectively (AUC: 0.635, PPV: 47.4%, NPV: 77.6%). CONCLUSIONS & INFERENCES In this dataset, the 3 oz. WST did not demonstrate adequate sensitivity or specificity to detect aspiration in people with ALS as a stand-alone dysphagia screening tool.
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Affiliation(s)
- Cara Donohue
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, USA
| | - Lauren Tabor Gray
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, USA
| | - Jennifer Chapin
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, USA
| | - Amber Anderson
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, USA
| | - Lauren DiBiase
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, USA
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, Florida, USA
| | - Emily K Plowman
- Aerodigestive Research Core Laboratory, University of Florida, Gainesville, Florida, USA.,Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida, USA.,Breathing Research and Therapeutics Center, University of Florida, Gainesville, Florida, USA.,Department of Neurology, University of Florida, Gainesville, Florida, USA.,Department of Surgery, University of Florida, Gainesville, Florida, USA
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22
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Dallal-York J, Segalewitz T, Croft K, Colsky J, DiBiase L, Anderson A, Vasilopoulos T, Pelaez A, Shahmohammadi A, Pipkin M, Machuca TN, Plowman EK. Incidence, Risk Factors and Sequelae of Dysphagia Mediated Aspiration Following Lung Transplantation. J Heart Lung Transplant 2022; 41:1095-1103. [DOI: 10.1016/j.healun.2022.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 04/11/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022] Open
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23
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Sharaf OM, Hao K, Demos D, Arnaoutakis GJ, Martin TD, Beaver TM, Plowman EK, Jeng EI. Utility of Fiberoptic Endoscopic Evaluation of Swallowing in Patients Undergoing Left Ventricular Assist Device Implantation. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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24
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Gandhi P, Mancopes R, Sutton D, Plowman EK, Steele CM. The Frequency of Atypical and Extreme Values for Pharyngeal Phase Swallowing Measures in Mild Parkinson Disease Compared to Healthy Aging. J Speech Lang Hear Res 2021; 64:3032-3050. [PMID: 34314250 PMCID: PMC8740655 DOI: 10.1044/2021_jslhr-21-00084] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 04/06/2021] [Accepted: 04/12/2021] [Indexed: 05/26/2023]
Abstract
Purpose Dysphagia is thought to be prevalent and a leading cause of morbidity and mortality in people with Parkinson disease (PwPD). The aim of this study was to compare the frequencies of atypical and extreme values for measures of swallowing physiology in PwPD and in an age- and sex-matched cohort of healthy adults. Atypical and extreme values were defined, respectively, as values falling in the 25% and 5% tails of the reference distribution for healthy adults under age 60 years. Method A standard videofluoroscopy (VF) protocol was performed in 17 adults with mild PD and 17 age- and sex-matched healthy adults using 20% w/v liquid barium ranging from thin to extremely thick consistency. Blinded VF analysis was performed according to the Analysis of Swallowing Physiology: Events, Kinematics and Timing Method. Frequencies for atypical and extreme values were tabulated by cohort and compared using odds ratios. Results Increased frequencies of atypical values (> 25%) were seen in the PwPD for prolonged swallow reaction time, prolonged time-to-laryngeal-vestibule-closure (LVC), and poor pharyngeal constriction. However, these findings were also observed in the healthy controls. The PwPD showed significantly higher odds of atypical values for narrow upper esophageal sphincter (UES) diameter on thin liquids, a short hyoid-burst-to-UES-opening interval on extremely thick liquids, and prolonged time-to-LVC, LVC duration, and UES opening duration on multiple consistencies. The frequencies of extreme values failed to show any significant cohort differences for any parameter. Conclusions In this study, a group of people with mild PD did not show clear evidence of swallowing impairments distinct from the changes seen in a healthy age-matched control group when odds ratios were used to compare the frequencies of atypical values between PwPD and the control group; only a few parameters showed significant differences. These were findings of significantly higher frequencies in PwPD of prolonged LVC and UES opening duration. Supplemental Material https://doi.org/10.23641/asha.15032241.
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Affiliation(s)
- Pooja Gandhi
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
| | - Renata Mancopes
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
| | - Danielle Sutton
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
| | | | - Catriona M. Steele
- Swallowing Rehabilitation Research Laboratory, KITE Research Institute – University Health Network, Toronto, Ontario, Canada
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
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25
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Dallal York J, Leonard K, Anderson A, DiBiase L, Jeng EI, Plowman EK. Discriminant Ability of the 3-Ounce Water Swallow Test to Detect Aspiration in Acute Postoperative Cardiac Surgical Patients. Dysphagia 2021; 37:831-838. [PMID: 34268585 DOI: 10.1007/s00455-021-10333-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 06/22/2021] [Indexed: 01/22/2023]
Abstract
Dysphagia is a common complication of cardiac surgery (CS) contributing to morbidity and mortality. Although early dysphagia detection is important, no current screening guidelines or validated tools exist in the cardiac intensive care setting. We therefore aimed to examine the discriminant ability of the 3-ounce water swallow test (3 oz. WST) to detect aspiration in acute postoperative CS patients. 196 postoperative CS patients were enrolled in this prospective single-center study. Participants completed the 3 oz. WST and a standardized Flexible Endoscopic Evaluation of Swallowing. Independent duplicate ratings of the penetration aspiration scale (PAS) were performed in a blinded fashion (100% agreement criteria). Receiver operating characteristic curve and area under the curve (AUC) analyses were performed with sensitivity, specificity, positive, and negative predictive values (PPV, NPV) derived. Fifty-four CS patients (28%) were confirmed aspirators (PAS ≥ 6), of whom 48% (n = 26) were silent aspirators (PAS = 8). Both the sensitivity and specificity of the 3 oz. WST to identify instrumentally confirmed aspiration was 63% (AUC: 0.63, 95% CI: 0.54, 0.72), and PPV was 39% and NPV 82%. The 3 oz. WST demonstrated fair discriminant ability to detect aspiration in acute postoperative CS patients. The high rate of silent aspiration may explain, in part, these findings given that the screening fail criteria include an overt cough response. In isolation, the 3 oz. WST does not represent a sensitive screen of aspiration in postoperative CS patients with a need to identify alternative screening tools for this setting.
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Affiliation(s)
- Justine Dallal York
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Department of Speech, Language & Hearing Science, College of Public Health, Health Professions, University of Florida, 1225 Center Drive, PO Box 100174, Gainesville, FL, USA
| | - Kelly Leonard
- Department of Speech, Language & Hearing Science, College of Public Health, Health Professions, University of Florida, 1225 Center Drive, PO Box 100174, Gainesville, FL, USA
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Eric I Jeng
- Department of Surgery, Division of Cardiothoracic Surgery, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA. .,Department of Speech, Language & Hearing Science, College of Public Health, Health Professions, University of Florida, 1225 Center Drive, PO Box 100174, Gainesville, FL, USA. .,Department of Surgery, Division of Cardiothoracic Surgery, University of Florida, Gainesville, FL, USA. .,Department of Neurology, University of Florida, Gainesville, FL, USA.
