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Utility of a Clinical Swallowing Exam for Understanding Swallowing Physiology

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Anand Balaji Rangarathnam at Midwestern University
Anand Balaji Rangarathnam
Gary H Mccullough at Appalachian State University
Gary H Mccullough
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Abstract

A clinical swallowing examination (CSE) is generally believed to be inadequate for making judgments regarding swallowing physiology compared to objective assessments. A large volume of studies has heavily focused on identifying aspiration using a CSE and research addressing physiologic information gathered from a CSE is sparse. The purpose of this study was to examine the utility of the CSE for assessing physiology compared to videofluoroscopic swallowing studies (VFSS). Data were derived from a prior investigation of sixty adult patients post-stroke tested with CSE and VFSS. The CSE included an examination of historical measures, oral motor/speech/voice, and trial swallows. The VFSS consisted of swallows of controlled portions of thin, thick, puree, and solid boluses. Previous results from these patients demonstrated significant accuracy in making binary estimates of aspiration and the presence of dysphagia. This analysis of data focused on physiologic measures, as well as overall dysphagia severity and diet recommendations. Significant associations between CSE and VFSS ratings were observed for hyolaryngeal elevation, overall swallowing severity, and diet recommendations. These findings were specific for certain bolus consistencies. These data suggest that the CSE may not provide significant physiological information other than hyolaryngeal excursion. This does not preclude the fact that the CSE is important in providing substantial information about overall dysphagia severity. It appears that the CSE is more powerful than simply a “screening” tool. More prospective research designs are warranted to substantiate the strengths of the CSE.
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ORIGINAL ARTICLE
Utility of a Clinical Swallowing Exam for Understanding
Swallowing Physiology
Balaji Rangarathnam
1
•Gary H. McCullough
2
Received: 10 February 2016 / Accepted: 3 March 2016 / Published online: 12 March 2016
Springer Science+Business Media New York 2016
Abstract A clinical swallowing examination (CSE) is
generally believed to be inadequate for making judgments
regarding swallowing physiology compared to objective
assessments. A large volume of studies has heavily focused
on identifying aspiration using a CSE and research
addressing physiologic information gathered from a CSE is
sparse. The purpose of this study was to examine the utility
of the CSE for assessing physiology compared to vide-
ofluoroscopic swallowing studies (VFSS). Data were
derived from a prior investigation of sixty adult patients
post-stroke tested with CSE and VFSS. The CSE included
an examination of historical measures, oral motor/speech/
voice, and trial swallows. The VFSS consisted of swallows
of controlled portions of thin, thick, puree, and solid
boluses. Previous results from these patients demonstrated
significant accuracy in making binary estimates of aspira-
tion and the presence of dysphagia. This analysis of data
focused on physiologic measures, as well as overall dys-
phagia severity and diet recommendations. Significant
associations between CSE and VFSS ratings were observed
for hyolaryngeal elevation, overall swallowing severity,
and diet recommendations. These findings were specific for
certain bolus consistencies. These data suggest that the
CSE may not provide significant physiological information
other than hyolaryngeal excursion. This does not preclude
the fact that the CSE is important in providing substantial
information about overall dysphagia severity. It appears
that the CSE is more powerful than simply a ‘‘screening’’
tool. More prospective research designs are warranted to
substantiate the strengths of the CSE.
Keywords Deglutition Deglutition disorders Clinical
Examination Physiology
Background
A clinical bedside swallow examination (CSE) is a non-
instrumental assessment that serves many purposes. It
provides critical historical medical information not typi-
cally gathered in the process of conducting instrumental
examinations. It examines cognitive abilities and cranial
nerve function in the context of a physical examination. It
provides our first look at a patient’s functional abilities that
support the process of feeding and swallowing. It also
allows us to assess swallowing in a natural context to
determine the need for, as well as type of, instrumental
examination. Depending on setting, hospital versus nursing
home or rehab, and availability of equipment, it may also
be used to attempt compensatory strategies and define a
treatment plan, though evidence suggests this may not be
optimal [1,2].
