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Sensorimotor Brain Plasticity in Stroke Patients with Dysphagia A Methodological Study on Investigation and Treatment


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Sensorimotor plasticity in stroke patients with dysphagia A methodological study on investigation and treatment Mary Hägg Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital, Uppsala, Sweden Dissertation for the degree of Doctor of Philosophy (Faculty of Medicine), presented at Uppsala University and to be publicly examined in Skoog Hall, Entrance 70, Academic Hospital, Uppsala, on Friday, December 14, 2007 at 13:00. The examination will be conducted in Swedish. 1. ABSTRACT Aims This study was undertaken to increase knowledge of how to improve oropharyngeal dysphagia therapies, and to validate investigation instruments for stroke patients with dysphagia. The aim was to assess the effects of orofacial sensorimotor stimulation on orofacial and swallowing dysfunction in stroke patients, to test the reliability of lip force measurements with a Lip Force Meter, LF100 (LF100), to assess a normal lower limit of lip force (LF), to determine sensitivity and specificity of the LF100 method with regard to LF, to investigate whether there is a functional relationship between LF and swallowing capacity (SC), and to evaluate whether training with an oral screen can improve LF and SC. Methods/Results In seven stroke patients with dysphagia for a median period of 1.5 years, symptoms improved after participating in a five-week sensorimotor stimulation therapy program, comprising manual body and orofacial regulation in combination with a palatal plate application. The most prominent results were found with a swallowing capacity test and with a meal observation test. An overall estimate showed objective and self-assessed swallowing improvement in all seven patients. In another study, including 42 healthy controls and 22 stroke patients with dysphagia, the intra- and inter-reliability, sensitivity (91%), and specificity (95%) of a Lip Force Meter, LF 100, were assessed. The controls had a significantly stronger lip force (mean 24.7 N ± 6.3 N) than the stroke patients (mean 9.5 N ± 5.5 N). The reliability was excellent. A normal lower limit of the lip force was set to 15 N. In 22 acute stroke patients, 12 with facial palsy and 10 without, impaired LF and impaired SC were parallel phenomena and did not differ; nor did the presence or absence of facial palsy affect the result. However, LF and SC differed significantly between controls (n =45) and stroke patients. SC correlated significantly with age in controls, but not sufficiently so to explain the low values in the stroke group. After daily self-training of the lip muscle with an oral screen, 19 of 30 stroke patients normalized their SC; an index of 10 ml/sec was regarded as the lower normal limit. Eight out of 13 patients with long-standing dysphagia started their lip training on average two years after their stroke attack. LF and SC improved significantly and were not significantly influenced by presence or absence of a central facial palsy, by the time lag between stroke attack and start of treatment, or by age or sex. Conclusions Orofacial sensorimotor stimulation seems to be a promising therapy and an excellent example of cerebral plasticity and cortical reorganisation in stroke patients with long-lasting and persistent oropharyngeal dysphagia. The LF100 is an appropriate and reliable instrument with high sensitivity and specificity for measuring lip force, and therefore can be used for evaluation of lip force training. The swallowing capacity and lip force in stroke patients are parallel and concomitant phenomena, making the lip force test a suitable screening instrument for impaired swallowing capacity in stroke patients. Training with an oral screen can improve lip force and swallowing capacity in stroke patients with oropharyngeal dysphagia. A subclinical facial paresis seems to be present in most stroke patients. Keywords Controls, Dysphagia, Deglutition, Facial palsy, Orofacial regulation, Lip force, Muscle training, Reliability, Sensitivity, Plasticity, Specificity, Stroke, Swallowing capacity Mary Hägg, Department of Otorhinolaryngology, Head and Neck Surgery, Academic University Hospital, Uppsala, SE-75 185 Uppsala, Sweden © Mary Hägg 2007 ISBN ISBN
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Digital Comprehensive Summaries of Uppsala Dissertations
from the Faculty of Medicine 299
Sensorimotor Brain Plasticity in
Stroke Patients with Dysphagia
A Methodological Study on Investigation and
ISSN 1651-6206
ISBN 978-91-554-7042-5
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To my two boys and three girls
Hans, Eiliv, Ylvali, Karin, Linn
“All my love”
Cover: Håkan Gustafsson
Image editing: Reimond Dempwolf
Picture design: Mary Hägg
This thesis is based on the following papers, referred to in the text by their
Roman numerals:
I Hägg M, Larsson B. Effects of motor and sensory stimulation in
stroke patients with long-lasting dysphagia. Dysphagia 19:219-230,
II Hägg M, Olgarsson M, Anniko M. Reliable Lip force measure-
ment in healthy controls and in patients with stroke. A methodologi-
cal study. Dysphagia, accepted for publication and in press, 2007.
III Hägg M. Correlation between lip force and swallowing capacity in
stroke patients and in controls. Submitted to Dysphagia, 2007.
IV Hägg M, Anniko M. Lip force training in stroke patients with dys-
phagia. Acta Oto-Laryngologica, accepted for publication and in
press, 2007.
Reprints were made with kind permission from the publishers
1. INTRODUCTION ....................................................................................11
Four levels of dysphagia ..........................................................................12
Oropharyngeal neurophysiology ..............................................................13
The oral phase......................................................................................16
The pharyngeal phase ..........................................................................17
Investigation procedures ..........................................................................18
Different investigation tools.....................................................................18
Therapeutic procedures ............................................................................19
2. AIMS OF THE STUDY ...........................................................................20
3. METHODS ...............................................................................................21
Diagnostic procedures..............................................................................21
Anamnesis ...........................................................................................21
Anamnesis ................................................................................................22
Body Mass Index - BMI .....................................................................22
Visual Analogue Scale - VAS (0-100) ...............................................22
Activity in Daily Living – ADL (0-6) .................................................23
Investigations ...........................................................................................23
Reaction Level Scale – RLS (1-8).......................................................23
Gross motor skills................................................................................23
Breathing – Velopharyngeal Closure Test (VCT) ...............................23
Orofacial motor skills (0-4).............................................................24
Lip force (LF), in Newton (N).............................................................24
Sensory function..................................................................................26
Intraoral examination...........................................................................26
Swallowing capacity test (SCT), in ml/sec..........................................26
Meal observation, scored (0-4)............................................................27
Videofluoroscopy, scored (0-3)...........................................................27
Therapy ....................................................................................................27
The first hypothesis..............................................................................27
The second hypothesis.........................................................................28
Function of the palatal plate and the oral screen .................................29
Body regulation ...................................................................................29
Orofacial regulation therapy ................................................................30
Palatal Plate .........................................................................................31
Oral screen training..............................................................................31
Breathing – Velopharyngeal Closure Training (VCT) ........................33
Statistics ...................................................................................................33
Study 1.................................................................................................33
Study II ................................................................................................33
Study III...............................................................................................34
Study IV...............................................................................................34
Ethical considerations ..............................................................................34
4. STUDY DESIGN-SUBJECTS-RESULTS...............................................35
Study 1 .....................................................................................................35
Methods ...............................................................................................35
Results .................................................................................................36
Study 2 .....................................................................................................36
Methods ...............................................................................................37
Results .................................................................................................37
Study 3 .....................................................................................................39
Methods ...............................................................................................39
Results .................................................................................................40
Study 4 .....................................................................................................42
Methods ...............................................................................................42
Results .................................................................................................42
5. GENERAL DISCUSSION .......................................................................48
6. CONCLUSIONS.......................................................................................50
7. PERSPECTIVES FOR FUTURE RESEARCH .......................................51
8. SAMMANFATTNING PÅ SVENSKA ...................................................52
9. ACKNOWLEDGEMENTS......................................................................54
10. REFERENCES .......................................................................................57
BMI Body Mass Index
CI Confidence Interval
CT Conventional Therapy
CV Coefficient of Variation
DCF Data Clarification Form
DMP Data Management Plan
DVP Data Validation Plan
ICC Intra-Class Correlation
EMG Electromyography
GCP Good Clinical Practice
MRT Manual Regulation Therapy
LF Lip force
LFM Lip Force Measurement
LF100 Lip Force Meter, LF100
SC Swallowing capacity
SCT Swallowing Capacity Test
SOP Standard Operating Procedure
ORT Orofacial Regulation Therapy
OST Oral Screen Training
OPD Oropharyngeal dysphagia
PASS Postural Assessment Scale for
Stroke patients
Uppsala Clinical Research
Center. UCR is a clinical re-
search consultant organisation
(CRO) at Uppsala University
and University Hospital in
VAS Visual Analog Scale
VCT Velopharyngeal Closure Test
Dysphagia is in most cases a severe physical handicap with consequences for
social and mental health as well. The search for treatment modalitites was
initiated in the early 1970s by speech therapists [46] who met patients with
various speech problems that are closely related to oropharyngeal dysphagia
(OPD). Most patients with OPD have been afflicted by stroke. Stroke pa-
tients are therefore most suited for studies on OPD.
In Sweden, more than 30 000 people are afflicted by cerebral stroke
every year, 85% due to infarction and 15% due to bleeding. Stroke affects
400 people in every 100 000/year [85] which can give a wide range of neu-
rological impairments of postural control, upper-limb function, visual, cogni-
tive, perceptual and communication abilities, and with problems in eating
and swallowing [4, 44, 52, 78]. OPD, i.e. an impaired or unsafe oropharyn-
geal transit of food or liquids, is common in the acute stage [64, 50, 83, 77].
Unilateral and bilateral cerebral hemispheric infarctions are seen more often
than brainstem events [21, 49, 68]. However, dysphagia is more likely to
occur when stroke involves the brainstem. In that case the prognosis is seri-
ous and will often have a fatal outcome [81]. The incidence of dysphagia
symptoms varies in different articles, probably due to how soon after the
stroke attack the evaluation has been performed and what investigatory mo-
dalities have been applied [21, 49].
OPD is seen in about half of stroke patients during the acute period
and after more than 14 days in about one-fifth [49, 67, 8, and 7]. Dysphagia
is of particular concern because of its potential risk for malnutrition, poor
hydration and aspiration pneumonia. Dysphagia even affects different psy-
chosocial functions and hence also the patient´s quality of life as well as that
of relatives and caregivers. When patients with stroke are afflicted by dys-
phagia the prognosis is more grave than in non-dysphagic patients [49].
They suffer more often from malnutrition [18], and have a slower rate of
recovery [20, 84]. Moreover, dysphagia - and its related complications
prolongs emergency hospitalization and is associated with increased mortal-
ity, co-morbidity, and increased health care costs [49, 71, and 12].
The presence of aspiration, including silent aspiration, with increased
risk of pneumonia [14], ranges from 22 – 42% as assessed at videofluoro-
scopy [52]. In many patients neither the clinical history, such coughing, im-
paired gag reflex, and voice changes, nor the neurological evaluation can-
predict the presence of silent aspiration [32, 70]. Aspiration following stroke
occurs more frequently in those with brainstem lesions [31]. However, pa-
tients with lesions in the posterior region and with a history of pneumonia
(reported by up to 32%) are at greater risk of impaired pharyngeal safety,
which signifies that videofluoroscopic examination is mandatory in these
patients [82, 71]. Unfortunately not even not videofluoroscopy nor fiberoptic
endoscopy can serve as a perfect “gold standard” for detection of aspiration,
because each yields both false-negative and false-positive results. It has been
claimed that dental status and good oral hygiene are of great importance in
order to avoid the risk of aspiration, especially in these patients [43, 74, 87
and 57].
Dysphagia comprises sensory and motor dysfunction of several differ-
ent cranial nerves. It is evident from videofluorographic studies of oro-
pharyngeal swallowing that stroke patients have some degree of sensory loss
in the pharynx [54, 47, and 48]. Identification of patients with dysphagia is
therefore the first vital step in their appropriate management. The primary
goals of dysphagia therapy should be to establish optimal nutrition and to
eliminate or reduce the risk of developing complications associated with
dysphagia [13]. Beside OPD speech difficulties are often present. This is the
reason why stroke patients with dysphagia meet a speech therapist in the first
Four levels of dysphagia
It seems appropriate to categorize dysphagia into its preoral, oral, pharyngeal
and esophageal forms [36]. Preoral dysphagia includes all kinds of difficul-
ties in conveying food and liquids from the plate to the mouth. Not only
palsy of an arm or hand but also an award position of body and head, ne-
glect, consciousness, and environment can all hamper optimal eating abil-
ity[5]. Oral dysphagia can be due to palsy of the tongue, facial paresis, re-
duced oral sensation, abscence of the swallowing reflex in the anterior faucal
arcs, jaw dysfunction, dryness of the mucosal membranes, mandibular and
maxillar injuries, etc.. Pharyngeal dysphagia is due to sensory failure, weak-
ness or palsy of pharyngeal swallowing muscles and hence inability to pro-
tect the laryngeal entrance. OPD often leads to aspiration, bronchopulmon-
ary complications, malnutrition, weight loss, and psychosocial complica-
tions. Esophageal dysphagia is often separated into (i) constant dysphagia
with retention of food due to a benign or malignant stricture, or to achalasia
cardiae, and (ii) intermittent dysphagia in patients with, e.g., a hiatus hernia.