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26
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Robison R, DiBiase L, Ashley A, McElheny K, Anderson A, Wymer JP, Plowman EK. Swallowing Safety and Efficiency Impairment Profiles in Individuals with Amyotrophic Lateral Sclerosis. Dysphagia 2021; 37:644-654. [PMID: 34037850 DOI: 10.1007/s00455-021-10315-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/13/2021] [Indexed: 12/01/2022]
Abstract
Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and associated with reductions in quality of life and health-related outcomes. Despite the high prevalence of dysphagia in ALS, functional impairment profiles of swallowing safety and efficiency have not been comprehensively examined. We therefore aimed to determine the relative prevalence of unsafe and inefficient swallowing in a large cohort of individuals with ALS. We further sought to examine the impact of global and bulbar disease progression (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised "ALSFRS-R" total and bulbar scores, respectively), disease duration, and onset type on swallowing impairment profiles. One hundred individuals with ALS completed a standardized videofluoroscopic swallowing examination Two independent and blinded raters performed validated ratings of safety (Penetration-Aspiration Scale, PAS) and efficiency (Analysis of Swallowing Physiology: Events, Kinematics, and Timing, ASPEKT % residue). Binary classifications of safety (unsafe: PAS ≥ 3), efficiency (inefficient: total residue ≥ 3% of C2-42) and global swallowing status were derived. The ALSFRS-R was completed to derive ALSFRS-R total and bulbar subscale scores. Demographic data (disease duration and onset type) for each participant was also recorded. Descriptives, 2 × 2 contingency tables with Fishers exact test, and independent samples t-tests were performed (α = 0.05). Prevalence of unsafe and inefficient swallowing was 48% and 73%, respectively. Global swallowing profiles were, in rank order: unsafe and inefficient (39%), inefficient but safe (34%), safe and efficient (18%), and unsafe but efficient (9%). There were no differences in global disease progression or disease duration across swallowing impairment profiles. ALSFRS-R bulbar subscale scores were significantly lower in unsafe versus safe swallowers, p < 0.05. Spinal onset patients had a greater proportion of safe swallowers as compared to bulbar onset patients (p = 0.000, Fisher's exact test). Both spinal and bulbar onset patients demonstrated a higher prevalence of inefficient swallowers as compared to efficient swallowers (p = 0.04, Fisher's exact test). Dysphagia was prevalent in this group of individuals with ALS. Approximately half demonstrated safety impairments and two-thirds had impairments in swallowing efficiency. Inefficient swallowing was approximately four times more likely to be the initial functional impairment in patients with one pathophysiologic functional impairment. A longitudinal study is needed to examine the temporal evolution of dysphagia in ALS.
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Affiliation(s)
- Raele Robison
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA. .,Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA. .,William S. Middleton Memorial Veteran's Hospital, Madison, WI, USA.
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Amy Ashley
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA
| | - Kasey McElheny
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - James P Wymer
- Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Speech, Language and Hearing Science Department, University of Florida, Gainesville, FL, USA.,Department of Neurology, University of Florida, Gainesville, FL, USA.,Department of Surgery, University of Florida, Gainesville, FL, USA
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27
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Plowman EK, Chheda N, Anderson A, Dallal York J, DiBiase L, Vasilopoulos T, Arnaoutakis G, Beaver T, Martin T, Bateh T, Jeng EI. Vocal Fold Mobility Impairment After Cardiovascular Surgery: Incidence, Risk Factors, and Sequela. Ann Thorac Surg 2020; 112:53-60. [PMID: 33075318 DOI: 10.1016/j.athoracsur.2020.07.074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/13/2020] [Accepted: 07/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND We aimed to determine the incidence and contributing risk factors of vocal fold mobility impairment (VFMI) in postoperative cardiovascular patients and evaluate the impact of VFMI on health-related outcomes. METHODS This single-site prospective study enrolled adults undergoing sternotomy or thoracotomy procedures who underwent a fiberoptic laryngoscopy examination within 72 hours of extubation. Potential demographic and surgical risk factors and health-related outcomes were collected. A blinded laryngologist assessed VFMI and mucosal injury. Descriptives, univariate and multivariable regression analyses with odds ratios (OR) were performed. RESULTS Of 185 eligible examinations, VFMI was confirmed in 25% of patients (7 complete, 39 partial VFMI) with left-sided involvement in 83% of cases. Laryngeal mucosal injury included granuloma (38%), posterior cricoid hypertrophy (37%), edema (29%), bruising (23%), and hemorrhage (9%). Independent risk factors for complete VFMI were aortic arch procedure (odds ratio 6.1), body mass index less than 25 (OR: 7.2), and African-American or Hispanic race (OR: 6.0). Patients with two or more identified risk factors had a 33.0 increased odds of complete VFMI compared with patients not having two or more risk factors. Compared with patients having normal vocal fold motion, patients with complete VFMI had a 2.7 increased odds of pneumonia, 5.7 higher odds of reintubation, a 7.3 times higher odds of death, and increased length of hospital stay and cost of care (P < .05). CONCLUSIONS Interdisciplinary postoperative care and laryngoscopy examination are recommended for high-risk patients to facilitate early detection and improve patient outcomes.
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Affiliation(s)
- Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, Florida; Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida; Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Florida.
| | - Neil Chheda
- Department of Otolaryngology, University of Florida, Gainesville, Florida
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, Florida; Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida
| | - Justine Dallal York
- Aerodigestive Research Core, University of Florida, Gainesville, Florida; Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, Florida; Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, Florida
| | | | - George Arnaoutakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Thomas Beaver
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Tomas Martin
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Tamara Bateh
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Florida
| | - Eric I Jeng
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, Florida
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Dallal York J, Miller S, Chapin J, Gore S, Jeng EI, Plowman EK. Swallowing screening practice patterns for nurses in the cardiac surgery intensive care unit. J Clin Nurs 2020; 29:4573-4582. [PMID: 32920944 DOI: 10.1111/jocn.15490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/23/2020] [Accepted: 08/24/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES The current study surveyed nurse practice patterns for performing swallowing screens in an academic cardiac intensive care unit (ICU). It aimed to index: training and levels of confidence in conducting dysphagia screens; screening methods employed; timing and frequency of implement; and subsequent plan of care in identified high-risk patients. BACKGROUND Swallowing impairment (dysphagia) is common following cardiac surgery and associated with significant morbidity and mortality. Early and accurate detection of dysphagia is therefore critical to afford implementation of interventions to optimise patient care. Currently, no validated instruments or guidelines exist for nursing screening of dysphagia in this setting. METHODS An anonymous and voluntary 10-item mixed-methods online survey was conducted using Qualtrics software. Nonprobability purposive sampling was utilised to recruit nurses working in an academic 24-bed cardiac ICU. Thematic analysis using operationally defined coding, SRQR checklist and descriptive statistics were employed. RESULTS Sixty-nine nurses completed the survey during a 1-month period, representing an 84% response rate. Formal training in performing swallowing screens was reported in 18.6% of nurses. In rank order, reported level of confidence was the following: "moderately" (49%); "somewhat" (35%); "not" (13%); and "very" (3%). The majority of nurses performed screens within 1 hr (40.6%) or between 1-4 hr (43.8%) of extubation. Fifteen different methods were utilised to screen swallowing function by nurses who reported a total of 31 different clinical signs indicative of dysphagia. CONCLUSIONS Survey data of practicing nurses in an academic cardiac ICU revealed limited formal training in swallowing screening methodology, a high degree of variability in screening methods employed and low levels of agreement for dysphagia signs. RELEVANCE TO CLINICAL PRACTICE Data highlight a knowledge gap and need for the development of formal education and validated rapid nursing dysphagia screening tools for standardised implementation in the cardiac surgery ICU setting.
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Affiliation(s)
- Justine Dallal York
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Department of Speech, College of Public Health, Health Professions, University of Florida, Gainesville, FL, USA
| | - Sarah Miller
- College of Nursing, Medical University of South Carolina, Charleston, SC, USA
| | - Jennifer Chapin
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA
| | - Stephanie Gore
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Eric I Jeng
- Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA
| | - Emily K Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, USA.,Department of Speech, College of Public Health, Health Professions, University of Florida, Gainesville, FL, USA.,Division of Cardiothoracic Surgery, Department of Surgery, University of Florida, Gainesville, FL, USA.,Department of Neurology, University of Florida, Gainesville, FL, USA
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Tabor-Gray L, Vasilopoulos T, Plowman EK. Differences in voluntary and reflexive cough strength in individuals with amyotrophic lateral sclerosis and healthy adults. Muscle Nerve 2020; 62:597-600. [PMID: 32776561 DOI: 10.1002/mus.27040] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Dystussia impacts the ability to protect the airway. Voluntary cough provides a metric of airway defense but differs from the reflexive response to aspiration during swallowing. Therefore, we evaluated relationships between voluntary and reflexive cough among individuals with amyotrophic lateral sclerosis (ALS) and a healthy cohort. METHODS Twenty-eight individuals with ALS and 26 healthy individuals completed voluntary and reflexive cough testing. Descriptive statistics, reliability, and paired t tests were conducted to evaluate differences in cough volume acceleration (CVA) and peak expiratory flow rate (PEFR) in voluntary vs reflexive cough. RESULTS Compared with reflexive cough, voluntary CVA and PEFR were greater in individuals with ALS [t(27) = 4.83, P < .001 and t(27) = 8.69, P < .001] and the healthy cohort [t(21) = 5.91, P < .001 and t(21) = 12.26, P < .001], respectively. DISCUSSION These findings hold important implications for the use and interpretation of voluntary peak cough flow during clinical swallowing evaluations.
