treatment of oropharyngeal dysphagia carolmckee(1) dpns study

iIt

Treatment of Oropharyngeal Dysphagia 1

Running head: TREATMENT oF oRopHARyNGEAL DyspI{AGIA

Effectiveness of Thermal Stimulation versus Deep Pharyngeal Neuromuscular Stimulation

in Improving Neurogenic Oropharyngeat Dysphagia

Secondary to Cerebrovascular Accident in Older Adults

Carol McKee

University of South Florida

SPA 6805 Research Procedures

Dr. Ruth Bahr

Summer,2000


Dysphagia" or the inability to swallow, affects vp to 59oA of those who have suffered a

cerebrovascular accident (Lugger,1994). Abnormalities may involve the oral, pharyngeal, or

esophageal stage of the swallowing sequence (Sellers, Campbell, Stott, Stewart, & Wilsorq

1999). The oral stage of swallowing includes the transfer of material from the mouth to the

oropharynx. The pharyngeal stage includes the highly coordinated transport of material away

from the oropharymq around an occluded laryngeal vestibule, and through a relaxed

cricopharyngeus muscle into the upper esophagus. The esophageal stage includes the transport

of material along the esophagus into the gastric cardia (Groher, 1997).

Impairment in swallowing ranges from delay in transfer to absence of transfer and

includes misdirection of transference, as in airway penetration or aspiration (Groher, 1997). It is

a common and potentially fatal complication of acute stroke associated with poor nutritional

state, pneumonia, increased mortality, and increased disability among survivors. Deglutitive

aspiration, or the entry of gastric juices, bacteria, or foreign matter into the lower respiratory

tract, is a complex phenomenon that may occur before, during, or after the swallow.

Generaiiy, aspiration before the swallow is caused by damaged tongue function and a

delayed or absent triggering of the swallow reflex. Aspiration during the swallow relates to

reduced laryngeal closure. Aspiration after the swallow may result from a variety of causes

including reduced pharyngeal peristalsis, unilateral pharyngealdysfunction, reduced laryngeal

elevation, or cricopharyngeal dysfunction. It can also be caused by certain anatomical

abnormalities, such as fistulae or diverticulae, because food tends to collect in these areas and

then be inhaled when the swallow is completed. fupiration in patients recovering from stroke


most cornmonly results from oropharyngeal motor dysfunction (Logemann, 1986). Identification

of the etiology, i.e., the anatomical and physiological reason for the dysfunction, is the key to

effective management or treatment of dysphagra.

Although swallowing therapy is associated with successful outcomes, recovery from

dysphagia is not guaranteed. Appropriate diagnosis and effective treatment of swallowing

disorders is challenging. Swallowing therapy begins with definition of the patient's anatomic

and physiologic swallowing disorder (Logemann, 1999). This usually involves a radiographic

study of the oropharyngeal region during swallows of carefully defined bolus types

Radiographic studies point toward a specific swallowing disorder. For example, residue in the

valleculae indicates reduced tongue base movement or reduced pharyngeal wall contraction.

Thus, it is incumbent upon the dysphagia clinician to identify the etiology of the dysphagia in

order to devise appropriate and effective treatment.

A variety of treatments have been developed for improving dysphagia in stroke patients.

Typically, swallowing therapy in patients with neurogenic dysphagia takes nvo basic forms:

direct and indirect (Neumaru1 Bartolome, Buchholz, & Prosiegel, 1995). Direct therapy

emphasizes compensatory techniques to help cope with sensorimotor impairment of the oral

cavity, pharynx, and/or lirryrix, resulting in swallowing dysfunction. Examples of these

compensatory techniques include postural adjustment, double swallowing, supraglottic

swallowing, and the Mendelsohn maneuver. On the other hand, indirect therapy attempts to

overcome sensorimotor impairment through stimulation techniques and exercises to enhance the

swallowing reflex, alter muscle tone, and improve the function of voluntary orofacial, lingual,

and laryngeal muscles. It is based on the principle that recovery of lost neurological functions


can be facilitated by specific stimulation and re-education of the neural pathways governing

those functions. This principle underlies many established neurologic rehabilitation strategies.