In stroke patients dysphagia is often of both oral and pharyngeal forms
Oropharyngeal neurophysiology
Chewing and swallowing are dependent on several motor and sensory cra-
nial nerves integrated into a coordinated oropharyngeal function. The swal-
lowing process is usually subdivided into three phases that are related to
their differing innervation patterns [55]. Swallowing has also been described
in two stages: the oropharyngeal (or buccopharyngeal) and esophageal stages
[36]. The former stage of swallowing is of short duration (range 0.6-1.0 s)
and is remarkably constant in all humans [36, 15] de spite the extraordinary
complexity involving not only pharyngeal and laryngeal muscles (IX, X) but
also muscles in the oral cavity such as tongue (XII) and suprahyoid muscles
(V, VII, XII). In the esophageal phase (X) the outer longitudinal muscle
contracts when the upper esophageal sphincter opens, and the inner circular
muscles contract, initiating a peristaltic wave having a transit time of 10 s in
the conscious human [36, 15]. The inner and outer muscles of the upper third
of the esophagus are striated muscles and the lower two-thirds are smooth
The motor part of the six different cranial nerves, with striated mus-
cles that are involved in oropharyngeal swallowing, is represented in the
precentral motor area 4 in the cortex (Fig.3). The importance of the oral
function is best illustrated by the relatively large area in cortex that is occu-
pied by the oropharyngeal cavity (Fig.1, 2). The enormous network of the
extrapyramidal tracts from cortex over the basal ganglia and reticular forma-
tion to end in the motor nucleus in the brainstem or in the spinal tract is a
prerequisite for the brain plasticity. Of similar importance for plasticity are
the afferent sensory pathways that, besides their direct connection with the
cortical postcentral sensory area have indirect connections via the reticular
The swallowing reflex centre in the brainstem consists mainly of nu-
cleus tractus solitarius (NTS), nucleus vagus, and nucleus ambiguus, an
autonomous function closely connected with the reticular formation as well
as with cortico-nuclear pathways.
The cranial facial nerve has two peripheral branches, an upper branch
from the forebrain to the eye closure muscles, and a lower branch to the na-
solabial muscles and to the buccal and the orbicularis oris muscles. The up-
per branch has a central bicortical representation and is therefore not clini-
cally affected by unilateral cortical lesions, whereas the lower branch has
only unilateral cortical representation. Central facial paresis in stroke pa-
tients causes a nasolabial smooth down and a dip in the angle of the lip on
the contralateral side.
Six cranial nerves are involved in swallowing: V, VII, IX, X, XI, XII.
Of particular interest in this context is the motor supply to the facial nerve
(VII; facial mimic muscles, orbicular oris muscles, stylohyoid muscles, pos-
terior parts of the digastric muscles, platysma, m. levator veli palatinae). In
central facial palsy, the upper facial muscles are unaffected, thanks to two
bilateral cortical representations.
The oral cavity and pharynx are anatomically separate yet functionally
integrated regions of the head and neck. These two regions are involved in
the complex motor responses that include feeding, chewing, swallowing,
speech, and respiration. The oral and pharyngeal phases are closely interre-
lated and the distinction between them is often unclear. In the oropharyngeal
region, several cranial nerves are involved in the sensory-motor reflex arc,
which is activated by sensory stimulation via the afferent pathway and the
impulses are transmitted to the medullary nucleus tractus solitarius (NTS).
Some impulses reach the cerebral motor cortex, area 4, and return via the
efferent motor pathways necessary for triggering the swallowing reflex. Pe-
rioral, submental, and lingual striated muscles can be controlled by the me-
dullary CPG (central pattern generator) beyond the cortical drive [16, 53].
Food/saliva in the mouth and the cortical drive to the tongue and the floor of
the mouth are necessary for voluntarily induced swallowing, whereas trig-
gering of spontaneous swallowing does not require any cortical drive [17].
However, a reflex mechanism does play a role in both types of swallowing.
During volitional swallowing, the total volume activity is significantly
greater in either hemisphere than that during a reflexive elicited swallow. A
reflex swallow produces significant greater left hemisphere activity [42].
Multiple and asymmetric cortical regions in both hemispheres are involved
in swallowing, with stronger activity in the right hemisphere.
Not only are these cranial nerves of importance for normal swallowing
function; body and head posture and appropriate breathing are also important
[10]. Studies evaluating swallowing disorders in stroke patients have found
that the soon recover [23], reflecting the enormous neuronal plasticity of the
central nervous system [22]. Recovery of swallowing is associated with in-
creased pharyngeal representation in the unaffected hemisphere [23, 22] and
is highly dependent upon the frequency, intensity, and duration of sensory
stimulus applied [19, 76 and 28]
Figs. 1, 2. Illustrating the vast representation of the oropharyngeal cavity in cortex.
Reproductions by Reimond Dempwolf from [1: Penfield and Boldrey´s homuncu-
lus; 2: Rasmussen and Penfielddiagram of sensory and motor sequences in cerebral
cortex of man as determined by electrical stimulation. Medical physiology. ISBN 0-
The oral phase
The oral phase of swallowing is mainly voluntary and highly variable in
duration depending upon taste, hunger, motivation, environment, and con-
sciousness. It even includes reflexive components integrated with feeding
and chewing [56]. It is primarily related to oral preparation including activat-
ing of jawclosing muscles of the mandible (viz. m. temporalis, m. masseter,
medial and lateral pterygoid); (V) chewing and stabilizing the mandible de-
spite activating the movements of the tongue;(XII) propelling the bolus
backwards to ward the pharynx. To raise the tongue, especially for a solid
bolus, the suprahyoid muscles in the floor of the mouth (V, XII) are particu-
larly important. Similarly, orbicularis oris (VII) and buccinator muscles
(VII) close the mouth to prevent food from escaping forwards [75]. Their
contraction and muscle tone acts as a valve mechanism [47, 48]. In EMG
studies it has been observed that perioral muscle activity ends just before the
pharyngeal phase of swallowing, while the masseter activity can continue or
reappear [66]. Loss of sensibility in the pharyngeal arcs has been proven to
be the main reason for dysphagia and aspiration in stroke patients [2, 3].
Fig. 3. Orofacial motor function of the cerebral cortex, represented by numbes 7-11:
7, retraction and elevation of the angle of the mouth; 8, elevation of the ala of the
nose and upper lip; 9 and 10, opening of the mouth, with protrusion (9) and retrac-
tion (10) of the tongue; 11, retraction of the angle of the mouth.
Reproduction by Reimond Dempwolf from [Ferrier´s original motor map of left
hemisphere of monkey. In: Medical Physiology. ISBN 0-8016-3550-0, 1974]
The pharyngeal phase
The pharyngeal phase is considered to be a reflex response. When a bolus is
propelled from the oral cavity to the base of the tongue, to the upper third of
the epiglottis, to the pillar of the fauces and to the walls of the pharynx, the
tactil-, mechano-, chemo-, and thermoreceptors provide information essen-
tial for bolus identification and to trigger of a swallowing. All sensory inputs
through the afferent fibres running within the maxillary branch of the
trigeminal nerve (V), the glossopharyngeal nerve (IX), and the vagus nerve
(X) especially its superior laryngeal branch, reach the brainstem and end in
the NTS [36, 56]. The NTS receives the main sensory fibres not only from
the oropharyngeal and laryngeal regions, but also from cortical descending
inputs. Some sensory inputs that initiate swallowing are transmitted to the
region of the caudolateral sensorimotor cortex that facilitates the initiation of
the swallowing [26].
Once swallowing is initiated, the cascade of muscle activation and
events occur in rapid overlapping succession. The main events are the trans-
port of food to pharyng-esophageal segments by the movements of the
tongue, submental/suprahyoid muscles and pharyngeal constrictor muscles,
and the relaxation and opening of the cricopharyngeal sphincter muscle
(UES). During food transport, the airway is protected and closed by several
laryngeal muscles, the larynx is drawn up and the epiglottis is tilted back-
wards to cover laryngeal entrance. All events cranial to the esophageal phase
are controlled mainly by the central pattern generator (CPG) of the brainstem
[55, 35, and 56].
Swallowing is a complex sensorimotor behaviour involving the coor-
dinated contraction and inhibition of the musculature located around the
mouth and at the tongue, larynx, pharynx and esophagus bilaterally. During
a swallow, different levels of the central nervous system from the cerebral
cortex to the medulla oblongata are involved and many of the striated mus-
cles innervated by the cranial nerves are excited and/or inhibited sequentially
for the execution of the passage of bolus from the mouth to the stomach [55,
36, 37, and 38].
The complexity makes neurophysiologic mechanisms difficult to
study in human experiments.
Investigation procedures
One persistent problem when evaluating post-stroke dysphagia is the vari-
ability in documentation of dysphagic symptoms, of their functional impact,
and of treatment results.
Different outcome scales on oral ingestion of food and liquid, and on
identification of the presence of dysphagia and aspiration symptoms are
available. The Subjective measures often used suffer from poor established
reliability or validity characteristics. However, the clinical examination is
important and with efficient screening instruments and with trained investi-
gators, and with speech and language therapist, it is possible to identify preo-
ral, oral, pharyngeal and esophageal dysphagia. Patients with OPD are risk
of aspiration and with esophageal dysphagia often need even a videofluoro-
scopic or endoscopic examination.
The water swallowing test of 30 ml water [65], and changes in voice
quality [82] have been identified as very useful and simple screening tools to
detect aspiration. The videofluoroscopic swallowing study (VSS) is regarded
as the “gold standard” in this field, but it has its limitations [71]. Not all pa-
tients can be transported to a radiological department and positioned as re-
quired; radiology entails radiation exposure; there is limited standardization
among centres with respect to volumes, consistencies, or textures of food
and fluids or screening used; VVS may not identify all problems encoun-
tered in the clinical meal observation [13].
Different investigation tools
Assessment sets for dysphagia usually comprise various examinations such
as different water swallowing tests, some combined with auscultation, oxy-
gen saturation monitoring, or bedside assessments, meal observation, body
posture/head control, orofacial motor function, sensory function, jaw func-
tion, gag reflex, voice quality, motor speech function, voluntary cough ca-
pacity, laryngeal elevation on saliva swallowing, electromyography, radiol-
ogy, and videofluoroscopy. Recent advances in functional brain imaging
including fMRI (magnetic response imaging) and PET (positron emission
tomography) studies now offer the opportunity to examine the cortical repre-
sentation of swallowing in humans [26, 59 and 51].
Therapeutic procedures
Currently available therapy modalities are 1) compensatory procedures and
2) acitive exercises combined with swallowing of food or liquid, so-called
direct therapy, or indirect procedures combined with swallows of only saliva
by patients who aspirate [48].
1. Compensatory procedures control/improve/or changes the flow of
food and can eliminate the patient symptoms but do not necessarily
change the pathophysiology. The procedures also include postural
techniques, to improve sensory input, adapted diet modifying vol-
ume/consistency/food presentation, and finally intraoral prosthetics.
2. Active exercises are designed to improve the range of motion of oral
and pharyngeal structures of lips, jaw, tongue, tongue base, larynx,
and vocal folds, to improve sensory input (thermal-taste-tactile
stimulation), and to take voluntary control over timing/coordination
of selected oropharyngeal movements through swallow manoeuvres
and respiration.
Other treatment modalities are orofacial regulation therapy [10, 34], inser-
tion of a palatal plate and [34] or an oral screen, DPNS (deep pharyngeal
neuromuscular stimulation), FMEP (facial muscular exercise program), and
so-called Vitalstim (neuromuscular electrical stimulation; (Logemann JA.
The Effects of VitalStim on Clinical and Research Thinking in Dysphagia.
Dysphagia 23:11-12, 2007).
x To assess the effects of sensorimotor stimulation on orofacial and swal-
lowing dysfunction persisting for more than 6 months in stroke patients
x To test the reliability of lip force measurements with a Lip Force Meter
LF100 (LF100) (II).
x To assess a normal lower limit of lip force (LF) (II).
x To determine sensitivity and specificity of the LF100 method with regard
to LF (II).
x To investigate if there is a functional relationship between LF and swal-
lowing capacity (SC) in acute stroke patients both with and without facial
palsy, and in healthy controls (III).
x To investigate whether there is a correlation between LF or SC and age
x To ascertain if training with an oral screen can improve lip force (IV).
x To ascertain whether training with an oral screen can improve swallowing
capacity (IV).
x To establish whether improvement in LF and SC is connected with (IV):
- the presence or absence of central facial palsy
- the time interval between the onset of a stroke and initiation
of treatment
- age
- sex
Diagnostic procedures
Anamnesis (Appendix)
x demography
x date of stroke
x social situation
x environment
x allergy
x smoking/alcohol habits
x other illnesses
x vision/hearing
x height/weight/ Body Mass Index (BMI)
x medical therapy
x symptoms
x Visual Analogue Scale; 0-100 (VAS)
x Activity in Daily Living; 0-6 (ADL)
Investigations (Appendix )
x general health
x Reaction Level Scale; 1-8 (RLS)
x communication
gross motor skills
x Postural Assessment Scale for Stroke patients; 0-36 (PASS),
x postural control (0-4)
x head control (0-4)
breathing, Velopharyngeal Closure Test (VCT)
orofacial motor skills (0-4)
x facial expression
x lip motility
x jaw function
x tongue motility
x velum motility
lip force (LF) (Newton, N)
sensory function (0/1)
x oral stereognosia
x 2-point discrimination
intraoral examination
x mouth opening ability (mm)
x jaw relation (normal/deviant; 0/1)
x teeth supply (fully supplied-lack of teeth; 0-4)
x palate shape (normal/deviant,; 0/1)
x parodontal status (no inflammation-severe infl.; 0-3)
x bite force capacity (normal-missing; 0-3)
x saliva production (normal-dry; 0-4)
x drooling (normal-abnormal; 0-4)
swallowing capacity test (SCT)
meal observation (0-4)
videofluoroscopy (0-3)
A thorough anamnesis is always mandatory in any medical investigation,
and this context, anamnesis also plays a fundamental role in the understand-
ing of the diseases and their complexity (See p.21 and all appendixes at the
back of this thesis).
Body Mass Index - BMI
Weight (kg)/height (m2) was calculated.
Visual Analogue Scale - VAS (0-100)
The impact of dysphagia on their quality of life was estimated by the patients
on a 100 mm VAS (0 = no impact, 100 = unbearable impact). Also a history
was taken regarding the frequency of bronchopulmonary complications,
hoarseness and caughing in connection with meals and the patient’s mental
status and hobbies.