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Affiliation(s)
- Lauren Tabor-Gray
- Department of Neurology, Phil Smith Neuroscience Institute, Fort Lauderdale, Florida, USA.,Swallowing Systems Core, University of Florida, Gainesville, Florida, USA
| | - Terrie Vasilopoulos
- Department of Anesthesiology and Orthopedics, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Emily K Plowman
- Swallowing Systems Core, University of Florida, Gainesville, Florida, USA.,Speech, Language and Hearing Science Department, University of Florida, Gainesville, Florida, USA.,Department of Neurology, University of Florida, Gainesville, Florida, USA
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30
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Chapin JL, Gray LT, Vasilopoulos T, Anderson A, DiBiase L, York JD, Robison R, Wymer J, Plowman EK. Diagnostic utility of the amyotrophic lateral sclerosis Functional Rating Scale-Revised to detect pharyngeal dysphagia in individuals with amyotrophic lateral sclerosis. PLoS One 2020; 15:e0236804. [PMID: 32790801 PMCID: PMC7425890 DOI: 10.1371/journal.pone.0236804] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 07/13/2020] [Indexed: 12/18/2022] Open
Abstract
Objective The ALS Functional Rating Scale–Revised (ALSFRS-R) is the most commonly utilized instrument to index bulbar function in both clinical and research settings. We therefore aimed to evaluate the diagnostic utility of the ALSFRS-R bulbar subscale and swallowing item to detect radiographically confirmed impairments in swallowing safety (penetration or aspiration) and global pharyngeal swallowing function in individuals with ALS. Methods Two-hundred and one individuals with ALS completed the ALSFRS-R and the gold standard videofluoroscopic swallowing exam (VFSE). Validated outcomes including the Penetration-Aspiration Scale (PAS) and Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) were assessed in duplicate by independent and blinded raters. Receiver operator characteristic curve analyses were performed to assess accuracy of the ALSFRS-R bulbar subscale and swallowing item to detect radiographically confirmed unsafe swallowing (PAS > 3) and global pharyngeal dysphagia (DIGEST >1). Results Although below acceptable screening tool criterion, a score of ≤ 3 on the ALSFRS-R swallowing item optimized classification accuracy to detect global pharyngeal dysphagia (sensitivity: 68%, specificity: 64%, AUC: 0.68) and penetration/aspiration (sensitivity: 79%, specificity: 60%, AUC: 0.72). Depending on score selection, sensitivity and specificity of the ALSFRS-R bulbar subscale ranged between 34–94%. A score of < 9 optimized classification accuracy to detect global pharyngeal dysphagia (sensitivity: 68%, specificity: 68%, AUC: 0.76) and unsafe swallowing (sensitivity:78%, specificity:62%, AUC: 0.73). Conclusions The ALSFRS-R bulbar subscale or swallowing item did not demonstrate adequate diagnostic accuracy to detect radiographically confirmed swallowing impairment. These results suggest the need for alternate screens for dysphagia in ALS.
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Affiliation(s)
- Jennifer L. Chapin
- Aerodigestive Research Core, University of Florida, Gainesville, FL, United States of America
| | - Lauren Tabor Gray
- Aerodigestive Research Core, University of Florida, Gainesville, FL, United States of America
- Department of Neurology, Phil Smith Neuroscience Institute, Holy Cross Hospital, Fort Lauderdale, FL, United States of America
| | - Terrie Vasilopoulos
- Department of Anesthesiology, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Amber Anderson
- Aerodigestive Research Core, University of Florida, Gainesville, FL, United States of America
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States of America
| | - Lauren DiBiase
- Aerodigestive Research Core, University of Florida, Gainesville, FL, United States of America
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States of America
| | - Justine Dallal York
- Aerodigestive Research Core, University of Florida, Gainesville, FL, United States of America
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States of America
| | - Raele Robison
- Aerodigestive Research Core, University of Florida, Gainesville, FL, United States of America
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States of America
| | - James Wymer
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States of America
| | - Emily K. Plowman
- Aerodigestive Research Core, University of Florida, Gainesville, FL, United States of America
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville, FL, United States of America
- Department of Neurology, College of Medicine, University of Florida, Gainesville, FL, United States of America
- Department of Surgery, College of Medicine, University of Florida, Gainesville, FL, United States of America
- * E-mail:
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Rogus-Pulia NM, Plowman EK. Shifting Tides Toward a Proactive Patient-Centered Approach in Dysphagia Management of Neurodegenerative Disease. Am J Speech Lang Pathol 2020; 29:1094-1109. [PMID: 32650651 PMCID: PMC7844336 DOI: 10.1044/2020_ajslp-19-00136] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Purpose Persons with neurodegenerative disease frequently develop comorbid dysphagia as part of their disease process. Current "reactive" approaches to dysphagia management address dysphagia once it manifests clinically and consist of compensatory approaches. The purpose of this article is to propose a paradigm shift in dysphagia management of patients with neurodegenerative disease from a "reactive to proactive" approach by highlighting amyotrophic lateral sclerosis (ALS) and dementia as case examples. Method The authors present several areas of special consideration for speech-language pathologists (SLPs) treating dysphagia in patients with neurodegenerative disease. The drawbacks of historical "reactive" approaches to dysphagia management are described. Concepts of functional reserve for swallowing and homeostenosis are discussed. A "proactive" patient-centered paradigm of care for these patients is proposed with evidence to support its importance. A rationale for use of this approach in patients with ALS and dementia is provided with strategies for implementation. Results When treating dysphagia in patients with neurodegenerative disease, SLPs must balance a variety of factors in their decision making, including disease severity and expected progression, cultural considerations, goals of care, patient empowerment, and caregiver support. Reactive approaches to dysphagia management in these populations are problematic in that they disempower patients by focusing on use of compensatory techniques (e.g., diet modification, postural changes, feeding tube placement). Proactive approaches that employ rehabilitative interventions to increase functional reserve, such as resistance training, may result in improvement or maintenance of swallowing function longer into disease progression. An interdisciplinary team with early SLP involvement is necessary. Conclusions SLPs play a critical role in the management of dysphagia in patients with neurodegenerative disease and should be integrated early in the care of these patients. By focusing on a proactive patient-centered approach, patients with neurodegenerative conditions, such as ALS and dementia, will experience improved quality of life and health outcomes for a longer time.