One of the most extensively utilized indirect treatments for oropharyngeal dysphagia is

thermal stimulation (Logemann, 1983, 1986, 1999). Cold stimulatioq or sensitizatiorq is

performed by stroking the base of the anterior faucial pillars with a laryngeal mirror. This

technique was designed to heighten oral awareness and provide an alerting sensory stimulus to

the cortex and brainstem such that, when the patient initiates the oral stage of swallow, the

pharyngeal swallow will trigger more rapidly (Kaatze-McDonald, Post, & Davis, 1996).

According to Logemann (1986), contact of the mirror to the facial arch does not trigger a

swallow. Rather, when the patient initiates the swallow after the stimulatiorq the reflex should

trigger more rapidly. Additionally, effects of thermal stimulation have been reported to continue

for several nonsensitized swallows following the stimulated swallows (Laz,arqLazarus, &

Logemann, 1986).

In thermal stimulatioq a size 00 laryngeal mirror is utilized to sensitize the faucial piiiars

(I-ogemanrg 1983, 1986, i999). The mirror is chilled in ice for 5-10 seconds, and it is then put in

contact with the anteriol faucial arch in a stroking motion. After 5-6 strokes on each side of the

oral cavity at the faucial hrch, the patient is given a small amount of material, usually a cold,

carbonated beverage, and asked to swallow. When the patient initiates the swallow after

stimulation, the reflex should trigger more rapidly. Thus, swallows after this sensitization are

normally faster than swallows that do not follow sensitization (Logemann, 1986). The clinical

acceptance of this technique suggests that the sensitivity of the faucial pillar can be enhanced by

cold and/or touch stimulation, which in some manner facilitates swallowing.


Another indirect method currently being used in the treatment of oropharyngeal

dysphagia is deep pharyngeal neuromuscular stimulation (Stefanakos, 2000). According to

Stefanakos (2000), deep pharyngeal neuromuscular stimulation (DPNS) is a systematized

therapeutic program that uses direct neuromuscular stimulation to the pharyngeal musculature to

restore muscle strength, endurance, pharyngeal reflex responses, and pharyngeal reflex

coordination. In this procedure, frozen lemon glycerin swabs are used to stimulate the lingual

base, velar musculature, and pharyngeal constrictors. Stefanakos (2000) suggests using a

minimal number of probes during the first treatment session, with graduated probe progression

over treatment sessions.

While DPNS adopts the anatomical and physiological bases for applying a cold stimulus

to the faucial pillar, this procedure is only 1 of 9 sequenced steps designed to provide maximum

sensory input to multiple cranial nerves involved in the swallowing process. Stefanakos (2000)

hypothesizes that thermal stimulation to the faucial arches, in isolation, provides minimal

stimulation of the glossopharyngeal nerye, which generally serves to elicit an impaired swallow

response. DPNS, on the other hand, provides ma:<imum sensory input to three reflex sites to

improve and restore a cbordinated swallow. These sites include: 1) tongue base and bitter taste

buds for improving the tongue base retraction reflex; 2) soft palate musculature for improving

the palatal reflex and velopharyngeal closure; and, 3) superior and medial pharyngeal constrictor

muscles for improving the pharyngeal constrictor reflex. In stimulating these three reflex sites,

DPNS elicits strong reflexes, which in turn activate muscle group contractions, which then

strengthen the pharyngeal and lingual musculature.

Treatment of Oropharyngeal Dysphaga 6

Of greatest concern to the clinicians providing treatment, and the patients receiving the

treatment, is the efficacy of such treatments. Thermal stimulation and deep pharyngeal

neuromuscular stimulation are two techniques that are in widespread use in the treatment of

oropharyngeal dysphagia. Unfortunately, limited data have been presented to support the

efficacy of these methods in the management of dysphagia.