Activity in Daily Living – ADL (0-6)
The participant’s ability to manage daily life activities, i.e. bathing, dress-
ing/undressing, going to the toilet, movement, continence and eating, were
assessed according to the Katz ADL index [40]. This index is graded as:
0=independent in all functions – 6=dependent on help in all 6 functions.
Reaction Level Scale – RLS (1-8)
The patients were assessed for consciousness using RLS [79]. Ranks 4-8
indicated that the patient was not mentally responsive, i.e. was unconscious.
If patients fluctuated in consciousness the higher (worse) rank was chosen.
Gross motor skills
Postural Assessment Scale for Stroke patients -– PASS (0-36) [6] is a clini-
cal scale for assessing stroke patients with respect to their capacity for pos-
tural control. It comprises an assessment of the patient's capacity to retain or
change his or her posture while lying down, sitting, or standing. The ability
to walk is not evaluated. The scale comprises twelve activities judged ac-
cording to a four-degree scale (0-3), which gives a range from 0 to 36 points.
The method assesses performance for different postures and activities at
varying levels of difficulty. The scale is primarily intended for acute stroke
patients but may also be used later on in the rehabilitation process.
Postural control includes assessments of head, body, pelvis, and foot
control [10].
The movements related to head control includes 6 variables (flexion,
extension, rotation and lateral flexion to the right and left). The different
items of postural, and head control are scored from 0 = normal to 4 = severe
dysfunction, and are registered in a test protocol. Motility test of head con-
trol was videotaped.
Breathing – Velopharyngeal Closure Test (VCT)
The ability to increase the intra-oral pressure was tested by instructing the
patients to inhale deeply and then exhale through a straw at a constant pace
and for as long as they could against a water pressure of 12 cm. The gener-
ally accepted lower normal limit is the ability to exhale against a water pres-
sure of 5 cm for at least 5 sec [63].
Orofacial motor skills (0-4)
The patients were placed in an upright and slightly forward position in a
chair in front of a table and instructed to perform 23 different movements
divided into 5 sections; these movements reflect the motor functions of facial
muscles, lips, jaw, tongue and soft palate [30].
The movements relate to facial expression, (4 variables, Va), n VII fa-
cialis: close the eyes tightly, make the eyes wide open and wrinkle the fore-
head, pull the brows close together, wrinkle the nose; lips, (7 Va), n VII fa-
cialis: pout the lips, smile with closed lips, smack as loud as possible, blow
up the cheeks against pressure of a finger, suck the cheeks together; repeat
“oh-eeh” and “pah” three times as quickly and rhythmically as possible (oral
diadochokinesy); jaw,(5 Va, assessing the functions of the four chewing
muscles), n V trigeminus ; n mandibularis: open and close the mouth; move
the lower jaw forward, backward and to the left and right side; tongue, (8
Va), n XII hypoglossus: stretch out the tongue as much as possible, move the
tongue to the left and to the right corner of the mouth, move the tongue three
times alternatively to the right and to the left as quickly and rhythmically as
possible, point the tip of the tongue upwards and downwards, lick the lips all
around and the front side of the teeth in the upper and lower jaws three
times; velum, (1 Va), n X vagus, n V trigeminus, n VII facialis: say “ah” for
evaluation of velum lift.
Lip force (LF), in Newton (N)
Lip force was measured, with a Lip Force Meter (LF100, MHC1 AB De-
tector, Sweden), blindly 3 times with a 2 minutes rest between and the
maximum force value was registered in newton (N).
Fig. 4. Lip Force Meter (LF100) is a measuring device. The handle, consisting of a
box with a water-level, is connected to an oral screen.
The Lip Force Meter (LF100) was developed by Mary Hägg and Anette
Westberg at the Speech & Swallowing Centre/ENT clinic in Hudiksvall,
Carl-Axel Wannerskog, MHC1 AB Detector, Gothenburg, Madeleine
Wertzén, Mölndal Hospital, Gothenburg, and Lotta Sjögreen, at the Mouth-
H-Centre in Gothenburg, all from Sweden, and was set into use in 2003.
The LF100, designed by MHC1 AB Detector (Gothenburg, Sweden),
is a lip force measuring device (Fig.4) approved and certificated according to
the Medical Device Directives in Sweden. It consists of a strain gauge at-
tached to an aluminium ring taking up the pulling force on an oral screen.
The detector is connected to an electronic unit for measuring maximal lip
force. In order to obtain the greatest possible reproducibility of the meas-
urement the pulling force must be applied at a right angle to the patient’s
mouth. To accomplish this end, a small box with a water-level is attached to
the device.
The subjects were seated in a certified chair (REAL 9100 EL,
Mercado Medic AB, Sweden) with the body and the head in a strict upright
position, with support for the feet, the knees in a straight angle position, and
the hands resting in the lap. The investigator applied the force by pulling the
handle gently with increasing force for 10 seconds, or until the pa-
tient/subject lost the grip of the screen.
Fig. 5. The subject to be investigated was seated in a certified chair (REAL
9100 EL, Mercado Medic AB, Sweden).
Fig. 6. During the lip force measurement, the pulling force had to be applied at
right angles to The patient’s mouth.
Sensory function
The oral sensory function was examined through
stereognosia tests [9]. Eight metallic objects of two
different sizes (10 mm and 20 mm in diameter) and
four different shapes (full circle, half circle, star and
triangle) were placed in the mouth of the patient, who
was asked to match the shape against a picture of five
different objects. The time allowed for identification
was at most 15 seconds. The objects were
administered randomly and each one was presented
twice to the patient.
Two-point discrimination [9] was tested with a pair of compasses. The two
points of the compasses were placed with equal pressure on the epithelium
until a slight indentation of the area was seen. The space between the points
differed depending on the area to be tested; the smallest distinguishable dis-
tances in millimetres (the upper normal limit) were set to 15 mm for the
cheeks, 5 mm for the lips, 3 mm for the tongue, and 3 mm for the anterior
faucial arch.
Intraoral examination
Jaw relation (0/1 = normal/deviant).Teeth supply (0-4 = fully supplied – lack
of teeth).
- Open-the-mouth ability (mm).
- Palate shape (0/1 = normal/deviant).
- Periodontal status (0-3 = no inflammation – severe parodontitis).
- Saliva production (0-4 = normal –dry).
- Drooling (0-4= normal – abnormal).
- Bite force capacity on the left/right side: (0-3 = normal, reduced, miss-
Swallowing capacity test (SCT), in ml/sec
The patient was asked to swallow 150 ml of cold tap water in one sweep and
as quickly as possible. The subject was instructed to sit upright with the
glass close to the lower lip, to start drinking when the “go” signal was given,
and stop drinking in case of difficulty. The time was measured from the on-
set of drinking until the last swallow was completed. Remaining water in the
glass was measured. A swallowing capacity index of 10ml/sec is regarded as
the lower normal limit [61].
Meal observation, scored (0-4)
Each patient was served a meal consisting of 2 dl sour milk (yoghurt that is
liquid, but thicker than ordinary milk), one slice of hard bread, and 1.5 dl of
water. During the meal observation [4], the patient was recorded with a
video camera on video tape and simultaneously observed by one of the au-
thors, who also filled in a questionnaire with the following parameters, each
scored from 0-4 (0=normal, 4=severe dysfunction):
Length of meal: 1= >20 min, 2= >30 min, 3= >40 min, 4= inability to com-
plete the meal.
Oral preparation time (time from intake to initiation of swallowing):
1= sometimes > 10 sec, 2= often > 10 sec, 3= always > 10 sec, 4= complete
inability to swallow.
Drooling/food leakage: 1= sometimes, 2= often, 3= always, 4= inability to
keep saliva and food in the mouth.
Coughing when eating: 1= sometimes, 2= often, 3= always.
Leakage to the nose: 1= sometimes, 2= often, 3= always.
Hoarseness (the patients were asked how frequently they experienced
hoarseness at meals): 1= sometimes, 2= often, 3= always.
Videofluoroscopy, scored (0-3)
The following parameters were analysed by means of videofluoroscopy us-
ing a low-density barium contrast medium [29]: bolus control, oral retention,
epiglottic closure, retention in vallecula, retention in the pyriform sinus,
aspiration (before, during, or after swallowing), and cough with aspiration.
All variables were given a score from 0-3 (normal - severe dysfunction).
The so-called orofacial regulation therapy developed by Castillo Morales
comprises three levels:1) manual body and 2) orofacial regulation in combi-
nation with 3) different oral devices such as a palatal plate used in study I, or
an oral screen as in study IV. The therapy has shown promising results in
stroke patients.
The first hypothesis
The first hypothesis by Castillo Morales that body and orofacial regulation
have impact on dysphagia is based on the interdependence of the orofacial
complex (orofacial muscles, mandible and oropharynx), breathing, head
control and body posture at deglutition – the first pattern way of motion [44].
To reach optimal results in the treatment of swallowing it is necessary
to recognize head, neck, and body as a functional entity [10, 1]. Normal
overall function depends on a complicated interplay of sensory and motor
functions involving a large number of muscle groups that must achieve a
proper balance. The goal of the therapy, therefore, is to secure that balance.
The hyoid bone is directly connected to the skull, to the mandible, and to the
shoulder girdle by minor muscle chains, and indirectly to the pelvis through
the large muscles (Fig.7, 9). This is why the hyoid bone always has to adjust
to the body posture.
Fig. 7. The orofacial regulation therapy is based not only on muscle exercises but
also on an improvement of the entire sensory-motor reflex arc involved in normal
deglutition, and on the knowledge that the function of face and oropharynx at deglu-
tition is closely interrelated with the entire body posture as well with appropriate
The second hypothesis
The second hypothesis by Castillo Morales is that different oral devices
(such as a palatal plate used in study I, or an oral screen as in study IV) and
orofacial regulation have an impact on swallowing dysfunctions based on the
sensory-motor reflex arc, which is activated by sensory stimulation through
the afferent path returning back as an impulse in the efferent motor path.
Five cranial nerves in the mouth are involved in that reflex arc - the second
pattern way of motion.
Function of the palatal plate and the oral screen
The palatal plate (Fig.12) and the oral screen (Fig.13) are designed to stimu-
late oral tactile receptors (passively) and oral motor function (actively and
passively), thus enabling a negative intraoral pressure, motility of the tongue,
and initiation of the swallowing reflex. The prerequisites for a negative in-
traoral pressure are good lip closure, good activity of the buccinator muscles,
and the closure of nasopharynx, which are achieved by the sensory-motor
reflex arc. The plate can also elicit a constant search of the tongue for unfa-
miliar intraoral objects. Furthermore, the plate improves the contact between
tongue and palatum, raises the tip of the tongue, helps the tongue to contract
upwards and backwards, activates m. levator anguli oris, m. zygomaticus
minor and major, and m. buccinator, thus indirectly facilitating swallowing.
[10, 48].
Body regulation
Body regulation (Fig.8, A-G) was restricted to the shoulder-neck-head re-
gion. It aimed at achieving optimal head control, and equilibrium of the in-
frahyoidal (n XII hypoglossus) and suprahyoidal muscles (n VII facialis, n V
trigeminus, n XII hypoglossus) (Fig.9), ín order to facilitate swallowing.
Body regulation included seven procedures (A-G); each procedure was per-
formed three times in 15 minutes. The therapist sat behind the patient who
was resting in supine position with a pillow under the knees. The patient’s
muscles were stretched under pressure and vibration, and then quickly re-
leased to evoke contraction. A muscle with low tonus demands short inter-
mittent vibration. A muscle with high tonus demands long vibration under
firm pressure. The same applies to orofacial regulation therapy. For a de-
tailed description, see the method section in Study I.
Fig. 8. Seven procedures (A-G) on body regulation therapy
Fig. 9. Body regulation is aimed to achieve optimal head control, equilibrium of the
infrahyoidal (n XII hypoglossus) and suprahyoidal muscles (n VII facialis, n V
trigeminus, n XII hypoglossus), and to stimulate the swallowing reflex.
Orofacial regulation therapy
Orofacial regulation therapy included 14 different procedures that are sum-
marized in Figs. 10 and 11. For a detailed description, see the method sec-
tion in Study I.
Fig. 10. Fig. 11.
Palatal Plate
The palatal plate (Fig.12 ) was inserted 2–3 times daily for 10–30 minutes
before eating (Study I). The main plate, made of thin acrylic material with
spring retention elements, covers the entire palatal region. Four vestibular
small acrylic plates (“bumpers”) with knobs in stainless steel act as stimula-
tors for the upper lip and the buccinator mechanism [69]. For stimulation of
the tip of the tongue, a mobile cube of stainless steel is attached to a dentoal-
veolar arch placed behind the incisors and in line with the canine teeth. For
tongue base stimulation, a velum arch provided with three small pointed
convexities in the middle and to the sides was placed close to the A-line that
is the border between the soft and hard palate. Three of the stroke patients
had full dentures and received a duplicate of their upper denture fitted with
the same type of stimulators. The patients were also encouraged to actively
exercise a) upper lip, b) tip of the tongue, c) tongue base, and d) the cheek,
making at least three movements against each stimulator each time.
Fig. 12. Palatal plate. Note the knobs on the small stimulating plates (“bumpers”)
and the sharp convexities on the velum arch for sensory stimulation. The patient can
place the mobile cube in the middle, left or right side of the dentoalveolar arch.
Oral screen training
Patients in Study IV were instructed to train with the oral screen (Fig.13) at
home three times daily before eating. Each exercise session consisted of
horizontal, gradually increasing pulling manoeuvres three times, for 5-10
seconds or until the patient lost the grip of the oral screen (Fig.14). For
training, the patient pulled the loop and tried to withhold the screen with the
If possible, the training was to be performed with the patient sitting in
a chair, the body and head in a strictly upright position, with support for the
feet, and the knees flexed at right angles. When the patient was unable to
hold the oral screen, relatives or ward staff were instructed to assist with the
traction. The training period was set to at least 5 weeks.