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Affiliation(s)
- Nicole M. Rogus-Pulia
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health
- Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health
- Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, Madison, WI
| | - Emily K. Plowman
- Department of Speech, Language and Hearing Sciences, University of Florida, Gainesville
- Aerodigestive Research Core, University of Florida, Gainesville
- Department of Neurology, College of Medicine, University of Florida, Gainesville
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Waito AA, Plowman EK, Barbon CEA, Peladeau-Pigeon M, Tabor-Gray L, Magennis K, Robison R, Steele CM. A Cross-Sectional, Quantitative Videofluoroscopic Analysis of Swallowing Physiology and Function in Individuals With Amyotrophic Lateral Sclerosis. J Speech Lang Hear Res 2020; 63:948-962. [PMID: 32310713 PMCID: PMC7242989 DOI: 10.1044/2020_jslhr-19-00051] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/17/2019] [Accepted: 12/11/2019] [Indexed: 05/04/2023]
Abstract
Purpose To date, research characterizing swallowing changes in individuals with amyotrophic lateral sclerosis (ALS) has primarily relied on subjective descriptions. Thus, the degree to which swallowing physiology is altered in ALS, and relationships between such alterations and swallow safety and/or efficiency are not well characterized. This study provides a quantitative representation of swallow physiology, safety, and efficiency in a sample of individuals with ALS, to estimate the degree of difference in comparison to published healthy reference data and identify parameters that pose risk to swallow safety and efficiency. Secondary analyses explored the therapeutic effect of thickened liquids on swallowing safety and efficiency. Method Nineteen adults with a diagnosis of probable-definite ALS (El-Escorial Criteria-Revised) underwent a videofluoroscopic swallowing study, involving up to 15 sips of barium liquid (20% w/v), ranging in thickness from thin to extremely thick. Blinded frame-by-frame videofluoroscopy analysis yielded the following measures: Penetration-Aspiration Scale, number of swallows per bolus, amount of pharyngeal residue, degree of laryngeal vestibule closure (LVC), time-to-LVC, duration of LVC (LVCdur), pharyngeal area at maximum constriction, diameter of upper esophageal sphincter opening, and duration of UES opening (UESOdur). Measures of swallow physiology obtained from thin liquid trials were compared against published healthy reference data using unpaired t tests, chi-squared tests, and Cohen's d effect sizes (adjusted p < .008). Preliminary relationships between parameters of swallowing physiology, safety, and efficiency were explored using nonparametric Cochrane's Q, Friedman's test, and generalized estimating equations (p < .05). Results Compared to healthy reference data, this sample of individuals with ALS displayed a higher proportion of swallows with partial or incomplete LVC (24% vs. < 1%), increased time-to-LVC (d = 1.09), reduced UESwidth (d = 0.59), enlarged pharyngeal area at maximum constriction, prolonged LVCdur (d = 0.64), and prolonged UESOdur (d = 1.34). Unsafe swallowing (i.e., PAS ≥ 3) occurred more frequently when LVC was partial/incomplete or time-to-LVC was prolonged. Pharyngeal residue was associated with larger pharyngeal areas at maximum constriction. Unsafe swallowing occurred less frequently with extremely thick liquids, compared to thin liquids. No significant differences in pharyngeal residue were observed based on liquid thickness. Conclusions Quantitative videofluoroscopic measurements revealed moderate-to-large differences in swallow physiology between this sample of individuals with ALS and healthy reference data. Increased time-to-LVC, noncomplete LVC, and enlarged pharyngeal area at maximum constriction were associated with impaired swallow safety or efficiency. Thickened liquids may mitigate the risk of acute episodes of aspiration in individuals with ALS. Further work is needed to corroborate these preliminary findings and explore how swallowing profiles evolve throughout disease progression.
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Affiliation(s)
- Ashley A. Waito
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
- Swallowing Rehabilitation Research Laboratory, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
| | | | - Carly E. A. Barbon
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
- Swallowing Rehabilitation Research Laboratory, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
| | - Melanie Peladeau-Pigeon
- Swallowing Rehabilitation Research Laboratory, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
| | - Lauren Tabor-Gray
- Department of Neurology, Holy Cross Hospital, Phil Smith Neuroscience Institute, Fort Lauderdale, FL
| | - Kelby Magennis
- Swallowing Systems Core, University of Florida, Gainesville
| | - Raele Robison
- Swallowing Systems Core, University of Florida, Gainesville
| | - Catriona M. Steele
- Rehabilitation Sciences Institute, University of Toronto, Ontario, Canada
- Swallowing Rehabilitation Research Laboratory, Toronto Rehabilitation Institute – University Health Network, Ontario, Canada
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Abstract
Bulbar impairment represents a hallmark feature of Amyotrophic Lateral Sclerosis (ALS) that significantly impacts survival and quality of life. Speech and swallowing dysfunction are key contributors to the clinical heterogeneity of ALS and require well-timed and carefully coordinated interventions. The accurate clinical, radiological and electrophysiological assessment of bulbar dysfunction in ALS is one of the most multidisciplinary aspects of ALS care, requiring expert input from speech-language pathologists (SLPs), neurologists, otolaryngologists, augmentative alternative communication (AAC) specialists, dieticians, and electrophysiologists—each with their own evaluation strategies and assessment tools. The need to systematically evaluate the comparative advantages and drawbacks of various bulbar assessment instruments and to develop integrated assessment protocols is increasingly recognized. In this review, we provide a comprehensive appraisal of the most commonly utilized clinical tools for assessing and monitoring bulbar dysfunction in ALS based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) evaluation framework. Despite a plethora of assessment tools, considerable geographical differences exist in bulbar assessment practices and individual instruments exhibit considerable limitations. The gaps identified in the literature offer unique opportunities for the optimization of existing and development of new tools both for clinical and research applications. The multicenter validation and standardization of these instruments will be essential for guideline development and best practice recommendations.
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Affiliation(s)
- Yana Yunusova
- Department of Speech Language Pathology, University of Toronto, Toronto, ON, Canada.,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute, Toronto, ON, Canada.,Volcal Tract Visualization Lab, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Emily K Plowman
- Swallowing Systems Core, Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, United States
| | - Jordan R Green
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA, United States.,Speech and Hearing Biosciences and Technology Program, Harvard University, Cambridge, MA, United States
| | - Carolina Barnett
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Peter Bede
- Computational Neuroimaging Group, Academic Unit of Neurology, Trinity College Dublin, Dublin, Ireland
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Tabor-Gray LC, Gallestagui A, Vasilopoulos T, Plowman EK. Characteristics of impaired voluntary cough function in individuals with amyotrophic lateral sclerosis. Amyotroph Lateral Scler Frontotemporal Degener 2019; 20:37-42. [PMID: 30652513 PMCID: PMC6513719 DOI: 10.1080/21678421.2018.1510011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/26/2018] [Accepted: 07/29/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Although cough impairment (dystussia) is common in individuals with amyotrophic lateral sclerosis (ALS) and contributes to a reduced physiologic capacity to defend the airway, characteristics of dystussia have not yet been delineated. Therefore, we aimed to compare voluntary cough spirometry airflow patterns between individuals with ALS and healthy age and gender-matched controls. METHODS Thirty-two individuals with a diagnosis of probable-definite ALS (El-Escorial Criterion) and 29 healthy age and gender-matched controls underwent voluntary cough spirometry testing. Two blinded raters derived six objective voluntary cough airflow measures including: peak inspiratory phase duration, peak inspiratory flow rate, compression phase duration, peak expiratory rise time, peak expiratory flow rate, and cough volume acceleration. Independent samples t-tests with Cohen's d effect sizes were performed between Healthy versus ALS groups for cough metrics (alpha =0.05). RESULTS ALS individuals demonstrated prolonged inspiratory phase and expiratory phase rise time durations, reduced inspiratory and expiratory flow rates, and lower cough volume acceleration during voluntary cough production compared with healthy controls (p < 0.05). No differences in compression phase duration were observed (p > 0.05). CONCLUSIONS This study compared characteristics of voluntary cough airflow patterns of individuals with ALS to healthy-matched controls. Findings identified impairments in both inspiratory and expiratory voluntary cough airflow, resulting in slower, weaker, and thus less effectiveness voluntary cough production in ALS individuals. These data afford insight into the impaired physiology underlying inadequate airway clearance and secretion management in individuals with ALS.