In essence, the clinical examination of swallowing is the
equivalent of a first office visit to any specialist. No matter
what field of medicine one considers—neurology, gas-
troenterology, urology, etc.—the first visit with a patient
employs a ‘‘clinical examination.’’ Instrumental evaluations
&Balaji Rangarathnam
rangarathnamb@ecu.edu
Gary H. McCullough
mcculloughgh@appstate.edu
1
Department of Communication Sciences and Disorders, East
Carolina University, 600 Moye Blvd., Mailstop 668,
Greenville, NC 27834, USA
2
Beaver College of Health Sciences, Appalachian State
University, ASU Box 32102, Boone, NC 28608, USA
123
Dysphagia (2016) 31:491–497
DOI 10.1007/s00455-016-9702-1
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... The evaluation of dysphagia in the general (non-laryngectomy) population commonly begins with a clinical assessment undertaken by the speech pathologist. The standard clinical swallow examination (CSE) is a fundamental component of dysphagia assessment used across patient populations [16][17][18]. The overall purpose of this process is to identify key swallow symptoms, most significantly, external indicators of potential airway invasion (e.g., voice change, throat clearing post swallow) and difficulties with bolus clearance (e.g., multiple swallows, sensation of pharyngeal residue). ...
... Hence participants agreed screening of CNXII function was essential to identify potential nerve injury and its impact on swallowing function. The consensus items also included tasks and observations common to the standard CSE (e.g., oral cavity review, food and fluid trials) [16,18] and laryngectomyspecific swallow symptoms. For example, early consensus was reached on items such as "observe for pressure/effort/ struggle on swallow" and "observe for evidence of backflow via oral/nasal cavities", both of which infer potential anatomical complications and/or physiological breakdowns confirmed in the laryngectomy literature [5,11,12]. ...
Clinical Swallow Examination Following Laryngectomy: An International e-Delphi Consensus Process
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Full-text available
  • Jan 2025
  • Dysphagia
Clinical swallow examination (CSE) following laryngectomy (± pharyngeal resection) remains a critical step in dysphagia evaluation. Whilst the core components of a standard CSE service a broad spectrum of patient populations, no evidence exists examining the essential assessment items specific to CSE in the laryngectomy population. The aim of this study was to identify the tasks, measures and observations considered necessary to include in a CSE post laryngectomy. Using an e-Delphi approach, a 4-round online survey series was undertaken with 34 speech pathologists experienced in laryngectomy swallowing management from 6 countries. In the first round (item generation) participants were provided with the questions from the swallowing outcomes after laryngectomy (SOAL) as stimulus, to generate a list of tasks, measures and observations as well as clarifying questions they would ask the patient during a CSE. In the subsequent e-Delphi rounds the participants rated the importance of the compiled assessment items. A total of 34 items were rated of critical importance for inclusion in a laryngectomy CSE by ≥ 75% of participants. Two thirds of the consensus items (23 items) were patient history and interview questions incorporating medical and swallowing history (4 items) and patient interview (19 items). The remaining 11 items related to swallow tasks and observations (9 items) and onward referral (2 items). These 34 consensus items can be considered as a draft framework for laryngectomy CSE to guide clinical practice and research.
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... 13 Research suggests that a CSE does not provide sufficient information for treatment planning. 14,15 Two imaging procedures used to assess swallowing are the modified barium swallow study (MBSS) and flexible endoscopic evaluation of swallowing (FEES). The MBSS uses fluoroscopy to examine the swallow, whereas FEES employs an endoscope. ...
... The information gathered from a CSE is insufficient to develop a treatment plan. 14,52 The result is unnecessary or inappropriate treatment, which increases costs and may facilitate malnutrition and dehydration, increase hospital recidivism, and decrease quality of life. 46,53 By continuing to treat dysphagia with altered solid textures and thickened liquidsdwhich have their own health risks that may be more problematic than untreated dysphagiadthe data in the current study suggest that SNF SLPs relying on acute care assessments and recommendations may place patients at risk of iatrogenic harm. ...