Fig. 13. An oral screen consists of a predental shield with a loop.
Fig.14. (a) The buccinator mechanism involving m. orbicularis oris, m. bucccinator,
m. constrictor pharyngeus superior (CPS) at rest, and (b) during activity with an oral
screen placed predentally. CR (m. cricopharyngeus) = upper esophageal sphincter.
a) b)
Breathing – Velopharyngeal Closure Training (VCT)
The patient was instructed to train the capability for increasing the intraoral
pressure by performing three expirations against a water pressure of 5-10 cm
H2O, three times a day before meals. The patient was instructed to sit upright
with the upper end of a tube (one centimetre in diameter) inserted in the
mouth and the other end of the tube resting on the bottom of the water glass
without pressure. The patient had to blow bubbles as evenly as possible and
for as long as possible each time.
Study 1
The average of each variable, for each patient, period and judge, has been
divided into quintiles. Agreement between each judge and quintiles was
assessed with the kappa coefficient. The kappa coefficient is in the range 0-1
and can be interpreted as follows: 0.00-0.20, slight agreement; 0.21-0.40,
fair agreement; 0.41-0.60, moderate agreement; 0.61-0.80, substantial
agreement; 0.81-1.00, almost perfect agreement [Study I ref.8].
Study II
Intra-investigator and inter-investigator reliability were assessed using intra-
class correlation (ICC) and the Bland–Altman plotting method [Study II
ref.12]. An ICC value of 1.0 indicates complete agreement. Examination of
the literature on interpretation of ICC values revealed that there are no
“hard-and-fast” rules for inferring acceptable reliability. In general, a value
of 0.70 or above suggests good reliability. Estimates of intra-investigator and
inter-investigator ICC were derived in the framework of a one-way random
effect model and a two-way random effect model, respectively. The lower
limit (LL) of one-sided 95% confidence intervals (CI) was estimated using
the method described by Fleiss [Study II ref.13]. The analysis of the inter-
investigator reliability was based on the first measurement made by observer
M.H. Student’s t-test was used to assess the difference in lip force between
stroke subjects and controls. Each test was based on the mean of three
LF100 measurements. All calculations of intra-reliability and inter-reliability
were performed for the stroke group and control group separately. A Re-
ceiver Operating Characteristics (ROC) curve was used to determine the
optimal cut-off value needed to classify the subjects as healthy subjects or
stroke patients with oropharyngeal dysphagia . The ROC curve was based on
the mean of three LF100 measurements.
A p-level of < 0.05 was deemed significant. All statistical analyses
were performed using SAS. 9.1software (SAS Institute Inc., Cary, NC,
Study III
Professional statisticians and a data manager from Uppsala Clinical Research
Centre (UCR) were involved from the outset in planning the study design.
The Good Clinical Practice (GCP) database consolidated all study data and
all analyses, which were performed according to the initial protocol. Stu-
dent’s t-test was used to assess the difference in LF between stroke patients
and controls. Multiple linear regression analyses and Pearson‘s correlation
coefficient was used to assess the relationship between LF, SC, and age. A
p-level of < 0.05 was deemed significant. All statistical analyses were per-
formed using SAS. 9.1 software (SAS Institute Inc., Cary, NC, USA).
Study IV
Professional statisticians and a data manager from Uppsala Clinical Research
Centre (UCR) were involved from the outset in planning the study design, to
consolidate all study date collected and for all analyses, which were per-
formed. The Wilcoxon signed rank test for paired observations was used to
asses the treatment effect on lip force and swallowing capacity. Spearman’s
rank-order correlation was used to assess the relationship between LF, SC,
interval between stroke attack and start of treatment, age and sex in stroke
with and without facial palsy. Differences between subgroups in SC and LF
were evaluated with the Mann-Whitney U-test. Median values = M in the
Tables. A p-value <0.05 was regarded as significant.
Ethical considerations
Studies I - IV were approved by the Ethical Committee for Human Research
at the Medical Faculty of Uppsala University, Sweden: study I (Ups 97340);
study II, III, IV (Dnr 2004: M-435). All the patients gave written consent to
participate in the studies.
Study 1
“Effects of Motor and Sensory Stimulation in Stroke Patients with Long-
lasting Dysphagia”
Orofacial regulation therapy, developed by Castillo Morales [10],
comprises body regulation and orofacial regulation in combination with a
palatal plate application; it has shown promising results in stroke patients.
This therapy is based not only on muscle exercises, but on an improvement
of the entire sensory-motor reflex arc involved in normal deglutition, and on
the knowledge that the deglutition function of the face and oropharynx is
closely related to the entire body posture and appropriate breathing. The
treatment concept is relatively unknown to caretakers, partly owing to a lack
of scientific evaluation of treatment results.
Therefore, the aim of this study was to assess the effect of motor and
sensory stimulation in stroke patients with dysphagia that had persisted for
more than six months.
Seven stroke patients participated in the study. Despite conventional therapy
comprising sitting and head position recommendations, adapted diet, and
instructions in good oral hygiene, these seven patients had suffered dys-
phagia for a median period of 1.5 years. The patients were evaluated with
respect to orofacial and pharyngeal motility and sensory function, both be-
fore and two weeks after a five-week treatment period. Patients were treated
once a week at the Speech and Swallowing Centre, and by a physiotherapist .
All subjects were instructed to train at home three times daily before each
meal; this training program consisted of facial stimulation (buccinator
mechanism, the lips, and the oral floor) manually or with an electrical
toothbrush, use of the palatal plate, and VCT.
The evaluation comprised a swallowing capacity test, a meal observa-
tion test, clinical examination of oral motor and sensory function, a velo-
pharyngeal closure test, and videofluoroscopy. In addition, patients evalu-
ated and assigned scores to their dysphagia symptoms.
Swallowing capacity (SC) improved in six patients, with a mean increase of
59%; the mean SC was 5.1 ml/s (range 0.6-14.4) before treatment, and 9.5
ml/s (range 1.7-18.9) after treatment. In the meal observation tests, all pa-
tients improved with a mean severity score of 2.5 before treatment and 0.7
after treatment. The most pronounced improvement was seen with respect to
drooling, coughing during meals, oral preparation time, and meal duration
time. All seven patients improved their orofacial motility, where the most
pronounced improvements occurred with respect to the facial, lip, and
tongue muscles; the mean severity score in this case improved from 1.8 to
0.7. Kappa coefficients were conducted on all reliability data, both inter- and
intra-rate reliabilities.
Sensory and motor stimulation seems to be a promising therapy in stroke
patients with long-lasting and persistent oropharyngeal dysphagia.
Study 2
“Reliable lip force measurement in healthy controls and in patients with
stroke. A methodological study”
A prefabricated oral screen has shown promising results as a muscle
self-training device to improve lip function of stroke patients affected by
oropharyngeal dysphagia. However, a technique for effective measurement
of lip muscle force, whether in healthy individuals or in stroke patients, is
lacking. The present study was designed to (i) test the intra-reliability and
inter-reliability of lip force measurements by means of a newly devised Lip
Force Meter LF100 (LF100), (ii) determine a normal lower limit of lip force
in Newtons (N), and (iii) ascertain the instrument’s sensitivity and specific-
ity. LF100 is a modified strain gauge for recording the ability of the lips to
withstand pressure from a predentally placed oral screen.
Forty-two healthy controls and 22 stroke patients consented to participate in
the study (Table 1). Among the stroke patients, 12 suffered from unilateral
central facial palsy, 6 on the right side of the face and 6 on the left side. The
healthy controls had a swallowing capacity (SC) greater than 10 ml/sec, and
the stroke patients had a pathological SC below 10 ml/sec. All subjects in the
two study groups were examined three times using the LF100, twice by in-
vestigator MH, and once by investigator MO; patients were allowed a two-
minute rest in between each test.
Characteristics Controls
(n = 22)
Stroke with
facial palsy
Stroke without
facial palsy
Age (yrs), median
77 (38-90)
Female/ Male 15/27 13/9 7/5 6/4
LF (N), mean ± SD 24.7 ± 6.3 9.5 ± 5.5 8.3±4.0 11.0±6.9
Table 1. Demographic features and mean lip force of healthy controls and stroke
The intra-investigator reliability with the LF100 was excellent for both con-
trols and stroke patients: ICC 0.83 and 0.90 respectively (Table 2, Figs. 15a,
b). Inter-investigator reliability was good or excellent in controls and stroke
patients: ICC 0.71 and 0.91 respectively (Table 2, Figs. 16a, b).The control
group had a significantly stronger lip force than the stroke group (Table
1).The difference between the means of the groups was 15.2 N (p < 0.001).
Lip force (LF) in 12 stroke patients with facial palsy did not differ signifi-
cantly from the patients without facial palsy (Table 1).The median age of the
control persons was lower than of the stroke patients, but the investigators
found no significant correlation between age and lip force. If a lower limit
for normal LF is set to 15 N, the sensitivity of the lip force test will be 91%,
and the specificity 95%.
Table. 2. Intra-investigator and inter-investigator reliability (ICC and 95% Lower
Limit (LL)) of lip force measurements (LFM), M=mean, in newton (N).
Intra-investigator Inter-investigator
ICC(95% LL) 0.83 (0.73) 0.90 (0.81) 0.71 (0.55) 0.91 (0.82)
M LFM (N) 24.3 9.2 24.8 9.8
a) b)
Fig. 15. Lip Force measurement in Newtons (N) made by investigator MH and MO,
with a line of equality. a) Healthy controls (x = n=42), b) Stroke patients (0 = n=22).
The symbol  represents 2 patients with the same result
a) b)
Fig. 16. Inter-observer reliability plots against their average. Difference between
LFM made by investigators MH and MO. a) Healthy controls (x = n=42), b) Stroke
patients (0 = n=22). The symbol  represents two patients with the same result.
The Lip force Meter LF100 (LF100) makes it possible to obtain reliable lip
force measurements. Lip force is significantly higher in control persons than
in stroke patients.
Study 3
“Correlation between lip force and swallowing capacity in stroke patients
and in healthy controls”
It has been found that impaired lip muscle function (Study I) can be
present in stroke patients with dysphagia. Central facial palsy is also a com-
mon feature, and it is conceivable that facial palsy will affect lip occlusion
and swallowing capacity (SC). Lip force (LF) and SC can be quantified
(Study II), but the extent to which they are functionally related and inde-
pendent of a facial palsy is poorly understood. The present study was de-
signed to investigate (i) the functional relationship between LF and SC in
acute stroke patients both with and without facial palsy, and in healthy con-
trols, and (ii) whether a correlation exists between LF or SC and age.
A prospective blind study was performed in 22 stroke patients with impaired
SC and in 45 healthy controls (Table 3). Initial unilateral facial palsy was
present in 12 of the stroke patients, 6 on the right side of the face and 6 on
the left (Table 3). All subjects were investigated using a Lip Force Meter,
LF100 (LF100) for recording the ability of lips to withstand pressure from a
predentally placed, preformed acrylic oral screen (Fig.13), and a swallowing
capacity test (SCT).
Characteristics Stroke
(n = 22)
(n = 45)
facial palsy
(n =10)
with initial
facial palsy
(n =12)
Age (yrs), median
77 (38-90)
57 (25-87)
Female/ Male 13/9 30/15 6/4 7/5
LF (N), mean ± SD 9.5 ± 5.5 24.4 ± 6.2 11.0±6.9 8.3±4.0
SC (ml/s), mean ± SD 2.7 ± 2.2 22.5 ± 8.4 2.7±2.5 2.7±2.0
Table. 3. Demographic features, lip force (LF), and swallowing capacity (SC) in
stroke patients (without and with facial palsy) and in controls. N = Newtons
The stroke group showed significantly lower LF values than the control
group (Table 3). The difference between the means of the groups was 14.8 N
(p< 0.001). There were significant differences in SC between stroke patients
and controls (Table 3).The correlation coefficient between LF and SC was
0.53 for the stroke patients, and 0.16 for controls (Figs. 17a, b). LF was not
age-related (Figs.18a,b). There was no significant correlation between SC
and age in stroke patients (Fig. 19a), whereas in the controls there was a
significant correlation (p<.0001; Fig. 19b).
Regression analysis showed that 73% of the variation in SC is attrib-
utable to LF and age. There were no significant differences in either LF or
SC between stroke patients without and with facial palsy (Table 3).
a) b)
Fig.17. Swallowing capacity (SC) vs. Lip force (LF) (a) in stroke patients= O (n =
22) and (b) in controls= X (n = 45).  = 2 O or 2 X.
SC(m l/s)
LF(N )
0 5 10 15 20 25 30 35 40
LF(N )
0 5 10 15 20 25 30 35 40
a) b)
Fig.18. Lip force (LF) vs. age (a) in stroke patients= O (n = 22), and (b) in con-
trols=X (n = 45).  = 2 X.
a) b)
Fig.19. Swallowing capacity (SC) vs. age (a) in stroke patients= O (n = 22), (b) in
controls=X (n = 45). = 2 X
LF(N )
20 30 40 50 60 7 0 80 90 100
LF(N )
20 30 40 50 60 7 0 80 90 100
20 30 40 50 60 70 80 90 100
20 30 40 50 60 70 80 90 100
In patients with stroke, impaired LF and impaired SC are parallel phenom-
ena. Both LF and SC are significantly weaker in stroke patients than in con-
trols. Stroke patients with impaired SC can suffer sub-clinical facial paresis
without ordinary signs of unilateral facial palsy.