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Affiliation(s)
- Lauren C Tabor-Gray
- a Department of Neurology , Phil Smith Neuroscience Institute , Fort Lauderdale , FL , USA
- b Swallowing Systems Core , University of Florida , Gainesville , FL , USA
| | | | - Terrie Vasilopoulos
- c Department of Anesthesiology and Orthopedics, College of Medicine , University of Florida , Gainesville , FL , USA
| | - Emily K Plowman
- b Swallowing Systems Core , University of Florida , Gainesville , FL , USA
- d Department of Speech, Language and Hearing Science , University of Florida , Gainesville , FL , USA
- e Department of Neurology , University of Florida , Gainesville , FL , USA
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35
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Pattee GL, Plowman EK, (Focht) Garand KL, Costello J, Brooks BR, Berry JD, Smith RA, Atassi N, Chapin JL, Yunusova Y, McIlduff CE, Young E, Macklin EA, Locatelli ER, Silani V, Heitzman D, Wymer J, Goutman SA, Gelinas DF, Perry B, Nalipinski P, Stipancic K, O'Brien M, Sullivan SL, Pioro EP, Gargiulo G, Green JR. Provisional best practices guidelines for the evaluation of bulbar dysfunction in amyotrophic lateral sclerosis. Muscle Nerve 2019; 59:531-536. [DOI: 10.1002/mus.26408] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/24/2018] [Accepted: 01/02/2019] [Indexed: 12/12/2022]
Affiliation(s)
| | - Emily K. Plowman
- Department of Speech, Language and Hearing SciencesUniversity of Florida Gainesville FL U.S.A
| | | | - John Costello
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, MA, U.S.A., ALS Augmentative Communication ProgramBoston Children's Hospital Boston MA U.S.A
| | | | | | | | | | - Jennifer L. Chapin
- Department of Speech, Language and Hearing SciencesUniversity of Florida Gainesville FL U.S.A
| | - Yana Yunusova
- Department of Speech‐Language PathologyUniversity of Toronto Toronto ON CANADA
| | | | - Eufrosina Young
- State University of New YorkDepartment of Neurology Syracuse NY U.S.A
| | | | | | - Vincenzo Silani
- Istituto Auxologico Italiano, IRCCS, Department of Neurology and Laboratory of Neuroscience, Department of Pathophysiology and Transplantation, “Dino Ferrari” CenterUniversità degli studi di Milano Milan 20122 Italy
| | | | - James Wymer
- University of Florida, Rehabilitation Science Gainesville FL U.S.A
| | | | | | - Bridget Perry
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, MA, U.S.A., ALS Augmentative Communication ProgramBoston Children's Hospital Boston MA U.S.A
| | | | - Kaila Stipancic
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, MA, U.S.A., ALS Augmentative Communication ProgramBoston Children's Hospital Boston MA U.S.A
| | - Meghan O'Brien
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, MA, U.S.A., ALS Augmentative Communication ProgramBoston Children's Hospital Boston MA U.S.A
| | | | - Erik P. Pioro
- Cleveland ClinicDepartment of Neurology Cleveland OH U.S.A
| | - Gisella Gargiulo
- National Scientific and Technical Research Council Buenos Aires Argentina
| | - Jordan R. Green
- Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, MA, U.S.A., ALS Augmentative Communication ProgramBoston Children's Hospital Boston MA U.S.A
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Arrese LC, Schieve HJ, Graham JM, Stephens JA, Carrau RL, Plowman EK. Relationship between oral intake, patient perceived swallowing impairment, and objective videofluoroscopic measures of swallowing in patients with head and neck cancer. Head Neck 2018; 41:1016-1023. [DOI: 10.1002/hed.25542] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 07/23/2018] [Accepted: 10/05/2018] [Indexed: 01/10/2023] Open
Affiliation(s)
- Loni C. Arrese
- Department of Otolaryngology ‐ Head & Neck SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | | | | | | | - Ricardo L. Carrau
- Department of Otolaryngology ‐ Head & Neck SurgeryThe Ohio State University Wexner Medical Center Columbus Ohio
| | - Emily K. Plowman
- Swallowing Systems Core, Departments of Speech, Language and Hearing Sciences and NeurologyUniversity of Florida Gainesville Florida
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Perry BJ, Martino R, Yunusova Y, Plowman EK, Green JR. Lingual and Jaw Kinematic Abnormalities Precede Speech and Swallowing Impairments in ALS. Dysphagia 2018; 33:840-847. [PMID: 29774424 PMCID: PMC6244810 DOI: 10.1007/s00455-018-9909-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2018] [Accepted: 05/10/2018] [Indexed: 11/18/2022]
Abstract
Early identification of bulbar involvement in persons with ALS is critical for improving diagnosis and prognosis; however, efficacious diagnostic markers have not yet been identified. The purpose of this study was to determine whether kinematic changes of the tongue and jaw during swallowing, measured using 3D electromagnetic articulography (EMA), predate clinically identifiable symptoms of speech and swallowing impairment in persons diagnosed with ALS. Data were collected from 16 adults diagnosed with ALS and 18 neurotypical controls. Groups were aged matched. Eligible participants with ALS were tolerating an unrestricted diet (FOIS = 7), produced intelligible speech (> 97%), and had a speaking rate greater than 150 words per minute. Participants completed a 3-mL water swallow task, during which EMA recorded kinematic measures of the anterior and posterior regions of tongue including lingual speed, range of motion, duration, coordination, and efficiency. Jaw speed and range of motion were also recorded. Persons diagnosed with ALS demonstrated reduced posterior lingual range of motion (11.40 mm ± 4.01 vs. 16.07 mm ± 5.27), slower posterior lingual speeds (83.67 mm/s ± 47.96 vs. 141.35 mm/s ± 66.54), increased lingual movement duration (13.46 s ± 6.75 vs. 9.21 s ± 3.28), and reduced lingual coordination (0.04 s ± 0.11 vs. 17 s ± 0.19) during the 3-oz water swallow task compared to controls. Persons diagnosed with ALS demonstrated increased range of motion (9.86 mm ± 5.38 vs. 6 mm ± 3.78) and increased jaw speed (68.62 mm/s ± 50.13 vs. 34.72 mm/s ± 17.75) during swallowing compared to controls. The current findings suggest that changes in lingual and jaw motor performance during a simple water swallow task are present in persons with ALS who are pre-symptomatic of clinically detectable bulbar impairment.
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Affiliation(s)
- Bridget J Perry
- MGH Institute of Health Professions, 79/96 13th Street, Charlestown, MA, 02109, USA
| | - Rosemary Martino
- Department of Speech-Language Pathology, University of Toronto, Toronto, ON, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, ON, Canada
- Department of Otolaryngology-Head and Neck Surgery, University of Toronto, Toronto, ON, Canada
- Krembil Research Institute, University Health Network, 160-500 University Ave, Toronto, ON, M5G 1V7, Canada
| | - Yana Yunusova
- Department of Speech-Language Pathology, University of Toronto, Toronto, ON, Canada
- University Health Network - Toronto Rehabilitation Institute, Toronto, Canada
- Biological Sciences, Sunnybrook Research Institute, 160-500 University Ave, Toronto, ON, M5G1V7, Canada
| | - Emily K Plowman
- Swallowing Systems Core, University of Florida, Gainesville, FL, USA
- Department of Speech-Language Hearing Sciences and Neurology, University of Florida, Gainesville, FL, 32610, USA
| | - Jordan R Green
- MGH Institute of Health Professions, 79/96 13th Street, Charlestown, MA, 02109, USA.
- Program in Speech and Hearing Bioscience and Technology, Harvard University, 260 Longwood Avenue, Boston, MA, 02115, USA.
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Plowman EK, Tabor-Gray L, Rosado KM, Vasilopoulos T, Robison R, Chapin JL, Gaziano J, Vu T, Gooch C. Impact of expiratory strength training in amyotrophic lateral sclerosis: Results of a randomized, sham-controlled trial. Muscle Nerve 2018; 59:40-46. [DOI: 10.1002/mus.26292] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/26/2018] [Accepted: 07/01/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Emily K. Plowman
- Swallowing Systems Core; University of Florida; Gainesville Florida USA
- Department of Speech, Language and Hearing Sciences, College of Public Health and Health Professions; University of Florida; P.O. Box 117420, Gainesville Florida, 32610 USA
- Department of Neurology; University of Florida; Gainesville Florida USA
| | - Lauren Tabor-Gray
- Swallowing Systems Core; University of Florida; Gainesville Florida USA
| | | | - Terrie Vasilopoulos
- Department of Anesthesiology; University of Florida; Gainesville Florida USA
| | - Raele Robison
- Swallowing Systems Core; University of Florida; Gainesville Florida USA
| | | | - Joy Gaziano
- Joy McCann Culverhouse Center for Swallowing Disorders; University of South Florida; Tampa Florida USA
| | - Tuan Vu
- Department of Neurology; University of South Florida; Tampa Florida USA
| | - Clifton Gooch
- Department of Neurology; University of South Florida; Tampa Florida USA
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Robison R, Tabor-Gray LC, Wymer JP, Plowman EK. Combined respiratory training in an individual with C9orf72 amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2018; 5:1134-1138. [PMID: 30250869 PMCID: PMC6144454 DOI: 10.1002/acn3.623] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 06/20/2018] [Accepted: 06/27/2018] [Indexed: 12/11/2022] Open
Abstract
This case study examined the impact of a respiratory strength training program targeting inspiratory and expiratory musculature in an individual with C9orf72 amyotrophic lateral sclerosis (ALS). The individual tolerated 24 months of respiratory training completed at home, 50 repetitions per day, and 5 days per week. Significant increases in maximum inspiratory pressure (from 71 to 134 centimeters of water), maximum expiratory pressure (from 108 to 197 centimeters of water) and peak cough flow (from 331 to 655 Liters per minute) were noted and forced vital capacity remained unchanged. A moderate intensity respiratory strength training program applied early in the disease progression improved function in this C9orf72 ALS individual.