Dysphagia and Diets in Skilled Nursing Facilities When Patient's Health Status Changes: The Role of Imaging
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  • Dec 2023
  • J AM MED DIR ASSOC
Purpose: The modification of diet textures and liquid viscosity represents the primary form of management of oropharyngeal dysphagia (OD) by speech-language pathologists (SLPs). Despite the ubiquitous use of modified texture diets (MTDs) to prevent aspiration in an attempt to prevent pneumonia, there is no convincing evidence that consumption of MTDs protects individuals with dysphagia from developing pneumonia. Furthermore, informed consent is required for the prescription of MTDs. To date, no study has investigated if practicing SLPs know the risks associated with MTDs, consider the risks when making clinical decisions, and disclose those risks to their patients. Method: Thirteen negative health outcomes associated with MTDs were identified in the research literature. A web-based survey was created and distributed. Participants were asked to identify known risks associated with MTDs, how often they considered the risks associated with MTDs before recommending them, and how often they informed patients with OD of the known risks associated with MTDs. Results: Only 6.3% of the SLPs surveyed identified all thirteen listed health risks associated with MTDs, and greater than one in five respondents (n = 55; 21.7%) were unable to select even one known risk. Seventy percent (n = 140) of participants indicated that they “almost always” weigh the risks associated with drinking thickened liquids, and fifty-four percent of respondents (n = 108) specified that they “almost always” weigh the risks associated with consuming modified texture solids. Less than half of the participants (n = 99; 49.7%) stated that they “almost always” inform the patient of the risks associated with thickened liquids and 39.9% (n = 79) indicated that they “almost always” inform patients of the risks associated with altered texture solids. Conclusions: Participants demonstrated poor overall knowledge of the hazards associated with MTDs, limited consideration of known risks of MTDs, and suboptimal levels of disclosure of the risks associated with MTDs to patients with OD.
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... Hyolaryngeal movement, as the only externally detectable movement during swallowing, is also regarded as important in the point that providing feedback to both dysphagia patients and clinicians. Attempts have been made to capture hyolaryngeal movements with surface electromyography (sEMG) or reflective photosensors for feedback (Bogaardt et al., 2009;Furuta et al., 2012;Sato et al., 2012;Athukorala et al., 2014;Azola et al., 2015;Rangarathnam and McCullough, 2016;Azola et al., 2017). These techniques have often been used to help patients acquire a swallow in which they can voluntarily adjust the range and/or duration of hyoid and larynx movement (Huckabee and Cannito, 1999;Carnaby-Mann et al., 2010;McCullough et al., 2012;McCullough and Kim, 2013). ...
... The simplicity of simply placing the device on the front neck is almost as easy as four-finger palpation, widely used in clinical dysphagia evaluation. However, intra-and inter-rater reliability issues have been reported for the assessment of laryngeal elevation by palpation (McCullough et al., 2000;Rangarathnam and McCullough, 2016). A previous study reported that patients showing obvious signs of aspiration or penetration were more likely to be evaluated as having less hyolaryngeal elevation, suggesting that the clinician's impression of hyolaryngeal movement was affected by the patient's signs of dysphagia (Brates et al., 2020). ...
Development and validation of a device for monitoring laryngeal motion during swallowing
Article
Full-text available
  • Nov 2023
Objectives: Hyolaryngeal movement during swallowing is essential to airway protection and bolus clearance. Although palpation is widely used to evaluate hyolaryngeal motion, insufficient accuracy has been reported. The Bando Stretchable Strain Sensor for Swallowing (B4S™) was developed to capture hyolaryngeal elevation and display it as waveforms. This study compared laryngeal movement time detected by the B4S™ with laryngeal movement time measured by videofluoroscopy (VF). Methods: Participants were 20 patients without swallowing difficulty (10 men, 10 women; age 30.6 ± 7.1 years). The B4S™ was attached to the anterior neck and two saliva swallows were measured on VF images to determine the relative and absolute reliability of laryngeal elevation time measured on VF and that measured by the B4S™. Results: The intra-class correlation coefficient of the VF and B4S™ times was very high [ICC (1.1) = 0.980]. A Bland–Altman plot showed a strong positive correlation with a 95% confidence interval of 0.00–3.01 for the mean VF time and mean B4S™ time, with a fixed error detected in the positive direction but with no proportional error detected. Thus, the VF and B4S™ time measurements showed high consistency. Conclusion: The strong relative and absolute reliability suggest that the B4S™ can accurately detect the duration of superior-inferior laryngeal motion during swallowing. Further study is needed to develop a method for measuring the distance of laryngeal elevation. It is also necessary to investigate the usefulness of this device for evaluation and treatment in clinical settings.