Study 4
“Lip muscle training in stroke patients with dysphagia”
A close relationship has been found between lip force (LF) and swal-
lowing capacity (SC) in stroke patients, regardless of whether these patients
are affected by a central facial palsy (Study III). Just how training of lip
function can improve swallowing capacity is not known. Therefore, our aim
was to evaluate (i) whether training with an oral screen could improve LF
and SC, and to establish if the improvement in LF and SC is independent of
(ii) the presence or absence of central facial palsy, (iii) the time interval be-
tween the onset of a stroke and the initiation of treatment, (iv) age, and (v)
A retrospective study was performed on 30 stroke patients with oropharyn-
geal dysphagia and a swallowing capacity lower than 10 ml/s. An initial
unilateral central facial paresis was present in 24 of the patients. All patients
had their stroke attack on average one month (range 2 days – 10 yrs) and all
had been given conventional therapy and guidance for their dysphagia, com-
prising swallowing instructions, adapted diet, oral hygiene instructions, ex-
ercises involving exhalation against water pressure through a tube, sitting
and head position recommendations. The lip training was performed with an
oral screen 3 times per session and 3 times daily for least 5-8 weeks.
The median LF was 7 Newtons (N) before treatment and 18.5 N after treat-
ment, (p<0.001). The median SC was 0 ml/s before treatment, and 12.1 ml/s
at follow-up, (p<0.001). There was no significant difference in improvement
of LF and SC between patients with an initial unilateral facial paresis (n=24;
Table 4; Figs. 20a, 21a) vis-à-vis without facial paresis (n=6; Table 4; Figs.
20a, 21a). The SC was normalized in 19 patients (57%), and 8 out of 13 pa-
tients had their start of lip training on average 2 years after their stroke attack
(Table 5). The interval between stroke attack and start of treatment, ranging
from a few days up to 10 years, had no significant influence on the treatment
results (Figs.20b, 21b); nor did age (Figs 20c, 21c) or sex. The facial paresis
was improved or at least ameliorated in all patients after the lip training pe-
riod. We found also that there was a significant correlation between mean
body control and the Postural Assessment Scale for Stroke patients (PASS);
for the stroke patient before treatment (r = -0.80, p = 0.001; Table 6, Fig.
22a) and after treatment (r = -0.86, p = 0.000; Table 6, Fig 22b).
Facial palsy LF (B)
MV (range)
LF (A)
MV (range)
SC (B)
MV (range)
SC (A)
MV (range)
Yes (n=24)
5.5 (0 – 27) N
17.5 (7-44) N
0 (0 – 9.1) ml/s
12.0 (0 – 36.7) ml/s
No (n=6) 8.5 (5-13) N 20 (16 – 24) N 0 (0 – 7.1) ml/s 13.4 (9.8 – 15) ml/s
B= before treatment, A= after treatment, MV= median value, N= Newton
Table. 4. Lip force (LF) and swallowing capacity (SC) of stroke patients with and
without central facial palsy, (n=24), (n=6)
Initial LF
MV (range)
LF after treatm.
MV (range)
Initial SC
MV range)
SC after treatm.
MV (range)
10 yrs (49) 2 29 5.3 36.7
8 yrs (63) 18 29 9.1 18.8
5 yrs (71) 2 23 5.6 13.3
4 yrs (68) 7 24 0 13.2
2 yrs (82) 10 23 0 10.5
2 yrs (84) 8 14 4.8 9.3
2 yrs (79) 10 16 0 5.2
6 mths (66) 18 36 7.9 13.3
6 mths (88) 1 17 3.0 8.5
4 mths (77) 6 17 0 9.5
3 mths (81) 0 15 3.1 9.8
2 mths (50) 1 17 0 14.8
2 mths (66) 8 16 0 10.7
Mean values 7 N 21 N 3.0 ml/s 13.4 ml/s
Table.5. Lip force (LF) and swallowing capacity (SC) of stroke patients (n=13/30)
before and after treatment with the longest interval between stroke attack and start of
treatment (duration)
Fig.20a. Lip Force (LF) of stroke patients (a) vs. absence (—)/presence (- - -) of
central facial paresis before, and after treatment.
Fig.20b. Lip force (LF) of stroke patients vs. the interval between stroke attack and
start of treatment. Absence (—)/presence (- - -) of central facial paresis.
Fig.20c. Lip force (LF) of stroke patients vs. age of stroke patients. Absence (—
)/presence (- - -) of central facial paresis.
Fig.21a. Swallowing capacity (SC) of stroke patients vs. absence (—)/presence (- - -
) of central facial Paresis before, and after treatment.
Fig.21b.Swallowing capacity (SC) of stroke patients vs. the interval between stroke
attack and start of treatment. Absence (—)/presence (- - -) of central facial paresis.
Fig.21c. Swallowing capacity (SC) vs. age of stroke patients. Absence (—)/presence
(- - -) of central facial paresis.
Body control
PASS (0-36)
Spearman Correlation Coefficient = r p-value
n= pat
Body control B r = -0.80 p = 0.001 13
Body control A r = -0.86 p = 0.000 13
B= before treatment, A= after treatment
Table 6. Spearman correlation coefficient (r) between mean body control (0-4), and
PASS (0-36) of the stroke patients.
a) b)
Fig.22. PASS vs. mean body control in stroke patients (a) before treatment and (b)
after treatment.
Training with an oral screen can improve lip force and swallowing capacity
in stroke patients with oropharyngeal dysphagia, irrespective of presence or
absence of a central facial paresis, or of pre-treatment duration of dysphagia,
or of age, or sex. It is more likely that the treatment results are more attrib-
utable to sensory motor stimulation and the plasticity of the central nervous
system, than to the training of the lip muscles per se.
Dysphagia following stroke has been found to be spontaneously relieved within 2-3 weeks after the
incident [50, 21, 49, 68, 8, and 7], due partly to regression of the inflammatory reaction around the
infarction area [80, 24,26 and 86], and partly to functional reorganization in the intact motor cortex
[22]. In the last decade, increased understanding of the brain´s plasticity has opened up new possibili-
ties for post-stroke rehabilitation [80]. In Studies I and IV the results of the therapeutic procedures
reflected the reorganization capacity and plasticity of the cortex, partly a result of increased pharyn-
geal activity in the unaffected hemisphere [23, 22], and also slosely dependent upon the frequency,
intensity, and duration of the sensory stimulus applied [19, 76 and 28].
The complexity of the oropharyngeal function involving six motor cranial nerves and three sen-
sory nerves, raises questions as to which sensorimotor pathways are of the greatest importance for
deglutition. In Study III, many stroke patients with dysphagia showed a complete loss of swallowing
capacity (0 ml/min). This could be due to a sensory dropout of the glossopharyngeal branch supplying-
the anterior faucal arcs from where the swallowing reflex for water is elicited. Another cause could be
hypoglossal nerve paresis with the consequence that the tongue is unable to propel the bolus back-
ward. Therefore the tongue training seems be the most appropriate muscle to activate. This is consis-
tent with Study I, where a palatal plate was used. It also accord with a study by Robbins et al,2007
[73], where lingual exercise increased its strength, with associated improvement in swallowing pres-
sure in both acute cases and chronic dysphagic stroke patients. In Study IV, an oral screen was used
for training of the entire Buccinator mechanism. The screen also stimulates the sensory input from the
intra-oral membranes and enhances the capacity for negative intra-oral pressure that requires good lip
closure and good activity in m. buccinator and velum, motility of the tongue, and the swallowing re-
flex, in the same way as does the palatal plate. Even if the oral screen training effect was recorded as
an increased lip force (Study IV), the improvement in swallowing capacity in Studies I and IV can
only be explained by brain plasticity and central reorganisation engendered by this complex sensory
motor activity triggered by a palatal plate or by LF training.
Paresis of the lower branch of the facial nerve will affect lip closure and the activity of the pos-
terior part of the digastric muscle. Defective lip closure with leakage and drooling cannot alone make
swallowing impossible. Nor does the digastric muscle seem to be of crucial importance for deglutition
It is well known in clinical praxis that when a medial cleft branch cyst is surgically removed, the mid
part of the hyoid bone is excised a couple of centimetres without any attempt to adjust the lateral bone
ends. The digastric muscles as well as the mylohyoid-, geniohyoid-, stylohyoid-, and the infrahyoidal
muscles are attached to the hyoid bone. Even if patients have some dysphagia for a couple of weeks,
the removal of part of the hyoid bone is thought to be free from complications [62]. Apparently there
are many other muscle groups that will compensate for any functional drop-out of the muscles at-
tached to the hyoid bone.
An interesting finding in Study III was that stroke patients with dysphagia-but without clinical
facial palsy- had a weak lip force. Yildiz et al, 2005 [86], claimed that facial paresis in stroke patients
generally is incomplete and mild because of ipsilateral cortical and multiple innervations out of the
infarction area, and recovery is rapid, thanks to cortical reorganization [86]. Perhaps there is a form of
subclinical facial paresis in stroke patients with dysphagia that weakens lip force without the usual-
signs of unilateral facial paresis. However, a pathological level of lip force and impaired swallowing
capacity are parallel phenomena in which the facial nerve is involved (Study III). Apparently oro-
pharyngeal dysphagia can be present even if the facial nerve function is intact
Swallowing and its neurophysiology are difficult to study. The swallowing capacity test (SCT)
used in Studies I, III, and IV, has been assessed to have a high validity and intra- and inter-reliability
[61, 39]. Lip force measurement (LFM) is a method in Study II that was shown to have excellent intra-
, and inter-reliability. LFM was therefore found suitable for studying the effect of lip force training in
stroke patients with longstanding oropharyngeal dysphagia in Study IV. Other investigatory methods,
such as meal observation test [4, 5], orofacial muscle function test [30], and videofluoroscopy investi-
gation [29, 45 and 72] used in Study I are, however, not quantifiable to the same extent.
When talking about compensatory procedures, are often alluded to peripheral mechanisms [48].
These include swallowing and breathing techniques, postural techniques, adapted diet, and intraoral
prosthetics. These techniques can facilitate deglutition but do not necessarily change the pathophysiol-
ogy [48]. Another therapeutic way is the active training of a muscle. In this thesis the main therapeutic
emphasis has utilized brain plasticity and been directed towards cortical reorganization, which is a
central compensatory mechanism, by means of sensorimotor stimulation.
x Orofacial sensorimotor stimulation seems to be a promising therapy and an excellent example of
cerebral plasticity and cortical reorganisation in stroke patients with long-lasting and persistent oro-
pharyngeal dysphagia.
x The LF100 is an appropriate and reliable instrument for measuring lip force (LF) and therefore can
be used for evaluation of LF training.
x A normal lower limit of LF is assessed to 15 N.
x With regard to LF, the sensitivity and specificity of the LF100 method are excellent.
x The swallowing capacity (SC) and LF in stroke patients are parallel and concomitant phenomena,
making the LF100 a suitable screening instrument for impaired SC in stroke patients.
x LF is not age-related in controls or in stroke patients.
x Training with an oral screen can improve LF and SC in stroke patients with oropharyngeal dys-
phagia irrespective of the following:
x the presence or absence of a central facial paresis
x the pre-treatment duration of dysphagia
x age, or sex
x Most stroke patients with facial palsy do not differ from those without facial palsy regarding SC
and LF. A subclinical facial paresis seems to be present in most stroke patients.
x Different therapeutic methods can be separately evaluated; especially oral screen training, manual
regulation therapy, and conventional therapy and to verify the results with EMG and PET.
x Study if the therapeutic effect with palatal plate or oral screen application will remain one year or
longer after a course of therapy.
”Hjärnans sensorimotoriska plasticitet hos stroke patienter med sväljsvårigheter. Undersökn-
ings - och behandlingsmetoder - en metodologisk studie”
Avhandlingen utfördes i syfte att öka kunskapen om hur behandling av sväljsvårigheter kan förbättras
och att validera/testa säkerheten i instrument för undersökning och utvärdering av behandlingsinsatser
på strokepatienter med orofaryngeal dysfagi.
(I) Effekter av motorisk och sensorisk stimulering vid långvarig dysfagi efter stroke. Publi-
cerad i Dysphagia november 2004.
Målet var att utvärdera effekten av sensomotorisk stimulering på nedsatt muskelfunktion i ansikte,
munhåla och svalg samt på sväljsvårigheter (dysfagi) efter stroke. Sju strokepatienter med dysfagi
sedan i medeltal 1,5 år förbättrades efter sensorisk och motorisk stimulering under en 5 veckors be-
handlingsperiod, vilken innefattade manuell terapi av kropp, ansikte och munhåla i kombination med
en gomplatta. De mest framträdande resultaten erhölls med ett sväljkapacitetstest och ett måltidsob-
serva-tionstest. Resultaten visade på både objektiv och självupplevd förbättring av sväljkapaciteten
(SC) hos alla sju patienter. Orofacial sensomotorisk stimulering är en lovande behandling och ett ut-
märkt exempel på hjärnans plasticitet och kortikala reorganisation i stroke-patienter med länge kvar-
stående orofaryngeal dysfagi.
(II) Säker mätning av läppkraft i kontrollgrupp och på patienter efter stroke. En metodologisk
studie. Accepterad och under publicering i Dysphagia, 2007.
I studien, inkluderande en kontrollgrupp med 42 friska individer och 22 strokepatienter med dysfagi,
bedömdes intra- och interreliabiliteten, sensitiviteten (91%) och specificiteten (95%) hos en
läppkraftsmätare, LF100. Kontrollgruppen hade en signifikant starkare läppkraft, mätt i newton, N
(medelvärde 24,7 N ± 6,3) jämfört med strokepatienterna (medelvärde 9,5 N ± 5,5). Reliabiliteten var
utmärkt. En normal undre gräns för läppkraft beräknades till 15 N. LF100 är ett lämpligt/pålitligt in-
strument med hög sensitivitet och specificitet för mätning av läppkraft och kan följaktligen användas
för utvärdering av läppkraftsträning.
(III) Korrelation mellan läppkraft och sväljkapacitet i stroke-, och kontrollgrupp. Insänd till
Dysphagia, 2007.