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Affiliation(s)
- Raele Robison
- Swallowing Systems Core University of Florida Gainesville Florida.,Speech, Language and Hearing Science Department University of Florida Gainesville Florida
| | - Lauren C Tabor-Gray
- Swallowing Systems Core University of Florida Gainesville Florida.,Speech, Language and Hearing Science Department University of Florida Gainesville Florida
| | - James P Wymer
- Department of Neurology University of Florida Gainesville Florida
| | - Emily K Plowman
- Swallowing Systems Core University of Florida Gainesville Florida.,Speech, Language and Hearing Science Department University of Florida Gainesville Florida.,Department of Neurology University of Florida Gainesville Florida
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40
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Plowman EK, Humbert IA. Elucidating inconsistencies in dysphagia diagnostics: Redefining normal. Int J Speech Lang Pathol 2018; 20:310-317. [PMID: 29724130 DOI: 10.1080/17549507.2018.1461931] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 03/05/2018] [Accepted: 03/23/2018] [Indexed: 06/08/2023]
Abstract
Speech-language pathologists (SLPs) are the primary healthcare providers responsible for the evaluation and treatment of dysphagia. Fundamental to this role is the ability to make accurate clinical judgements to distinguish between normal versus disordered swallowing for subsequent treatment planning. In this review, we highlight recent data collected from practising clinicians in the USA that reveal low levels of agreement across clinicians and poor to moderate levels of accuracy for making binary diagnostic ratings (normal vs. disordered). We then propose and discuss barriers that may represent challenges to practising SLP's understanding of normal swallowing physiology. Proposed barriers include: (1) an educational focus on the disordered system; (2) system 1 processing; (3) complexity of the swallowing system; (4) inability to directly visualise the swallowing process; (5) degree of variability of normal swallowing; and (6) high clinical productivity requirements. This article concludes with suggestions for reducing identified educational and clinical barriers to ultimately improve diagnostic decision-making practices and to benefit patient-related outcomes in dysphagia management.
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Affiliation(s)
- Emily K Plowman
- a Swallowing Systems Core , University of Florida , Gainesville , FL , USA
- b Department of Speech, Language and Hearing Sciences , University of Florida , Gainesville , FL , USA and
- c Department of Neurology , University of Florida , Gainesville , FL , USA
| | - Ianessa A Humbert
- a Swallowing Systems Core , University of Florida , Gainesville , FL , USA
- b Department of Speech, Language and Hearing Sciences , University of Florida , Gainesville , FL , USA and
- c Department of Neurology , University of Florida , Gainesville , FL , USA
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41
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Tabor LC, Plowman EK, Romero-Clark C, Youssof S. Oropharyngeal dysphagia profiles in individuals with oculopharyngeal muscular dystrophy. Neurogastroenterol Motil 2018; 30:e13251. [PMID: 29144056 PMCID: PMC5878694 DOI: 10.1111/nmo.13251] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 10/19/2017] [Indexed: 01/11/2023]
Abstract
BACKGROUND Although dysphagia represents a hallmark manifestation of oculopharyngeal muscular dystrophy (OPMD), limited knowledge exists regarding the underlying nature of oropharyngeal swallowing impairments in this patient population. We aimed to delineate global pharyngeal dysphagia profiles in OPMD and identify the prevalence and physiologic associations of impairments in swallowing safety and efficiency. METHODS Twenty-two individuals with OPMD completed a videofluoroscopic swallowing evaluation. Blinded raters completed validated scales of global dysphagia (dynamic imaging grade of swallowing toxicity, DIGEST), efficiency (normalized residue ratio scale, NRRS), and safety (penetration-aspiration scale, PAS). Degree of laryngeal vestibule closure and aspiration events were described. Descriptives and chi-squared analyses were conducted with alpha set at P < .05. KEY RESULTS One hundred and thirty-four swallowing trials were analyzed. DIGEST scores revealed that 96% (n = 21) of participants demonstrated pharyngeal dysphagia (score >1). Presence of a cricopharyngeal bar was noted in 10 individuals. The predominant swallowing categorization across patients was safe and inefficient (51%) followed by unsafe and inefficient (32%). 77.3% demonstrated vallecular residue (NRRSv>0.07) and 90.1% piriform sinus residue (NRRSp > .20). 33% (n = 54) of swallows were unsafe (PAS>3) with 45 episodes of penetration and 9 episodes of aspiration. Aspiration occurred during the swallow in 100% of identified occurrences. Incomplete epiglottic inversion was associated with airway compromise and postswallow residue (P < .05). CONCLUSIONS & INFERENCES These findings highlight the high prevalence of oropharyngeal swallowing impairments in both swallowing efficiency and safety. A high proportion of physiologic impairments in epiglottic inversion and laryngeal vestibule closure were noted that related to functional impairments in swallow safety and inefficiency.
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Affiliation(s)
- Lauren C. Tabor
- Swallowing Systems Core, University of Florida, Gainesville FL, USA,Department of Physical Therapy, University of Florida
| | - Emily K. Plowman
- Swallowing Systems Core, University of Florida, Gainesville FL, USA,Department of Speech, Language and Hearing Science, University of Florida,Department of Neurology, University of Florida,Department of Physical Therapy, University of Florida
| | | | - Sarah Youssof
- University of New Mexico Health Sciences Center,Department of Neurology
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Pattee GL, Plowman EK, Brooks BR, Berry JD, Atassi N, Chapin JL, Garand K, Yunusova Y, Mcilduff CE, Young E, Costello JM, Macklin EA, Locatelli ER, Silani V, Heitzman D, Wymer J, Goutman SA, Gelinas DF, Smith R, Perry B, Nalipinski P, Stipancic K, O'Brien M, Sullivan SL, Green J. Best practices protocol for the evaluation of bulbar dysfunction: summary recommendations from the NEALS bulbar subcommittee symposium. Amyotroph Lateral Scler Frontotemporal Degener 2017; 19:311-312. [DOI: 10.1080/21678421.2017.1404109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Emily K. Plowman
- University of Florida, Rehabilitation Science, Gainesville, FL, USA
| | - Benjamin R. Brooks
- Department of Neurology, Neuroscience and Spine Institute, Carolinas Medical Center, Carolinas Neuromuscular/ALS-MDA Center, Charlotte, NC, USA
| | - James D. Berry
- Massachusetts General Hospital, Department of Neurology, Boston, MA, USA
| | - Nazem Atassi
- Neurology Clinical Trials Unit, Massachusetts Gerenal Hospital, Department of Neurology, Chalestown, SC, USA
| | - Jennifer L. Chapin
- Neuromotor Speech and Swallowing Restoration Lab, University of Florida Gainesville, Gainesville, FL, USA
| | - Kendrea Garand
- Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Yana Yunusova
- Department of Speech-Language Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Courtney E. Mcilduff
- Beth Israel Deaconess Medical Center, Department of Neurology, Boston, MA, USA
- Dartmouth-Hitchcock Medical Center, Department of Neurology, One Medical Center Drive, Lebanon, PA, USA
| | - Eufrosina Young
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - John M. Costello
- Children's Hospital Boston at Waltham, ALS Augmentative Communication Program, Waltham, MA, USA
| | | | | | - Vincenzo Silani
- Department Neurological Sciences, University of Milan, Milan, Italy
| | | | - James Wymer
- University of Florida, Rehabilitation Science, Gainesville, FL, USA
| | | | - Deborah F. Gelinas
- Grifols Inc, Medical Director Neuroimmunology, Research Triangle Park, NC, USA
| | | | - Bridget Perry
- MGH Institute of Health Professions, Boston, MA, USA
| | - Paige Nalipinski
- Massachusetts General Hospital, Speech Language Pathology, Boston, MA, USA
| | | | - Meghan O'Brien
- Children's Hospital Boston, Speech Language Pathology, Waltham, MA, USA
| | - Stacey L. Sullivan
- Massachusetts General Hospital, Speech Language Pathology, Boston, MA, USA
| | - Jordan Green
- MGH-Institute of Health Professions, Rehab Sciences, Boston, MA, USA
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Hutcheson KA, Barrow MP, Warneke CL, Wang Y, Eapen G, Lai SY, Barringer DA, Plowman EK, Lewin JS. Cough strength and expiratory force in aspirating and nonaspirating postradiation head and neck cancer survivors. Laryngoscope 2017; 128:1615-1621. [PMID: 29114887 DOI: 10.1002/lary.26986] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/09/2017] [Accepted: 10/02/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Expiratory functions that clear aspiration from the airway are compromised in patients with neurogenic dysphagia for whom cough and expiratory force may be impaired by the primary disease process. The relationship between expiratory function, cough, and aspiration is less clear in head and neck cancer (HNC) survivors for whom the disease process does not directly impact the lower respiratory system. Our objective was to compare mechanisms of airway clearance (expiratory force and cough) with aspiration status in postradiated HNC survivors. STUDY DESIGN Cross-sectional study. METHODS One hundred and three disease-free HNC survivors ≥ 3-months postradiotherapy referred for modified barium swallow studies were prospectively enrolled regardless of dysphagia status. Maximum expiratory pressures (MEPs) and peak cough flow (PCF) measures were taken at enrollment and examined as a function of aspiration status using generalized linear regression methods. RESULTS Thirty-four (33%) patients aspirated. Maximum expiratory pressure and PCF demonstrated a moderate positive correlation (Pearson's r = 0.35). Adjusting for sex and age, MEPs were on average 19.2% lower (21.1 cm H2 O, 95% confidence interval [CI] 5.3, 36.8) among aspirators. Peak cough flow was also 14.9% lower (59.6 L/minute, 95% CI 15.8, 103.3) among aspirators after adjusting for age and sex. CONCLUSION Expiratory functions were depressed in postradiated HNC aspirators relative to nonaspirators, suggesting that airway protection impairments may extend beyond disrupted laryngopharyngeal mechanisms in the local treatment field. Exercises to strengthen subglottic expiratory force-generating capacity may offer an adjunctive therapeutic target to improve airway protection in chronic aspirators after head and neck radiotherapy. LEVEL OF EVIDENCE 2b. Laryngoscope, 128:1615-1621, 2018.