Thermal Stimulation

Thermal stimulation, in published descriptions (Logemann, 1983, L986. 1999), is widely

used in the management of oropharyngeal dysphagia. Data establishing the method's efficacy

are limited. The anatomical and physiological bases for the technique are founded in a study by

Pommerenke (1928). In that study, Pommerenke reported that mechanical probing of the faucial

pillar evoked swallowing most consistently in the human oropharynx. AJthough the temperature

condition of the rod was not described, it is possible that even a rod at room temperature could

transmit some degree of cooling to the pillar mucosa (Kaatze-NlcDonald, Post, & Davis, 1996).

In conclusion, Pommerenke emphasized that, although the faucial pillars evoked the swallowing

most consistently, no single area could be ascribed the exclusive power of causing the

swallowing act because' of individual variability.

Over a decade of research has fueled cautious optimism about thermal stimulation's

treatment potential. Only a few studies have actually attempted to evaluate the efficacy of cold

stimulation as a treatment for dysphagia. In an early study, Lazzar\Lazarus, & Logemann

(1986) found that thermal stimulation improved triggering of the swallow reflex in23 of 25

neurologically impaired patients whose reflexes were delayed. Additionally, results from a

different protocol with a limited number of these same patients suggested that the ef[ects of a


single sensitization lasted for 2-3 swallows after the stimulation. That study provided strong

support for the use of thermal stimulation in improving swallow function for neurologlcally

impaired patients. However, since only short-term effects were evaluated, it was suggested that

additional studies to evaluate long-term effects be undertaken.

In a more recent study, Rosenbek, Robbins, Fishback, & Levine (1991) measured the

effect of thermal application to the anterior faucial pillars on the swallow response in seven

subjects whose dysphagia resulted from multiple strokes. Subjects received two weeks of

thermal application alternating with two weeks of no thermal application over a period of one

month. Three judges completed visual inspections of data plots for eight durational and four

descriptive measures to determine whether daily thermal application influenced the swallowing

of liquid boluses. An operational definition of "influence" was a'!es" judgment by at least two

of the three judges. Two of the three judges agreed that fwo subjects demonstrated improvement

in the duration of stage transition (DST) secondary to treatment. Overall, that study failed to

reveal strong evidence that thermal application improved dysphagia for patients with multiple

strokes. Had all three judges agreed reliably on the presence of changes in one or more of the

durational or descriptivd measures, that would have been considered strong evidence.

Bisch, Logemann, Rademaker, Kahrilas, &Lazarus (199a) conducted a study to examine

the efFects of bolus temperature, volume, and viscosity on the durations of pharyngeal stage

swallow events and the frequency and nature of oropharyngeal swallowing problems and bolus

transit. They hypothesized that a cold bolus might have the same facilitatory effects as those

reported in the use of thermal stimulation. That study revealed that a cold bolus facilitated

triggering of the pharyngeal swallow on 1 ml boluses in patients with mild neurogenic

TreatmentofOropharyngealDysphagia 8

dysphagra" but not in more severely dysphagic patients. Additionally, it was found that bolus

volume had a greater effect than bolus temperature on improving the speed of triggering of the

pharyngeal swallow.

Selinger, Prescott, & Hoffinan (1994), in a related study, examined the temperature

acceleration in cold oral stimulation. The purpose of this study was to investigate the warming

effect of a cold probe upon contact with the oral mucosa. The results indicated that 6 seconds

after a probe was lifted from the ice, the temperature of the probe closely approximated

temperatures perceived as warm or at least neutral, but not cold. The warming was affected first

by temperature changes resulting from the probe being moved from the ice into room

temperature and, second by the contact to the oral mucosa. The clinical implication of that study

was that stimulation to the faucial pillars with a cold probe may not be what it is believed to be.

According to Selinger, et al., (1994), the only potentially consistent stimulation to the oral cavity

is tactile and that too is not controlled for in terms of time or amount.

In another study, Rosenbek, Roecker, Wood, & Robbins (1996) examined swallowing

variability and short-term effects of thermal application by comparing two durational measures

for l0 untreated swallows and 10 treated swallows. The recommended treatment for cold

thermal stimulation was followed by icing a 00 laryngeal mirror and subsequently stroking each

faucial pillar three times. The results of that study showed that thermal stimulation reduced the

duration of stage transition and total swallow duration. Although those findings were interpreted

as having a therapeutic effect, it was emphasized that demonstrating a method's enduring effects

is the real acid test of its efficacy. That study was not designed to address long-term effects.