Vi ville undersöka om det finns ett funktionellt samband mellan läppkraft (LF) och sväljkapacitet
(SC). Till studien inkluderades 22 nyinsjuknade strokepatienter, 12 med facialis pares och 10 utan,
samt 45 friska individer utan subjektiva sväljsvårigheter (inkluderar delvis samma pat.material som i
studie II). I stroke gruppen visade sig en försämrad LF och SC vara till största delen parallella
fenomen och skiljde sig inte åt oavsett närvaron eller frånvaron av facialis pares. LF och SC var signi-
fikant högre i kontrollgruppen och dessutom var SC signifikant korrelerat till ålder. I stroke gruppen
däremot kunde de låga SC nivåerna inte enbart förklaras av åldern. Då SC/LF i stroke gruppen är i
stort sett åtföljande fenomen innebär detta att läppkraftsmätaren, LF100 är ett lämpligt screeningsin-
strument vid nedsatt SC.
(IV) Träning av läppkraft vid dysfagi efter stroke. Accepterad och under publicering i Acta Oto-
laryngologica, 2007.
Efter daglig egenträning, 5-8 v, av läppmuskeln med en munskärm normaliserade 19 av 30 strokepa-
tienter sin SC; ett index på 10 ml/sek anger den undre normala gränsen. Åtta av 13 patienter med
långvarig dysfagi påbörjade sin läppträning i genomsnitt 2 år efter sin stroke. LF och SC förbättrades
signifikant och ingen signifikant påverkan noterades av vare sig närvaron eller frånvaron av central
facialis pares eller av tidsintervallet mellan stroken och behandlingsstarten eller av ålder eller kön.
Träning med en munskärm kan förbättra både LF och SC hos strokepatienter med orofaryngeal
dysfagi. En subklinisk facialis pares verkar finnas närvarande hos de flesta strokepatienter.
Läppkraftsmätaren är ett instrument som ger säkra mätningar av läppkraft. Förbättrad sväljfunktion
genom manuell kropps-, och orofacial sensorisk och motorisk stimulering i kombination med gom-
platta eller träning med en munskärm är utmärkta exempel på hjärnans plasticitet och reorganisatoriska
This thesis project was performed at the Department of Oto-Rhino-Laryngology, Head and Neck Sur-
gery at Uppsala University Hospital, Uppsala in cooperation with the Centre for Research & Devel-
opment, Uppsala University/Gävleborg County Council. I am greatly indebted to all who, in many
different ways, helped me to complete this work. I would like to express my sincere gratitude to all of
them. My special thanks to:
Matti Anniko, my supervisor, for introducing me to the field of research and, giving me the opportu-
nity to conduct scientific work; for administrative, financial and academic support, for constructive
advice, for always seeing options, and for a positive attitude during the process.
Ulla Friberg, my supervisor, for your helpfulness, kind and supportive encouragement, for construc-
tive comments and for giving me expert advice.
Lita Tibbling Grahn, for putting me on the right track; for your commitment, never-ending patience,
excellent scientific guidance, constructive criticism with a sensitive ear for my views, and for being a
source of inspiration and knowledge. Thanks for all the encouraging and interesting discussions.
Tom Ekstrand, in memory, for believing in me and for introducing me to the field of research.
Reidunn Wettermark, Head of the ENT Department, Hudiksvall, for encouragement and support both
in my work with this thesis and in management of the Speech & Swallowing Centre.
Viveca Tunek, for translating the book “Die Orofaziale Regulationstherapie” by Castillo Morales to
Swedish, for always inspiring and helping me in my research, for both practical and moral support,
and for being such a good friend.
Lisa Wernroth, Patrik Holmqvist and Lars Berglund, at UCR for excellent statistical work and for
interesting and constructive discussions.
Karin Edebol EEG Olofsson, at Dept of Clinical Neurofysiology, for interesting, stimulating and con-
structive talks about my work, and for all your support.
Bengt Larsson, Margaretha Olgarsson and Matti Anniko, my co-authors, for fruitful and stimulating
discussions during planning, data collection, analysis and reading.
Margaretha Olgarsson, Rakel Sjödin, Eva Munther, and Agnetha Pettersson, and my fellow workers
who managed our clinic with excellence while I was working on my thesis. Margaretha Olgarsson for
commitment to the task during development and layout of the evaluation documents at Speech &
Swallowing Centre, Hudiksvall. I am very thankful for all your hard work.
Inga-Britt Gill, and Eva Jeppson-Eldrot, thank you for being the right persons who came to me at the
right time, for all work, and for all support during the development of Speech & Swallowing Centre.
Karl-Axel Wannerskog, AnnetteWestberg, Madeleine Wertzenen, Lotta Sjögreen, thank you for invalu-
able support and skilful help during the development of the Lip Force Meter, LF100.
Göran Åkerlund, Forsa Folkhögskola, for help since the start of our activities with technical aspects
and editing of videotape sequences.
Lucas Böök, Max Brandt and Peggy Ocarsson (Letrix), for invaluable help with correction of my the-
Reimond Dempwolf and Håkan Gustafsson for image editing.
All kind and helpful staff members at the Stroke Unit at the Department of Medicine through Dr. Mir-
jam Nahum, Dr. P-O Wiklund, Dr. Olov Häggblom, and Dr. Tahir Osman; Orthopedic Clinic through
department head Eva Risén, Department of Pediatric Habilitation through manager Kerstin Dahlgren
and Dr. Ragnar Sidenvall , Department of Educational Hearing Care through previous manager Kris-
tina Trolin, and the Department of Rehabilitation through manager Marie Bergsten.
Bitte Ahlborg at “Mun-H-Center”in Gothenburg, Bo Hedås at Hospital Dental Care in Säter, Gunilla
Nordenram at Karolinska Institutet, Institute of Odontology , for introducing me to the fields of oral
motor function/regulation and geriatric dental care, which gave me confidence to move on.
Olle Ekberg, and Margareta Bülow, Dept of Clinical Sciences/Medical Radiology
Malmö University Hospital for your generous contributions of knowledge and skills in radiology ex-
aminations with standardised bolus/analysis, and development of the radiology reporting form.
Håkan Larsson, Jens Holmboe, Kjell Glitterstam, Odd Lind, Karwan Sinjawi, Fabiola Köhler and all
the rest of the staff at the Dept of Otorhinolaryngology for support and being kind to me.
Ingrid Carlsson and Maria Karrberg, at the Dept of Speech and Language, and Eva Maria Widlund at
the Department of Radiology, for support and help whenever I needed it and for being kind and con-
siderate to me.
P-O and Elisabeth Östlund – thank you for everything! All thanks to you Sören Lejonclou for all the
ski competitions.
Anneli Persson at Department of Otorhinolaryngology, Uppsala, Elinor Falk-Bergström, her predeces-
sor Monica Winbäck, and the staff at the Library of Hudiksvall Hospital for assistance in finding
medical files and journals, always with great competence and kindness, and Ulla Markström, for ex-
cellent secretarial work.
My colleagues and friends in the “Oral Motor and Dysphagia Team”, in the “Länsdysfagigruppen”:
Gunnar Almgren, Margareta Gonzale Lindhz, IngeHillman, Magnus Hjelm, Barbro karelius, Ingrid
Larsson, Ruth Lechuga, Elisabeth Persson Calderon, and Helena Persson.
Bert-Owe Olofsson, Sylvia Jäderberg, Barbro Sandlund Hämen, Kerstin Widman, Gun-Irene Lång
and Christina Wiksten for your support and for being good friends and colleagues.
My neighbours Gerd Hermansson, Anni and Lars-Erik Berglöf, Lena and Stig-Owe Lindgren, Anna-
Lisa and Bosse Carlsson, Harry Hermansson and all the rest of my neighbours for being good
friends, and for helping me whenever I needed it.
The “Sewing Bee”; Marta Trolin, Agneta Berglund, Brita-Lena Hansdotter,Annika Eriksson, Maria
Svensson, Anna Söderlund, Anja Sandberg; The Tjejmilen 10K ladies Eva Färlin, and Lena Andreas-
son; ski competition ladies Grethel Lindroth and Ann-Britt Stridsman, all my dear friends, for all the
laughs, the long talks and long walks, and the delicious meals.
My parents Gerda and Kaarle Keränen, brother Ronny, and sisters Siv and Lena with their families:
thank you for all your encouragement and for always believing in me.
Hans, my beloved, for just being such a nice man, and my children Ylvali, Karin, Linn, and Eiliv, my
much loved family who bring me back to the real world, for all the things in life that really matter.
And to Hans’s adult children Oskar and Helene with her family for long-lasting friendship and sup-
This work was supported by grants from the Centre for Research & Development, Uppsala Univer-
sity/Gävleborg County Council, the Capio Research Foundation, Sweden, and from Uppsala Univer-
Professor Castillo Morales together with the author during the 18th Congress of IADH, International Association
for Disability and Oral Health, Gothenburg, Sweden, August 23-26, 2006.
I hereby want to express my sincere gratitude to Professor Castillo Morales and to Professor
Lita Tibbling Grahn, who have played the most important part for my comprehension and my knowl-
edge about dysphagia and that the function of face and oropharynx at deglutition is closely interrelated
with the entire body posture as well as with appropriate breathing. My special thanks to you. You
made this thesis possible!
Professor Lita Tibbling Grahn MD PhD
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74. Sasaki H, Sekizawa K, Yanai M, Arai H, Yamaya M, Ohrui T: New Strategies for Aspiration
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Hudiksvall Hospital
Ear-Nose-Throat Clinic
Speech&Swallowing Centre
Oralmotor investigation
Patient data
Date of event
Therapeutic authority
Place of attendance Hudiksvall, Bollnäs, Gävle
Referral sent by: Clinic/signature
Referral received by: Clinic/signature
diagnostic number
Social factors
Relations, need of assistance, participation,
social belonging, environmental factors
Housing environment
Leisure time
including field of vision, visual/auditive
perception, vestibular function, tinnitus,
Standby person(s)
Food: type, -intake; oral managing of food/
sucking/biting/chewing; breathing-problems;
pain; vomiting/nausea; duration of meal;
body temperature; appetite; bruxism;
drooling; eating in public places; deviant
facial expressions; vocal disorders
including environmental factors
Visual Analogue Scale (0-100)
Eating, drinking, swallowing, talking; pain;
other factors
Examination/treatment time
Activities of Daily Living (0-6)
Bodily care, dressing/undressing,
eliminations, continence/incontinence;
movability; food-intake
Communication, sight, hearing; meals
STATUS Score (0-4): 0 = normal function, 4 = loss of function
State of health
RLS 1-8
Degree of consciousness
Including psycho-/emotional
functions like motivation, impulse
control, attention, sleep, cognitive
skills, orientation to
time/place/person, memory,
fear/anxiety, resignation
Gross motor skills
Head control
Postural control, sitting position
Mobility, muscular function, - tonus,
- endurance, reflexes, postural reactions,
control of voluntary/non-voluntary reflexes,
Fine motor skills
Orofacial motor skills
Breathing, phonation, facial expression, lips,
jaws, tongue, velum, mouth opening wide,
chewing, lip force
Mirror test
Orofacial sensory function
Smelling, tasting, oral stereognosis, two-
point discrimination
Swallowing Capacity Test (SCT)
Normal index (10 ml/sec)
Meal observation
Intraoral examination
Mouth opening wide
Biting conditions
Hard palate
Parodontal status
Amount of saliva (0-4)
Drooling (0-4)
Scale(0-4), 0= normal function, 4= loss of function.
1. Gross motor
2. Orofacial:
motor skills
sensory skills
biting deviation
biting dysfunction
oral hygiene
Step 1, 2 etc.
A. Body therapy
B. Orofacial regulation therapy
C. Breathing exercises
D. Oral screen training
E. Active exercising
F. Palatal plate
G. Other odontological procedures
H. Referrals to other therapists
Summary of the results of the investigations
given to the patient/family
Procedures carried out during the
Preliminary result of referral
Referral to other therapists
Next visit
Name ………………………………………… Birth registration number………………….……
Orofacial function score
GROSS MOTOR SKILLS (0-36 or 0-6)
0 = total loss of function, 36 and 6 respectively = normal function
PASS Postural Assessment Scale
for Stroke Patients (0-36)
LSS Level of sitting scale (0-6)
Head control (0-4)
0 = normal function, 4 = total loss of function
Lateral flexion
X (=X/6)
Body posture – sitting (0-4)
Head control
Body control
Pelvic control
Foot control
X (=X/4)
Against a water pressure of 120
mm. Duration in seconds.
PEF (Peak Expiratory Flow)
Phonation (0-4)
X (=X/2)
Facial expression (0-4)
Eyes: shutting/closing tightly
Eyes: opening wide
Brows: puckering up
Nose: wrinkling
X (=X/8)
Lips (0-4) Right Left
Cheeks: blowing up
Cheeks: sucking in
”u” ”i”
X (=X/11)
Jaw (0-4)
Mouth: opening
Mouth: closing, clenching one’s
Jaw: protruding
Jaw: moving sideways right to left,
left to right
X (=X/5)
Chewing force (0-4)
Lip force (N)
Tongue (0-4)
Putting it out
Licking on the right and left corners
of the mouth
Point of the tongue: moving from
side to side
Point of the tongue: moving
Point of the tongue: moving
Dorsum of the tongue: pulling
Licking around the lips
Licking around the rows of teeth
X (=X/9)
Velum (0-4) Right Left
Velum: moving
MIRROR TEST (0-1) 0 = normal, 1 = deviant)
”i dag är det tisdag”
Sense of smell (0-1)
Sense of taste(0-1)
Oral stereognosis(0-1) Tall fig. Small fig.