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Affiliation(s)
- Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Martha P Barrow
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Carla L Warneke
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Yiqun Wang
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - George Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A.,Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Denise A Barringer
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
| | - Emily K Plowman
- Department of Speech, Language, and Hearing Sciences, The University of Florida, Gainesville, Florida, U.S.A
| | - Jan S Lewin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, U.S.A
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Hutcheson KA, Barrow MP, Plowman EK, Lai SY, Fuller CD, Barringer DA, Eapen G, Wang Y, Hubbard R, Jimenez SK, Little LG, Lewin JS. Expiratory muscle strength training for radiation-associated aspiration after head and neck cancer: A case series. Laryngoscope 2017; 128:1044-1051. [PMID: 28833185 DOI: 10.1002/lary.26845] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 06/15/2017] [Accepted: 07/13/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE/HYPOTHESIS Expiratory muscle strength training (EMST) is a simple, inexpensive, device-driven exercise therapy. Therapeutic potential of EMST was examined among head and neck cancer survivors with chronic radiation-associated aspiration. STUDY DESIGN Retrospective case series. METHODS Maximum expiratory pressures (MEPs) were examined among n = 64 radiation-associated aspirators (per penetration-aspiration scale score ≥ 6 on modified barium swallow). Pre-post EMST outcomes were examined in a nested subgroup of patients (n = 26) who enrolled in 8 weeks of EMST (25 repetitions, 5 days/week, 75% load). Nonparametric analyses examined effects of EMST on the primary endpoint MEPs. Secondary measures included swallowing safety (Dynamic Imaging Grade of Swallowing Toxicity [DIGEST]), perceived dysphagia (M.D. Anderson Dysphagia Inventory [MDADI]), and diet (performance status scale for head and neck cancer patients [PSSHN]). RESULTS Compared to sex-matched published normative data, MEPs were reduced in 91% (58 of 64) of aspirators (mean ± standard deviation: 89 ± 37). Twenty-six patients enrolled in EMST and three patients withdrew. MEPs improved on average 57% (87 ± 29 to 137 ± 44 cm H2 O, P < 0.001) among 23 who completed EMST. Swallowing safety (per DIGEST) improved significantly (P = 0.03). Composite MDADI scores improved post-EMST (pre-EMST: 59.9 ± 17.1, post-EMST: 62.7 ± 13.9, P = 0.13). PSSHN diet scores did not significantly change. CONCLUSION MEPs were reduced in chronic radiation-associated aspirators relative to normative data, suggesting that expiratory strengthening could be a novel therapeutic target to improve airway protection in this population. Similar to findings in neurogenic populations, these data also suggest improved expiratory pressure-generating capabilities after EMST and translation to functional improvements in swallowing safety in chronic radiation-associated aspirators. LEVEL OF EVIDENCE 4. Laryngoscope, 128:1044-1051, 2018.
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Affiliation(s)
- Katherine A Hutcheson
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Martha P Barrow
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Emily K Plowman
- Department of Speech, Language, and Hearing Sciences, The University of Florida, Gainesville, Florida, U.S.A
| | - Stephen Y Lai
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas.,Department of Molecular and Cellular Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Clifton David Fuller
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Denise A Barringer
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - George Eapen
- Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Yiqun Wang
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rachel Hubbard
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Sarah K Jimenez
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Leila G Little
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Jan S Lewin
- Department of Head and Neck Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas
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Plowman EK, Tabor LC, Wymer J, Pattee G. The evaluation of bulbar dysfunction in amyotrophic lateral sclerosis: survey of clinical practice patterns in the United States. Amyotroph Lateral Scler Frontotemporal Degener 2017; 18:351-357. [PMID: 28425762 DOI: 10.1080/21678421.2017.1313868] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Speech and swallowing impairments are highly prevalent in individuals with amyotrophic lateral sclerosis (ALS) and contribute to reduced quality of life, malnutrition, aspiration, pneumonia and death. Established practice parameters for bulbar dysfunction in ALS do not currently exist. The aim of this study was to identify current practice patterns for the evaluation of speech and swallowing function within participating Northeast ALS clinics in the United States. METHODS AND RESULTS A 15-item survey was emailed to all registered NEALS centres. Thirty-eight sites completed the survey. The majority (92%) offered Speech-Language Pathology, augmentative and alternative communication (71%), and dietician (92%) health care services. The ALS Functional Rating Scale-Revised and body weight represented the only parameters routinely collected in greater then 90% of responding sites. Referral for modified barium swallow study was routinely utilised in only 27% of sites and the use of percutaneous gastrostomy tubes in ALS patient care was found to vary considerably. CONCLUSIONS This survey reveals significant variability and inconsistency in the management of bulbar dysfunction in ALS across NEALS sites. We conclude that a great need exists for the development of bulbar practice guidelines in ALS clinical care to accurately detect and monitor bulbar dysfunction.
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Affiliation(s)
- Emily K Plowman
- a Swallowing Systems Core , University of Florida , Gainesville , FL , USA.,b Department of Speech, Language and Hearing Science , University of Florida , Gainesville , FL , USA.,c Department of Neurology , University of Florida , Gainesville , FL , USA.,d Department of Physical Therapy , University of Florida , Gainesville , FL , USA , and
| | - Lauren C Tabor
- a Swallowing Systems Core , University of Florida , Gainesville , FL , USA.,d Department of Physical Therapy , University of Florida , Gainesville , FL , USA , and
| | - James Wymer
- c Department of Neurology , University of Florida , Gainesville , FL , USA
| | - Gary Pattee
- e Department of Neurology, Neurology Associates , University of Nebraska , Lincoln , NE , USA
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46
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47
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Watts SA, Tabor L, Plowman EK. To Cough or Not to Cough? Examining the Potential Utility of Cough Testing in the Clinical Evaluation of Swallowing. Curr Phys Med Rehabil Rep 2016; 4:262-276. [PMID: 28529824 DOI: 10.1007/s40141-016-0134-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE The clinical swallowing evaluation (CSE) represents a critical component of a comprehensive assessment of deglutition. Although universally utilized across clinical settings, the CSE demonstrates limitations in its ability to accurately identify all individuals with dysphagia. There exists a need to improve assessment and screening techniques to improve health outcomes, treatment recommendations and ultimately mortality in individuals at risk for dysphagia. The following narrative review provides a summary of currently used validated CSE's and examines the potential role of cough testing and screening in the CSE. RECENT FINDINGS Recent evidence highlights a relationship between objective physiologic measurements of both voluntarily and reflexively induced cough and swallowing safety status across several patient populations. Although more research is needed across a wider range of patient populations to validate these findings; emerging data supports the consideration of inclusion of cough testing during the CSE as an index of airway defense mechanisms and capabilities in individuals at risk for aspiration. SUMMARY The sensorimotor processes of cough and swallowing share common neuroanatomical and functional substrates. Inclusion of voluntarily or reflexively induced cough testing in the CSE may aide in the identification of dysphagia and reduced airway protection capabilities.