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... Still, since it has a specificity of just 30%, no reliable conclusions can be drawn about the presence of a disturbance in the swallowing act. A comparative study between CSE and VFSS showed that the use of CSE could only assess laryngeal elevation while failing to assess other parameters of swallowing physiology, such as oral transit, swallowing reflex latency, and total duration of swallowing (34) . ...
Consensus on the Screening, Assessment, and Nutritional Management of Dysphagia
Article
Full-text available
  • Dec 2024
Dysphagia, characterized by impaired swallowing function, presents a substantial healthcare burden globally, affecting various populations and conditions. The present article aims to present a comprehensive clinical consensus on dysphagia diagnosis, assessment, and management, derived from an expert group comprising diverse healthcare professionals in India. Through systematic literature reviews and consensus development methodologies adhering to international standards, evidence-based recommendations were formulated to address key aspects of dysphagia care. Recommendations encompass screening protocols, diagnostic modalities, nutritional assessments, and therapeutic interventions, including exercises and feeding strategies. The consensus underscores the importance of early detection and tailored interventions, particularly in high-risk populations such as stroke patients. By integrating contemporary evidence and expert insights, this consensus offers a structured framework to enhance dysphagia care standards, with the overarching goal of improving patient outcomes and reducing associated morbidity and mortality. This comprehensive guideline is a valuable resource for healthcare practitioners involved in managing dysphagia, facilitating optimized patient care and improved quality of life. Keywords: Dysphagia, Texture-modified, Commercial thickeners, Aspiration, Swallowing
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... Despite its widespread use in everyday clinical practice, due to its simplicity and practicality, caution should be exercised when making decisions based on digital palpation, as concerns have been raised regarding its sensitivity, objectivity, and replicability (Brates et al., 2019;McCullough et al., 2000;Rangarathnam & McCullough, 2016;Smithard et al., 1998). In this context, there is a need to increase the objectivity of procedures performed by speech-language therapy teams, for which the use of objective evaluation techniques is recommended. ...
Ultrasonic evaluation of the thyrohyoid approximation percentage as support for clinical swallowing assessment in decannulation of a tracheostomized patient: A case report [Evaluación ecográfica del porcentaje de aproximación tirohioidea como apoyo a la evaluación clínica de la deglución en la decanulación de una persona con traqueostomía: Un reporte de caso]
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ABSTRACT Decannulation is crucial in the rehabilitation of tracheostomized patients, and its success depends on an interdisciplinary and rigorous assessment of airway patency, respiratory parameters, and secretion swallowing safety. However, clinical evaluation of swallowing, while essential, remains a subjective procedure that is highly dependent on the clinician's experience. This case report explores the usefulness of ultrasound as a complementary tool that can enhance the objectivity of clinical evaluation. We present the case of a man with a tracheostomy and prolonged mechanical ventilation. After meeting the respiratory criteria for decannulation, the clinical evaluation of swallowing suggested a possible restriction in hyolaryngeal mobility. To objectively quantify this disturbance, ultrasound was employed, and the findings were later confirmed through an endoscopic swallowing evaluation. The results revealed that ultrasound enabled the objective measurement of hyolaryngeal excursion, identifying an impairment in its movement. This was quantified by calculating the percentage of change in the approximation between the thyroid cartilage and the hyoid bone compared to their resting positions. In conclusion, ultrasound appears to be a promising tool to complement the clinical evaluation of swallowing in individuals with a tracheostomy, allowing for objective measurement of hyolaryngeal function, particularly when conventional instrumental evaluations (videofluoroscopy or endoscopy) are not feasible. Clinicians are encouraged to share their experiences with the use of ultrasound to enhance knowledge in this and other clinical contexts.