Two-point discrimination (0-1) Right Left
Point of the tongue
Cheek, upper part
Cheek, lower part
Upper lip
Lower lip
Lateral half of the tongue
Dorsum of the tongue
Palatoglossal arch
Gaping capacity (millimeter)
Biting conditions (0-1)
Open frontal bite
Open lateral bite
Right open bite (mm)
Left open bite (mm)
Proclination lower incisors
Proclination upper incisors
Retroclination lower incisors
Retroclination upper incisors
Neutral bite right/left
Prenormal bite right/left
Postnormal bite right/left
Deep bite with/without gingival
Scissors bite
Edge-to-edge bite
Crowding maxillar/mandibular
Teeth (0-4)
Abrasion (0-1)
Erosion (0-1)
Enamel mineralising (0-1)
Agenesis (0-1)
Palatal roof (0-1)
Normal palate
High, pointed/low, flat
Stepped palate right/left
Defined rugae
Anterior flat/broad wall
Cleft palate, total/partial
Tonsils right/left (0-1)
Tongue (0-1)
Surface structure
Parodontal status (0-3) Right Left
Gingivitis max/mand
Parodontitis max/mand
Supragingival calculus
Subgingival calculus
Saliva (0-4)
Dry mouth
Swallowing Capacity Test (10ml/s)
Duration of testing
Residual volume
Swallowing capacity (ml/sec)
Clinical signs of impaired
Cervical auscultation (0-1)
Laryngeal elevation (0-1)
Tal & Svälj Center
The Postural Scale for Stroke Patients (PASS) - score
Maintaining a Posture
1 Sitting without support.
2 Standing with support.
3 Standing without support.
4 Standing on non paretic leg.
5 Standing on paretic leg.
Changing Posture
6 Supine to affected side lateral.
7 Supine to non-affected side lateral.
8 Supine to sitting up on the edge of the table.
9 Sitting on the edge of the table to supine.
10 Sitting to standing up.
11 Standing up to sitting down.
12 Standing, picking up a pencil from the floor.
Benaim C, Pérennou DA, Villy J, Rousseaux M, Pelissier JY: ”Validation of a Standardized Assessment of Postural
Control in Stroke patients”; Stroke 1999; 30(9): 1862-1868
Hui-Fen Mao, I-Ping Hsueh, Pei-Fang Tang, Ching-Fan Sheu, Ching-Lin Hsieh: “Analysis and Comparison of the
Psychometric Properties of Three Balance Measures for Stroke Patients; Stroke 2002, 33(4): 1022-27
G:\TSC\Utvärderingsinstrument\PASS - score
Tal & Svälj Center Datum Sidnr
Hudiksvall 2007-11-09 1(2)
The Postural Scale for Stroke Patients (PASS) - manual
Items and Criteria for Scoring:
Maintaining a Posture
1 Sitting without support (sitting on the
edge of an 50-cm-high examination
table, a Bobath plane for instance,
with the feet touching the floor)
0= cannot sit
1= can sit with slight support, for ex by 1 hand
2= can sit for more than 10 sec without support
3= can sit for 5 min without support
2 Standing with support (feet position
free, no other constraints)
0= can not stand, even with support
1= can stand with strong support of 2 people
2= can stand with moderate support of 1 person
3= can stand with support of only 1 hand
3 Standing without support (feet posi-
tion free, no other constraints)
0= can not stand without support
1= can stand without support for 10 sec or leans
heavily on 1 leg
2= can stand without support for 1 min or stands
slightly asymmetrically
3= can stand without support for more than 1 min
and at the same time perform arm movements about
shoulder level
4 Standing on nonparetic leg (no other
0= can not stand on nonparetic leg
1= can stand on non paretic leg for a few sec
2= can stand on non paretic leg for more than 5 sec
3= can stand on non paretic leg for more than 10 sec
5 Standing on paretic leg (no other con-
0= can not stand on paretic leg
1= can stand on paretic leg for a few sec
2= can stand on paretic leg for more than 5 sec
3= can stand on paretic leg for more than 10 sec
Changing Posture
Items 6-11 are to be performed with a
50-cm-high examination table, like a
Bobath plane; items 10-12 are to be
performed without any support, no
other constraints.
6 Supine to affected side lateral. 0= can not perform the activity
1= can perform the activity with much help
2= can perform the activity with little help
3= can perform the activity without help
7 Supine to non-affected side lateral. 0= can not perform the activity
1= can perform the activity with much help
2= can perform the activity with little help
3= can perform the activity without help
8 Supine to sitting up on the edge of
the table.
0= can not perform the activity
1= can perform the activity with much help
2= can perform the activity with little help
3= can perform the activity without help
9 Sitting on the edge of the table to
0= can not perform the activity
1= can perform the activity with much help
2= can perform the activity with little help
3= can perform the activity without help
10 Sitting to standing up. 0= can not perform the activity
1= can perform the activity with much help
2= can perform the activity with little help
3= can perform the activity without help
11 Standing up to sitting down. 0= can not perform the activity
1= can perform the activity with much help
2= can perform the activity with little help
3= can perform the activity without help
12 Standing, picking up a pencil from
the floor.
0= can not perform the activity
1= can perform the activity with much help
2= can perform the activity with little help
3= can perform the activity without help
Benaim C, Pérennou DA, Villy J, Rousseaux M, Pelissier JY: ”Validation of a Standardized Assessment of Postural
Control in Stroke patients”; Stroke 1999; 30(9): 1862-1868
Hui-Fen Mao, I-Ping Hsueh, Pei-Fang Tang, Ching-Fan Sheu, Ching-Lin Hsieh: “Analysis and Comparison of the
Psychometric Properties of Three Balance Measures for Stroke Patients; Stroke 2002, 33(4): 1022-27
G:\TSC\Utvärderingsinstrument\PASS - manual
BMI / ADL / Meals / Blood Test
ENT Department
Speech & Swallowing Center, Hudiksvall Hospital
Social Security No.: …..………………….
Health care personnel (
)/pat. evaluation
Name: …………………………………….
Body mass index Acute 25days
4 3 months 6 months
BMI= weight (kg)
Pat height (cm):
Pat weight for each period:
ADL index
3 months
6 months
1. Independent i six activities (bathing,
dressing and undressing, toileting,
mobility, continence, eating)
2. Independent in five activities
3. Independent in four activities
4. Independent in three activities
5. Independent in two activities
6. Independent in one activity
7. Dependent in all six activities
8. Unable to evaluate
Meals for each period
3 months
6 months
1. Normal meals
2. Normal meals with restrictions,
minced/strained foods
3. Pureed foods
4. Gelatin foods
5. Viscous (thick liquid) foods
6. Feeding via nasogastric tube or via
7. Parenteral food administration
Blood Test
3 months
6 months
1. P-albumin (g/l)
Gävleborg County Council
Speech & Swallowing Center/ENT
Hudiksvall Hospital Test Meal
Social Security No.:
Stroke diagnosis/date:______________________________________________________
Meal served:
2 dl sour milk, one slice hard bread,
one glass fruit drink.
4 days
after stroke debut
After 5 weeks of
1.Does pat require more than 20 min to
consume meal?
Exact time for meal ……………
1= > 25 min
2= > 30 min
3= > 40 min
4= Complete inability to consume a meal
yes no
yes no
2. Does food/ beverage/saliva remain in
pats mouth more than 10 s before pat
can swallow?
1= Sometimes > 10 s
2= Often > 10 s
3= Always > 10 s with every mouthful
4= Complete inability to swallow
yes no
yes no
3. Is there leakage of food/saliva from
pats mouth?
1= Drools sometimes
2= Always drools with every mouthful
3= Frequent food leakage/drooling
4= Complete inability to keep food/saliva
in mouth
yes no
yes no
4. Does pat cough during/after eating and
1= Sometimes
2= Often
3= Always with every mouthful
yes no
yes no
Gävleborg County Council
Speech & Swallowing Center/ENT
Hudiksvall Hospital
Test Meal
Social Security No.:
4 days
after stroke debut
After 5 weeks of
5. Does pats voice become hoarse at
food/beverage intake?
1= Sometimes
2= Often
3= always for each mouthful
4= Inability to speak because of need to
cough/clear throat t1 min
yes no
yes no
6. Does pat have difficulty raising food to
mouth level?
1= Sometimes
2= Often
3= Always
(0-4= Ability to blow up the face cheeks?
Evaluation according to motor skills test in
measurement record).
yes no
yes no
7. Is pat conscious of remaining
food/beverage in mouth?
yes = 0 no = 4
yes = 0 no = 4
Enter total points in each column
Enter pats current level of care/placement
at time of evaluation
Speech & Swallowing Center,
Hudiksvall Hospital, 824 81 Hudiksvall. Tel: 0650-925 92 el 927 54
Speech and Swallowing Centre, ENT, Hudiksvall Hospital
Patients admitted to the Speech and Swallowing Centre are assessed according to the model
of oralmotor examination.
This manual is used as a scoring as well as a documentation instrument assessing the motor-,
sensory- and intraoral status including swallowing capacity and the outcome of the mirror test
performed by the patient during the visit.
Date To be noted on top of each page
Used in assessing postural control of stroke-patients (scores 0-36).
Manual and documentation of assessment, see Word LG.HH (G:): TSC-
gamla \Utvärderingsinstrument\PASS-score or PASS-manual
Used in assessing postural control, in sitting position, of children with
neuromotor deficits (scores 0-6).
Manual, see Word LG.HH (G:): TSC-
gamla\Utvärderingsinstrument\Level of sitting scale.
Estimation of gross motor and orofacial motor skills according to a score of 0-4:
0=normal, 1=slightly impaired, 2=moderately impaired,
3=seriously impaired, 4=loss of function.
Assessment of muscular strength, range of motion, coordination and speed.
Head control
The patient’s performance include flexion, extension, rotation and lateral
flexion, and each direction is assessed.
The total score is divided by six.
The functions of body, pelvis and feet in the patient’s natural sitting
posture are assessed and scored. The average score of head control (see
above) is included in the total score.
The total score is divided by four.
To be noted: Any preoral motor deficits.
Fine motor skills Describe any loss of function.
Breathing ¾ The patient is sitting upright on a chair at a table. In front of
him/her there is a pitcher with a lid, containing 120 mm of water.
Through the lid there is a tube of 10 mm in diameter. The patient
is asked to take a deep breath and then blow out the air through
the tube making bubbles for as long time as possible.
The examiner takes the time from the first till the last bubble.
¾ The patient, still in the same sitting posture, is asked to exhale
with maximum force and as fast as possible into the PEF-meter.
The best score out of three is noted.
To be noted: Any change of breathing pattern in passivity or activity as
well as observations of breathing during speech and breathing through
nose and/or mouth.
Phonation The patient is asked to cough and then to hawk vigorously.
To be noted: Any change of voice, like pitch (low, monotonous,
unstable), strength (high, low, monotonous, unstable), quality (pressed,
raucous, grating, creaky, leaking, tremulous, diplophonic, aphonic, or if
there is a register break).
The total score is divided by two.
Facial expression The patient is asked to:
- shut his/her eyes and close them tightly (m. orbicularis);
- make his/her eyes wide open (m. frontalis, and others);
- pucker up his/her brows (m. corrugator supercilii, m. procerus);
- wrinkle his/her nose (m. levator labii superioris alaeque nasi, and
Each facial half is assessed independently.
To be noted: Any facial asymmetry. Facial expressiveness or
The total score is divided by eight.
Lips The patient is asked to:
- make his/her lips pout (m. orbicularis oris);
- draw the corners of the mouth to a broad smile with the mouth
open/closed (m. risorius, m. zygomaticus minor/major, m. levator
anguli oris);
- make a distinct smacking sound;
- blow up the cheeks and press a finger against one cheek at a time;
- suck in the cheeks;
- repeat /u i/ as fast and rhythmically as possible;
- repeat /pa pa/ as fast and rhythmically as possible.
The total score is divided by eleven.
The patient is asked to:
- open his/her mouth (m. digastricus anterior, m. platysma);
- close his/her mouth and clench his/her teeth (m. temporalis, m.
masseter, m. pterygoideus medialis);
- make his/her jaw protrude and then pull it back into normal (mm.
pterygoideus lateralis sin./dx.)
- move his/her jaw to the right (m. pterygoideus lateralis sin.);
- move his/her jaw to the left (m. pterygoideus lateralis dx).
To be noted: Any deviation when opening the mouth wide/putting the
jaws together; any inhibited mobility; any snapping sound.
The total score is divided by five.
Chewing force The patient is asked to bite onto the breathing tube and not let go of it
when the examiner pulls it forward and outward.
Lip force The patient is sitting with his/her body and head in an upright position,
the feet are put firmly on the floor, the knees flexed in a right angle and
hands and underarms are resting on the thighs. An oral screen is put
between the patient’s teeth and lips and thereafter the screen is adapted to
the lip force meter. The patient is asked to press his/her lips together as
tight as possible around the screen, while the examiner keeps pulling the
handle of the lip force meter. The handle is pulled horizontally for 10
seconds with increasing force until maximum force is obtained, or until
the patient lets go of the screen.
The lipforce (in Newton) is measured three times and the best score is
The patient is asked to:
- put out his/her tongue (m. genioglossus);
- lick the right corner of his/her mouth (m. genioglossus sin.);
- lick the left corner of his/her mouth (m. genioglossus dx.);
- move the point of his/her tongue from side to side as fast and
rhythmically as possible;
- move the point of his/her tongue downwards (m. longitudinalis
- move the point of his/her tongue upwards (m. longitudinalis
- pull his/her tongue backwards/upwards (m. styloglossus);
- lick around his/her mouth;
- lick along the upper and lower rows of his/her teeth.
To be noted: Any sign of atrophia, any fasciculations, involuntary
movements and/or impaired coordination.
Velum The patient is asked to say ”a” with his/her mouth open. The activity in
the soft palate is inspected by the examiner.