Deep Phar.vneeal Neuromuscular Stimulation

Another method widely used method in the management of oropharyngeal dysphagia is

deep pharyngeal neuromuscular stimulation (Stefanakos, 2000). Although no studies on the

efficacy of this method have been published, it was built upon the following anatomical and

physiological facts:

1. The pharyngeal phase of the swallow is reflexive.

2. There are multiple receptors in the tongue, epiglottis, and larynx which are additional

receptors for the elicitation of the swallow reflex.

3. It has been hypothesized that sensory endings in the posterior oral cavity, innervated

by the glossopharyngeal nerve (CN DO provide information to the reticular

formation in the brainstem to stimulate various reflexive actions as tongue base

retraction refle:; palatal reflex triggering gag reflex, and the swallow reflex.

4. Contact of food material in the pharynx, or at the top of the larynx, may occasionally

trigger a swallow reflex via the superior laryngeal nerye of the vagus nerve (CN D.

5. In the normal individual, the sensory input for the triggering of the swallow reflex

comes predominantly via the glossopharyngeal nerve (CN D0 However,

a. Velopharyngeal closure (palatal reflex) is accomplished by means of

innervation from the glossopharyngeal nerve (CN IX) and the vagus nerve

(cN x)

b. Pharyngeal constrictor activity is controlled through the vagus nerve (CN )().

c. LaryngeaVairway protection (elevation of the larynx, and closure of the

larynx) is accomplished by the hypoglossal nerve (CN )OI).

Treatment of Oropharyngeal Dysphagia l0

d. Closure of the laryna by means of the adductor mechanisms of the true and

false vocal folds and aryepiglottic folds, is innervated by the spinal accessory

nerve (CIll)il) and the vagus nerve (CN X).

e. The cricopharyngeus muscle and pharyngoesophageal segment relaxation for

bolus transfer to the esophagus is accomplished through the vagus nerve (CN

x)

6. AII pharyngeal reflexes provide direct input into the brainstem, specifically, the

reticular formation within the medulla oblongata.

7. Swallow function is severely impaired when pharyngeal reflexes and pharyngeal

muscle strength are diminished.

A number of related studies support the anatomical and physiological bases underlying

DPNS. For example, Miller (1986), as part of his effort to lay the physiological groundwork for

a variety of swallowing treatments, specified the criteria that sensory stimuli must meet if they

are to evoke swallowing. Criteria were based on previous investigations that identified which

sensory fibers in the oral cavity responded only to temperature, only to touctr/pressure, or to both

temperature and touch/pfessure. One criterion was that the stimulus must excite several different

kinds of sensory fibers. DPNS provides thermal, gustatory, and tactile stimulation to a wide

range of sensory fibers. Another criterion was that the sensations most likely to influence

swallowing with the lowest threshold travel along the superior laryngeal nerve (SLN). The

anterior faucial pillars, which are the primary site for traditional thermal stimulatiorg are

primarily innervated by the glossopharyngeal nerye (CN IX), which has a higher threshold to

evoke swallowing. Another criterion was that the application of the stimulus be dynamic rather


than static. DPNS employs dynamic application. Another criterion was that sensory information

from the oral cavity, if it is to influence the swallow, must synapse in the dorsal region of the

brainstem swallowing center. This dorsal region includes the nucleus tractus solitarius CItmS)

and the surrounding reticular region. Presumably, NTS receives input from the trigeminal

sensory nuclei. DPNS provides sensory stimuli to the trigeminal nerve (CN V).

The anatomical and physiological information provided by Miller appears to support the

use of DPNS over thermal srimulation. This information is important as a rationale for continued

experimentation with sensory stimulation in the management of dysphagia. More importantly, it

provides a rationale for clinical researchers to compare types of stimulation and to identify the

most efficient and efficacious program.