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... Assessing swallowing physiology using multiple bolus consistencies is a core component of a clinical swallow examination [1]. It is based on the evidence pool that swallowing physiology is different for solid and liquid consistencies [2]. ...
Assessing Swallowing and Mastication Using the Swallowing Proficiency for Eating and Drinking Protocol Among Healthy Adults
Article
Full-text available
  • Mar 2024
Background: Objective evaluation of swallowing using single bolus consistency are popular among Speech-Language Pathologists (SLPs) but has limited generalization to other bolus consistencies. The Swallowing Proficiency for Eating and Drinking (SPEAD) test assesses the oral and pharyngeal phases of swallowing using three different consistencies. Objectives. The aim of this study was to establish normative data for the SPEAD test among healthy individuals aged 20–79 years. Method and Materials. One hundred and twelve healthy adults recruited from the community were divided into three age groups (20–39.11, 40–59.11, & 60–79.11 years). Participants swallowing 100 g of water and thickened Electral, and 6.67 g of Parle Monaco was video recorded for data analysis. Results. Cronbachs Alpha test indicated good to excellent internal consistency and inter-class correlation test revealed a high level of inter-rater reliability for all SPEAD parameters. Older adults exhibited a higher number of bites, chews, and swallows, and required more time to swallow compared to younger and middle adults. Similarly, speed of ingestion and SPEAD rate were lowest in older adults. SPEAD indices also showed significant differences across the three consistencies at p < 0.01. Conclusion. In summary, the SPEAD test was found to be feasible, reliable, and valid in healthy adults of India between 20 and 79 years of age. The age and sex based normative data established in this study will enable SLPs in assessing the presence and / or absence of swallowing difficulties in the oral and pharyngeal phases across different consistencies using one test.
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... Because of the known limitations of the CSE [49,50], dysphagia assessment is ideally complemented by instrumental testing such as a flexible endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallowing study (VFSS) [6,14,[51][52][53]. Both FEES and VFSS are gold standard; however, FEES is preferential in the ICU setting as it is more accessible and viable for the critically ill patient. ...
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Leitlinie „Neurogene Dysphagie“
Article
  • Mar 2024
Die S1-Leitlinie „Neurogene Dysphagie“ der Deutschen Gesellschaft für Neurologie in Zusammenarbeit mit der Deutschen Gesellschaft für Dysphagie, zuletzt überarbeitet im Februar 2020, gibt aktuelle Empfehlungen zur Diagnostik und Therapie von Dysphagien verschiedenster Ursachen.
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Safety-related outcomes for patients with a tracheostomy and the use of flexible endoscopic evaluation of swallowing (FEES) for assessment and management of swallowing: A systematic review
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  • Mar 2024
Purpose: The purpose of this systematic review was to examine safety-related outcomes for patients with tracheostomy after flexible endoscopic evaluation of swallowing (FEES) to assess and manage their swallow, when compared to other non-instrumental swallow assessments such as clinical swallowing examination (CSE) and/or a modified Evans blue dye test (MEBDT). Method: Three databases were searched for articles referring to safety-related outcome data for adults with a tracheostomy, who underwent FEES and CSE and/or MEBDT. Articles were screened using predefined inclusion/exclusion criteria. Result: The search strategy identified 2097 articles; following abstract and full-text screening, seven were included for review. The summary of evidence found low to very low certainty that FEES was associated with improved outcomes across swallow safety, physiological outcomes, tracheostomy cannulation duration, functional outcomes, and detection of upper airway pathologies. Conclusion: This systematic review demonstrated low to very low certainty evidence from seven heterogeneous studies with low sample sizes that incorporating FEES may be associated with improved safety-related outcomes. There is less evidence supporting the accuracy of other swallow assessments conducted at the point of care (i.e. CSE and MEBDT). Future research requires studies with larger sample sizes and routine reporting of safety-related outcomes with use of FEES.