To be noted: Any signs of asymmetry, fasciculations, tremor.
MIRROR-TEST The patient, sitting upright, is asked to say a long ”s”, a long “i” and
“idag är det tisdag” (to be repeated). During this sequence the examiner
is putting a laryngeal mirror under the patient’s right and left nostril
To be noted: Leakage if any (then the mirror will be misted over).
0=normal, mirror not misted, 1=deviant, misted mirror.
Smell The patient is asked if there is any change in the smelling functions.
0=no change, 1=change, deviation.
Taste The patient is asked if there is any change in the tasting functions.
0=no change, 1=change, deviation.
The patient is sitting in an upright position in a chair with a paper
showing five different shapes. The examiner has got eight metal objects
(of two different sizes: 20 mm and 10 mm) corresponding four of the
depicted shapes (star, ring, half circle, triangle). The examiner puts one
object at a time on the tongue of the patient. The patient is asked to move
the tongue and press the object against the palate in order to identify the
object’s shape as represented on the paper. The bigger sized objects (20
mm) are to be used before the smaller ones (10 mm) in the test..
0=correct answer, 1=wrong answer.
The patient is sitting in an upright position on a chair. The examiner is
using a pair of compasses whose two legs are put on the skin of the
patient with an even pressure. The distance between the points of the
compasses varies (see below):
- the upper part of the cheek (15 mm, right/left);
- the lower part of the cheek (15 mm, right/left);
- the upper lip (5 mm, right/left);
- the lower lip (5mm, right/left);
- the lateral part of the tongue (3mm, right/left);
- the dorsal part of the tongue (3 mm, right/left);
- the tip of the tongue (3 mm);
- palatoglossal arch (3 mm, right/left).
The patient is asked to tell if he/she can feel one or two points.
0=normal, 1=deviant.
Mouth opening
To be measured in millimeters.
To be assessed by a dentist:
- open bite, frontal/lateral;
- over bite, horisontal/vertical;
- proclined incisors, upper/lower;
- retroclined incisors, upper/lower;
- neutral, pre-/postnormal bite;
- deep bite with/without gingival contact;
- crossbite, scissors bite;
- edge-to-edge bite.
0=normal, 1=deviant.
To be noted: Bruxism, uncontrolled bite reflex.
To be assessed:
0=own teeth;
1=own teeth and bridge (upper/lower) or prosthesis (upper/lower);
2=prostheses, upper and lower;
3=ill-fitting bridge or prosthesis;
4=few teeth/no teeth and no bridge or prosthesis.
To be noted: Any sign of abrasion, erosion, enamel mineralization or
0=normal, 1=deviant.
Hard palate To be assessed:
- narrow/wide;
- high and pointed/low and flat;
- stepped palate, right/left;
- defined rugae;
- anterior flat/broad wall;
- cleft palate, total/partial.
0=normal, 1=deviant.
Tonsils To be assessed:
0=normal, 1=deviant.
Tongue To be assessed: any deviation regarding size, shape, surface structure,
coating, frenulum, diastasis, impressions.
0=normal, 1=deviant.
To be assessed: Any sign of gingivitis, parodontitis, supragingival
calculus, subgingival calculus.
0=no finding, 1=mild, 2=moderate, 3=grave.
To be noted: Any redness, mucosal change, pain, hyperplasia, gingival
Saliva To be assessed: Any sign of dry mouth or drooling.
0=no finding, 1=mild, 2=moderate, 3=much, 4=very much.
The patient is sitting on a chair in an upright position. A pulse oximeter
is put on his/her index finger. He/she gets a glass containing 150 ml
water, lifts it up so that the brim of the glass is resting against the lower
lip. At a given signal the patient is to start drinking all of the water if
possible and as fast as possible. The patient is told to discontinue if this
feels difficult. The examiner takes the time from start on until the last
swallowing, when larynx is lowered into resting position. A cervical
auscultation is carried out.
To be assessed:
- time (sec.);
- residual volume if any (ml);
- swallowing capacity (ml/sec.);
- cervical auscultation (0=normal, 1=deviant);
- larynx elevation (0=normal, 1=deviant);
- saturation before/after 2 minutes (%).
To be noted: Any clinical signs of swallowing problems, changed voice,
coughing, hawking or leaking through the nose.
To be assessed: normal meal and/or specific testing meal according to
Karin Axelsson 2003-01-28.
Note: Extra observations are to be listed within each section of the Orofacial Assessment
Hudiksvall Hospital
Social Security No.:
Diagnosis/severity: ________________________________________________________________________
At examination:
Position – standing or sitting
Bolus presentation with cup (possible HDB with spoon)
LDB = Low-density barium contrast
HDB = High-density barium contrast
ANALYSIS of SWALLOWING FUNCTION on a scale (0-3); see above.
Date (Yr-Mo-Day)
Barium contrast LDB HDB LDB HDB
Oral phase 1st exam. Follow-up Comments
Lip closure
Bolus control
Leakage over base of
Tongue sweep
Asymmetrical tongue
Reduced right / left
Oral retention
Elevation of velum
Penetration to epipharynx
Oropharyngeal phase 1st exam. Follow-up Comments
Vocal cord function
Symmetrical / Reduced right / left
Larynx elevation
Epiglottis movement
Oropharyngeal contraction
Symmetrical / Reduced right / left
Opening of pes
Retention in vallecula
Retention in pyriform
Symmetrical / Reduced right / left
Wrong way swallowing Before / During / After swallowing
Wrong way swallowing,
how often?
Seldom / Often / Regularly
Cough with aspiration
Simultaneously / Afterward
Normal Dysfunction
0 1 2 3
Social Security No.:
Date: Comments
Esophageal phase 1st exam. Follow-up
Reduced motility
Morphological change
Impression of osteophytes
Zenker’s diverticulum
Esophageal ring
Hiatus hernia
Bengt Larsson Mary Hägg
Radiologist Dentist
Radiology Clinic Speech & Swallowing Ctr, ENT,
Hudiksvall Hospital Hudiksvall Hospital
Normal Dysfunction
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Acta Universitatis Upsaliensis
Digital Comprehensive Summaries of Uppsala Dissertations
from the Faculty of Medicine 299
Editor: The Dean of the Faculty of Medicine
A doctoral dissertation from the Faculty of Medicine, Uppsala
University, is usually a summary of a number of papers. A few
copies of the complete dissertation are kept at major Swedish
research libraries, while the summary alone is distributed
internationally through the series Digital Comprehensive
Summaries of Uppsala Dissertations from the Faculty of
Medicine. (Prior to January, 2005, the series was published
under the title “Comprehensive Summaries of Uppsala
Dissertations from the Faculty of Medicine”.)
... A causa mais comum de disfagia e aspiração é o AVC, podendo ocorrer em cerca de um terço dos doentes (Marques, André e Rosso, 2008), sendo mais evidente nos primeiros dias após o AVC, independentemente do hemisfério afetado (Ropper e Brown, 2005). Contudo, a incidência temporal dos sintomas varia, dependendo do início da avaliação pós-AVC e do meio de diagnóstico utilizado (Hägg, 2007). A literatura sugere que a incidência de disfagia pode variar entre 22% e 65%, variando conforme os métodos de avaliação utilizados, e pode persistir durante muitos meses ou ressurgir no contexto de comorbilidades futuras (Ramsey, Smithard e Kalra, 2003). ...
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In Portugal, stroke is considered the leading cause of death and disability associated with cognitive and motor sequelae. The incidence of dysphagia ranges from 22% to 65% of patients (Ramsey, Smithard and Kalra, 2003). Several studies reveal that 30 to 40% of institutionalized elderly people have swallowing disorders, which results in a high incidence of complications due to aspiration (World Gastroenterology Organization, 2004). Based on these assumptions, a systematic review was performed to minimize the risk of ad hoc evaluation and by identifying the available low cost and easy access resources in order to enhance health gains. The methodology was guided by Cochrane Handbook and was designed to answer the following question: “What methods of non-invasive evaluation of dysphagia in people with neurological disease with demonstrated validity and reliability are published?” Therefore we conducted a search for primary studies, published since 2005, in the most relevant computerized databases. From that search, we identified two studies with the results of the application of two distinct scales used in the diagnosis of dysphagia in stroke survivors (in acute and / or rehabilitation), one of which also assessed the risk of aspiration. The results may predict high gains in health with the application of these scales, although further studies are needed to obtain a substantial sample.
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There is no evaluation of the evidence for the screening of oropharyngeal dysphagia in stroke. We reviewed the literature on clinical screening for oropharyngeal dysphagia in adults with stroke to determine (a) the accuracy of different screening tests used to detect dysphagia defined by abnormal oropharyngeal physiology on videofluoroscopy and (b) the health outcomes reported and whether screening alters those outcomes. Peer-reviewed English-language and human studies were sought through Medline (from 1966 to July 1997) by using the key words cerebrovascular disorders and deglutition disorders, relevant Internet addresses, and extensive hand searching of bibliographies of identified articles. Of the 154 sources identified, 89 articles were original, peer-reviewed, and focused on oropharyngeal dysphagia in stroke patients. To evaluate the evidence, the next selection identified 10 articles on the comparison of screening and videofluoroscopic findings and three articles on screening and health outcomes. Evidence was rated according to the level of study design by using the values of the Canadian Task Force on Periodic Health Examination. From the identified screening tests, most of the screenings were related to laryngeal signs (63%) and most of the outcomes were related to physiology (74%). Evidence for screening accuracy was limited because of poor study design and the predominant use of aspiration as the diagnostic reference. Only two screening tests were identified as accurate: failure on the 50-ml water test (likelihood ratio = 5.7, 95% confidence interval = 2.5–12.9) and impaired pharyngeal sensation (likelihood ratio = 2.5, 95% confidence interval = 1.7–3.7). Limited evidence for screening benefit suggested a reduction in pneumonia, length of hospital stay, personnel costs, and patient charges. In conclusion, screening accuracy needs to be assessed by using both abnormal physiology and aspiration as diagnostic markers for dysphagia. Large well-designed trials are needed for more conclusive evidence of screening benefit.
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Aspiration pneumonia is a major cause of morbidity and mortality among the elderly who are hospitalized or in nursing homes. Multiple risk factors for pneumonia have been identified, but no study has effectively compared the relative risk of factors in several different categories, including dysphagia. In this prospective outcomes study, 189 elderly subjects were recruited from the outpatient clinics, inpatient acute care wards, and the nursing home care center at the VA Medical Center in Ann Arbor, Michigan. They were given a variety of assessments to determine oropharyngeal and esophageal swallowing and feeding status, functional status, medical status, and oral/dental status. The subjects were followed for up to 4 years for an outcome of verified aspiration pneumonia. Bivariate analyses identified several factors as significantly associated with pneumonia. Logistic regression analyses then identified the significant predictors of aspiration pneumonia. The best predictors, in one or more groups of subjects, were dependent for feeding, dependent for oral care, number of decayed teeth, tube feeding, more than one medical diagnosis, number of medications, and smoking. The role that each of the significant predictors might play was described in relation to the pathogenesis of aspiration pneumonia. Dysphagia was concluded to be an important risk for aspiration pneumonia, but generally not sufficient to cause pneumonia unless other risk factors are present as well. A dependency upon others for feeding emerged as the dominant risk factor, with an odds ratio of 19.98 in a logistic regression model that excluded tube-fed patients.
Although the cerebral cortex has been implicated in the control of swallowing, the functional organization of the human cortical swallowing representation has not been fully documented. Therefore, the present study determined the cortical representation of swallowing in fourteen healthy right-handed female subjects using single-event-related functional magnetic resonance imaging (fMRI). Subjects were scanned during three swallowing activation tasks: a naive saliva swallow, a voluntary saliva swallow, and a water bolus swallow. Swallow-related laryngeal movement was recorded simultaneously from the output of a bellows positioned over the thyroid cartilage. Statistical maps were generated by computing the difference between the magnitude of the voxel time course during 1) a single swallowing trial and 2) the corresponding control period. Automatic and volitional swallowing produced activation within several common cortical regions, the most prominent and consistent being located within the lateral precentral gyrus, lateral postcentral gyrus, and right insula. Activation foci within the superior temporal gyrus, middle and inferior frontal gyri, and frontal operculum also were identified for all swallowing tasks. In contrast, activation of the caudal anterior cingulate cortex was significantly more likely in association with the voluntary saliva swallow and water bolus swallow than the naive swallow. These findings support the view that, in addition to known brain stem areas, human swallowing is represented within a number of spatially and functionally distinct cortical loci which may participate differentially in the regulation of swallowing. Activation of the insula was significantly lateralized to the right hemisphere for the voluntary saliva swallow, suggesting a functional hemispheric dominance of the insula for the processing of swallowing.
The data collected in the laboratories over a number of years gives an opportunity to suggest that systemogenesis is a real regulator of the development of the brain structures and functions. The development goes on all the time selectively and is accelerated in accordance with the earliest needed adaptation to the outside surroundings by the newborn animal. It is seen that the well-timed consolidation of the vitally needed functional systems of the organism is continuously monitored by the systemic initial arrangement, the growth, and consolidation of the components of the functional system. It is also seen that this heterochronic maturation of different components of the functional system takes place everywhere, including the finest organizations on the level of molecular combinations and in the processes of the selective and successive maturation of individual synaptic organizations, in particular, on the cortical level. It is true that the systemogenetic type of the maturation and the growth is the most marked for those functional systems of the organism, which must be mature exactly at the moment of birth. They are evidently inborn, the preparation for their consolidation is preformed, and in fact, in the process of the ontogenesis, they correspond demonstrably to the ecological factors of that species of animal. The combination of the components of later and finer organized functional systems on the basis of which different behavioral acts are formed is less easily demonstrated. In that case, maturation and formation of new synaptic organizations of the brain in the presence of the completely mature peripheral working apparatus begin to play a leading role.