In an effort to examine the effectiveness of additionai sensory stimulation, Logemanrq

Pauloski, Colangelo, Lazarus, Fujiu, & Kahrilas (1995) examined the use of a cold sour stimulus

in the treatment of dysphagia. It was hypothesized that a cold sour bolus may provide

heightened sensory input to the brainstem and the cortex since the stimuli incorporated both

temperature and taste. That study showed that a cold sour bolus reduced the pharyngeal delay

time, reduced oral and pharyngeal transit times, and improved oropharyngeal swallow efficiency.

The study further supporied earlier findings that the degree of sensory input was crucial in

improving swallow function (Miller, 1986).

Although data establishing DPNS's efficacy are not yet published, Stefanakos (2000)

reported, in a patient study, thatg3Yo (57 out of 61) of cerebrovascular accident patients showed

improvement within 2-l2weeks of treatment. Those improvements, determined in pre/post

videofluoroscopic evaluations, were significant enough to warrant diet upgrades. That study


provided strong support for the use of DPNS in the treatment of oropharyngeal dysphagra.

However, further research to corroborate these findings would provide additional support for the

use of this technique.

In an unpublished master's thesis, Willis (L997) attempted to compare the effectiveness

of deep pharyngeal neuromuscular stimulation versus thermal gustatory stimulation to determine

which treatment technique was more beneficial to the dysphagic patient. Six subjects were

treated for four consecutive days with an alternating treatment design. Willis evaluated swallow

initiation time and degree of lingual movement at the beginning and end of each treatment

session. The outcomes of that study did not reveal that one treatment was significantly more

effective than another in treating oropharyngeal dysphagia. Howeveq alarge effect size was

noted, which suggested that DPNS may be more effective than thermal stimulation.

Rationale for the Cunent Study

Despite the limited number of efficacy studies to support or refute the use of thermal

stimulation and deep pharyngeal neuromuscular stimulation, these two techniques are in

widespread use in the treatment of orpha4mgeal dysphagia. According to Logemann (1999),

..clinicians working in dysphagia should be knowledgeable about the literature supporting each

treatment procedure used. Before applying a new treatment procedure, clinicians should be

aware of the existing data published in peer-reviewed journals regarding the efficacy and

outcomes of the procedure. That is the basis of evidence-based practice. Therapy procedures

that have no such published evidence should not be utilized. Unfortunately, data on thermal

stimulation and DPNS are in short supply. It remains for clinical researchers to compare types of

treatment and identily the most efificient and efficacious methods.

Treatment of Oropharyngeal Dysphagia

Thus, the present study was designed to examine the effectiveness of thermal stimulation

versus deep pharyngeal neuromuscular stimulation in improving neurogenic oropharyngeal

dysphagia secondary to cerebrovascular accident in older adults. Specifically, this study was

designed to answer two questions. First, does treatment approach improve oropharyngeal

swallow efficiency? Second, is the relationship between treatment approach and improvement in

oropharyngeal swallow efficiency influenced by the amount of liquid barium utilized during the

MBS study?

This study differs from the Willis study in several ways. Specifically, this study is a

group design that employs two different treatments to fwo different groups over a four week

period of time. The Willis study was a multiple single subject design that employed an ABAB

alternating.treatment design within all subjects over four consecutive days. Furthermore, the

present study measures oropharyngeal swallow efficiency; whereas, the Willis study measured

lingual motility and lengh of swallow initiation. This study is similar to the Willis study in that

it compares the effectiveness of thermal stimulation versus deep pharyngeal neuromuscular

stimulation and, therefore, will add to the armamentarium of efficacy studies in the management

ofdysphagia.

13

Treatment of Oropharyngeal Dysphagia 1,4

Method

Participants

Twenty participants will be selected for this study. Ail participants shall meet the

following criteria: (1) at least 60 years of age; (2) presence of a single left anterior hemispheric

stroke verified by magnetic resonance imaging; (3) presence of stroke-caused dysphagia

characterized by reduced lingual motility and delayed pharyngeal swallow evidenced by

videofluoroscopic examination; (4) duration of dysphagia between one and four weeks; (5)

medical stability as judged by a referring neurologist; and, (6) ability to cooperate with the

treatment procedure as revealed by a short period of trial therapy. Participants shall be excluded

if they are (1) tracheotomized; (2) suffering from dysphagia from a cause other than stroke, as

determined.by consultation with a referring neurologist; and/or, (3) treated with any other

version of the experimental therapy within two weeks of enrollment in the present study.