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Affiliation(s)
- Stephanie A Watts
- Joy McCann Culverhouse Center for Swallowing Disorders, University of South Florida, 13330 USF Laurel Drive MDC Box 72, Tampa, FL 33612, USA.,Neuromotor Speech and Swallowing Restoration Laboratory, University of Florida, Gainesville, USA
| | - Lauren Tabor
- Neuromotor Speech and Swallowing Restoration Laboratory, University of Florida, Gainesville, USA.,Department of Speech, Language and Hearing Sciences, University of Florida, PO Box 117420, Gainesville, FL 32611, USA
| | - Emily K Plowman
- Neuromotor Speech and Swallowing Restoration Laboratory, University of Florida, Gainesville, USA.,Department of Speech, Language and Hearing Sciences, University of Florida, PO Box 117420, Gainesville, FL 32611, USA
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Tabor LC, Rosado KM, Robison R, Hegland K, Humbert IA, Plowman EK. Respiratory training in an individual with amyotrophic lateral sclerosis. Ann Clin Transl Neurol 2016; 3:819-823. [PMID: 27752517 PMCID: PMC5048392 DOI: 10.1002/acn3.342] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 12/04/2022] Open
Abstract
We examined the impact of expiratory muscle strength training on maximum expiratory pressure, cough spirometry, and disease progression in a 71‐year‐old male with amyotrophic lateral sclerosis. Maximum expiratory pressure declined 9% over an 8‐week sham training period, but subsequently improved by 102% following 8 weeks of expiratory muscle strength training. Improvements in cough spirometry and mitigated disease progression were also observed post expiratory muscle strength training. Improvements in maximum expiratory pressures were maintained 6 months following expiratory muscle strength training and were 79% higher than baseline data obtained 301 days prior. In this spinal‐onset amyotrophic lateral sclerosis patient, respiratory training improved subglottic air pressure generation and sequential cough generation.
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Affiliation(s)
- Lauren C Tabor
- Department of Physical Therapy University of Florida Gainesville Florida; Swallowing Systems Core University of Florida Gainesville Florida
| | - Karen M Rosado
- Swallowing Systems Core University of Florida Gainesville Florida
| | - Raele Robison
- Department of Physical Therapy University of Florida Gainesville Florida; Swallowing Systems Core University of Florida Gainesville Florida
| | - Karen Hegland
- Speech, Language and Hearing Science Department University of Florida Gainesville Florida
| | - Ianessa A Humbert
- Swallowing Systems Core University of Florida Gainesville Florida; Speech, Language and Hearing Science Department University of Florida Gainesville Florida
| | - Emily K Plowman
- Department of Physical Therapy University of Florida Gainesville Florida; Swallowing Systems Core University of Florida Gainesville Florida; Speech, Language and Hearing Science Department University of Florida Gainesville Florida
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Arrese LC, Carrau R, Plowman EK. Relationship Between the Eating Assessment Tool-10 and Objective Clinical Ratings of Swallowing Function in Individuals with Head and Neck Cancer. Dysphagia 2016. [PMID: 27538876 DOI: 10.1007/s00455-016-9741-7.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The Eating Assessment Tool-10 (EAT-10) represents a validated, easy to administer patient report dysphagia severity scale. Although its ability to detect swallowing impairment has been investigated in other patient populations, the utility of this instrument in individuals with head and neck cancer (HNC) has not been studied. The aim of the current investigation was to determine the relationship between patient ratings of swallowing impairment (EAT-10) and objective clinical ratings of swallow physiology in individuals with HNC. Forty-four HNC participants completed the EAT-10 and a standardized videofluoroscopy swallow study. Blinded raters determined airway safety using the penetration-aspiration scale (PAS) and swallowing function using the modified barium swallow impairment profile (MBSImP™©). Participants were stratified into three groups (pre-treatment through 1 year post-treatment, 1-5 years post-treatment, and >5 years post-treatment). Independent t tests, Pearson's and Spearman's Rho correlations, and a Bonferroni correction for multiple comparisons were performed. EAT-10 scores were significantly higher in HNC patients with unsafe swallowing (M 24.45, SD 8.32) compared to those with safe swallowing (M 16.20, SD 12.14), t(21) = -2.36, p < 0.04. Significant correlations were revealed between EAT-10 scores and the MBSImP™© (pharyngeal composite), and PAS scores (p < 0.05) for the pre-treatment to within 1 year post-treatment group. No associations, however, were observed for HNC patients in the time groups representing greater than 1-year post cancer treatment.
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Affiliation(s)
- Loni C Arrese
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W. 10th Ave, Columbus, OH, 43210, USA.
| | - Ricardo Carrau
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W. 10th Ave, Columbus, OH, 43210, USA
| | - Emily K Plowman
- Department of Speech, Language and Hearing Sciences, Neuromotor Speech and Swallowing Restoration Laboratory, University of Florida, 1225 Center Drive, Room 2141, Gainesville, FL, 32610, USA
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Arrese LC, Carrau R, Plowman EK. Relationship Between the Eating Assessment Tool-10 and Objective Clinical Ratings of Swallowing Function in Individuals with Head and Neck Cancer. Dysphagia 2016; 32:83-89. [PMID: 27538876 DOI: 10.1007/s00455-016-9741-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 08/05/2016] [Indexed: 12/12/2022]
Abstract
The Eating Assessment Tool-10 (EAT-10) represents a validated, easy to administer patient report dysphagia severity scale. Although its ability to detect swallowing impairment has been investigated in other patient populations, the utility of this instrument in individuals with head and neck cancer (HNC) has not been studied. The aim of the current investigation was to determine the relationship between patient ratings of swallowing impairment (EAT-10) and objective clinical ratings of swallow physiology in individuals with HNC. Forty-four HNC participants completed the EAT-10 and a standardized videofluoroscopy swallow study. Blinded raters determined airway safety using the penetration-aspiration scale (PAS) and swallowing function using the modified barium swallow impairment profile (MBSImP™©). Participants were stratified into three groups (pre-treatment through 1 year post-treatment, 1-5 years post-treatment, and >5 years post-treatment). Independent t tests, Pearson's and Spearman's Rho correlations, and a Bonferroni correction for multiple comparisons were performed. EAT-10 scores were significantly higher in HNC patients with unsafe swallowing (M 24.45, SD 8.32) compared to those with safe swallowing (M 16.20, SD 12.14), t(21) = -2.36, p < 0.04. Significant correlations were revealed between EAT-10 scores and the MBSImP™© (pharyngeal composite), and PAS scores (p < 0.05) for the pre-treatment to within 1 year post-treatment group. No associations, however, were observed for HNC patients in the time groups representing greater than 1-year post cancer treatment.
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Affiliation(s)
- Loni C Arrese
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W. 10th Ave, Columbus, OH, 43210, USA.
| | - Ricardo Carrau
- Department of Otolaryngology - Head and Neck Surgery, The Ohio State University Wexner Medical Center, 460 W. 10th Ave, Columbus, OH, 43210, USA
| | - Emily K Plowman
- Department of Speech, Language and Hearing Sciences, Neuromotor Speech and Swallowing Restoration Laboratory, University of Florida, 1225 Center Drive, Room 2141, Gainesville, FL, 32610, USA
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