Once a patient's eligibility is established, randomizationto I of 2 treatment groups will

be accomplished. Each group will include l0 parricipants.

Treatment Protocols

Thermal stimulatiorq in published descriptions (Logemann i983, 1986,Ig99), will be

administered to all participants in Group A. A 00 laryngeal mirror will be chilled in a cup of

crushed ice for several seconds. The patient will then be asked to open his or her moutlq and the

mirror will be put in contact, in a vertical stroking motion, with the anterior faucial arch. After

five strokes on each side of the oral cavity at the faucial arches, the patient will be grven a small

amount of water and asked to swallow This procedure will constitute one complete trial. Trials

Treatment of Oropharyngeal Dysphagta l5

will be repeated for a period of 30 minutes each day. Each participant will receive treatment five

times a week for four weeks.

Deep pharyngeal neuromuscular stimulation, as described by Stefanakos (2000), will be

administered to all participants in Group B. Frozen lemon glycerine swabs will be placed in an

iced chest to maintain temperature. Stimulation techniques will be applied first to the weaker

side, then to the stronger side as follows: (1) glide swab across the palatal pharyngeal

musculature firmly for l-3 seconds; (2) moving anteriorly-posteriorly from nasal spine region,

stimulate bilaterally on soft palate, then straight down the uvula along the palatal raphe for l-2

seconds; (3) glide swab firmly across bitter taste buds 1-3 seconds; ( ) holding tongue with

gauze, stimulate anterior to posterior on lateral sides of tongue to bitter taste bud region firmly

for 2-4 seconds; (5) moving posterior to anterior, stimulate lingual apex along lingual septum

while depressing lingual base with gloved hand for 2 seconds, (6) holding tongue with glove,

stimulate posterior pharyngeal wall firmly for 7-2 seconds; (7) holding tongue with gauze,

stimulate straight down the ulula; (8) stimulate distal palatopharyngeus area across soft palate

time down side of the uvula; and, (9) stimulate nasal spine position. Completion of these steps

will constitute one complete trial. Trials will be repeated for a period of 30 minutes each day.

Each participant will receive treatment five times a week for four weeks.

Instrumentation

Standardized videofluoroscopic evaluations of the oropharyngeal stages of deglutition

will be obtained one day prior to the initial treatment session and one day following the final

treatment session. Studies will be completed in the hospital's videbfluoroscopic suite using a

Sony VO-5800 video recorder at a rate of 30 frames per second. A specially designed timer


(Thalner Electronics, Ann Arbor, MI) will encode an analog time signal in hundredths of a

second (accurate to 0.01) on the video image. Slow motion and frame by frame analysis will be

used to measure oropharyngeal swallow efficiency (OPSE) for each participant. OPSE is a

measure developed by Logemann, Kahrilas, Kobara, & Vikal (1989) to quantifr the ability of the

oral cavity and pharynx to move food efficiently and safely into the esophagus. OPSE is the

ratio of the percent swallowed to the total swallowing time in the oral and pharyngeal stages.

More specifically,

OPSE = 100-(ORES + PRES + ASPB + ASPD)OTT+PDT+PRT

This formula defines OPSE as a function of multiple component measures typically

obtained from the videofluorographic assessment. OPSE has been found to be a representative

summary measure of swallowing function in various groups of dysphagic patients (Rademaker,

Pauloski, Logemann, & Shanaha 199$.

Procedures

Trial Therapy. Prior to the first treatment session, each participant will receive an

orientation and trial therapy session for each of the two procedures. First, each method will be

described to each subject, and each will be shown the simple tools necessary to provide the

treatment. Next, each subject will receive ten minutes of thermal stimulation followed by ten

minutes of deep pharpgeal neuromuscular stimulation to determine tolerance for the procedures.

Tolerance for both procedures will be required for inclusion in the study.

Treatment Procedure. Treatment will be administered by an experienced speech

language pathologist with a certificate of clinical competence and certification in deep


pharyngeal neuromuscular stimulation. Treatment sessions will be scheduled for five

consecutive days per week with a two-day rest period befween each five-day treatment period.

In the event that a participant is unable to attend a regularly scheduled session, a make-up

session will be required during the originally scheduled two-day rest period

Videofluoroscopic Procedure. Participants will be seated in the lateral plane and given

standardized instructions. The fluoroscopic camera will focus on the lips anteriorly, the posterior

pharyngeal wall posteriorly, the hard palate superiorly, and the cervical vertebra inferiorly.

Participants will be given one, 1-ml thin liquid barium bolus on a spoon by an experienced

speech-language pathologist and instructed to hold the material in the mouth until the command

"swallow" is given. The procedure will be repeated with one, 3-rnl thin liquid barium bolus.

The formula for mixing the liquid barium will be maintained constant for all subjects.

Data Collection

AII videofluoroscopic swallowing examinations will be analyzed by an experienced

speech-language pathologist with a certificate of clinical competence, and a speech-language

pathology graduate student. Each swallow will be analyzed in slow motion and frame by frame

to determine the following measures: (a) oral transit time (OTT) - the time (in seconds) from the

onset of bolus movement'in the mouth until the head of the bolus reaches the point where the

Iower rim of the mandible crosses the tongue base; (b) pharyngeal delay time (PDT) - the time

(in seconds) from the arrival of the bolus head at the point where the lower rim of the mandible

crosses the tongue base until first laryngeal elevation; (c) pharyngeal response time (PRT) - the

time (in seconds) from first laryngeal elevation until the bolus tail passes through the

cricopharyngeal region; (d) oral residue (ORES) - the approximate percent of the bolus

Treatment of Oropharyngeal Dysphagia

remaining in the oral cavity, (e) pharyngeal residue (PRES) - the approximate percent of the

bolus remaining in the pharyngeal region after completion of the first swallow of the bolus; (f)

aspiration before the swallow (ASPB) - the approximate percent of bolus aspirated before a

swallow; and, (g) aspiration during the swallow (ASPD) - the approximate percent of the bolus

aspirated during a swallow. These measures will then be calculated, using the formula

previously defined, to obtain the OPSE ratio. Ten percent of the swallows will be reanalyzed by

the same observers to determine intrajudge and interjudge reliability.

Proposed Data Analysis

Oropharyngeal swallow efficiency (OPSE) scores will be meaned for each of the two

groups. A 3-way analysis of variance (ANOVA) will be utilized to determine the relationships,

if any, between the following variables: (l) type of treatment (thermal stimulation and deep

pharyngeal neuromuscular stimulation) between groups; (2) test times (pre and post) within

groups; and, (3) bolus types (1 ml and 3 ml) within groups. Post-hoc analyses will be conducted

as needed. Effect sizes will be calculated to determine clinical significance.

Conclusion

Based on hypo,thetical data obtained, a significant main effect will show that deep

pharyngeal neuromuscular stimulation is more efilective than thermal stimulation in treating

neurogenic oropharyngeal dysphagia secondary to cerebrovascular in older adults (Appendix A).

No other significant main effects will be present. Such data will support the Stefanakos (2000)

finding that deep pharyngeal neuromuscular stimulation has shown that more stimulation input,

via multiple cranial nerve tracts within the pharyrx, improves swallow function significantly.

18


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Treatment of Oropharyngeal Dysphagia 2l

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APPENDIX A

TMPROVEMENT rNOROPHARYNG EAL SWALLOW EF FICIENCY

ao(n(u+JF-ool-oCL

UJao-o

[ort---l

[*r-i

1 mr LroulpPRE.TEST

3 ml LIQUIDPRE.TEST

1 ml LIQUIDPOST-TEST

3 ml LIQUIDPOST.TEST

Swallow Condition