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Clinical Assessment of Swallowing and Prediction of Dysphagia Severity
Article
Full-text available
Dysphagia with aspiration is prevalent in acute stroke; however, noninvasive clinical screening assessments to identify patients at risk of developing aspiration are limited. This study was undertaken to determine whether risk factors detected in the clinical examination approximated the videofluoroscopic swallow study (VSS) in identification of dysphagia severity. Six clinical features—dysphonia, dysarthria, abnormal volitional cough, abnormal gag reflex, cough after swallow, and voice change after swallow—were assessed by means of an oropharyngeal evaluation and a clinical swallowing examination. Clinical assessments and VSS were completed on consecutive stroke patients (n=59) within 5 days of hospital admission. The VSS was scored on a scale of 0 to 4 (0=normal, 1=mild, 2=moderate, 3=moderate-severe, 4=severe dysphagia). Results showed that the presence of at least 2 of the 6 clinical features consistently distinguished patients with moderate to severe dysphagia from patients with mild dysphagia/normal swallowing. These data demonstrate that this clinical dysphagia screening tool can provide objective criteria for the need for VSS in acute stroke patients.
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Evaluation and Treatment of Swallowing Disorders
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Full-text available
The effects of laryngotracheoesophageal cleft, rheumatoid arthritis, gastroesophageal reflux disease, supracricoid partial laryngectomy with cricohyoidopexy, and postsurgical unilateral recurrent nerve paralysis on swallowing function are examined. Procedures for screening patients for symptoms of swallowing problems and diagnostic techniques that define swallowing anatomy and physiology are compared and contrasted. Surgical and behavioral treatments for swallowing disorders are described.
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Teledynamic Evaluation of Oropharyngeal Swallowing
Article
Full-text available
Purpose The objective of the present investigation was to test the feasibility and clinical utility of a real-time Internet-based protocol for remote, telefluoroscopic evaluation of oropharyngeal swallowing. Method In this prospective cohort study, the authors evaluated 32 patients with a primary diagnosis of stroke or head/neck cancer. All patients participated in 2 separate fluoroscopic swallowing evaluations—one traditional on site and one telefluoroscopic off site—through the use of a telemedicine system. Agreement between sites was tested for 3 categories of variables: (a) overall severity of swallowing difficulty, (b) presence and extent of laryngeal penetration and aspiration as rated by the 8-point Penetration-Aspiration scale, and (c) treatment recommendations. Results Results showed overall good agreement in subjective severity ratings (κ = 0.636) and in Penetration-Aspiration scale ratings (mean absolute difference = 1.1 points) between the onsite and offsite clinicians. Agreement in treatment recommendations was moderate to high, ranging from 69.3% to 100%. Conclusions The present study supports the feasibility and clinical utility of a telemedicine system for evaluating oropharyngeal swallowing. Given the difficulty and expertise needed to complete such evaluations, this study offers promising clinical avenues for patients in rural, remote, and underserved communities and countries where expert swallowing specialists are not available.
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Predictors of Aspiration Pneumonia: How Important Is Dysphagia?
Article
Full-text available
  • Feb 1998
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.
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Is the information about a test important? Applying the methods of evidence-based medicine to the clinical examination of swallowing
Article
  • Sep 2004
  • J COMMUN DISORD
A hotly debated topic in oropharyngeal dysphagia is the Clinical Swallowing Examination's (CSE) importance in clinical practice. That debate can profit from the application of evidence-based medicine's (EBM) principles and procedures. These can guide both appropriate data collection and interpretation as will be demonstrated in the present report. The study's purpose from which data for this report are drawn was to determine the relationship among signs elicited by a CSE and aspiration on a subsequent videofluoroscopic swallowing examination (VFSE). Sensitivity, specificity; positive and negative predictive values (NPV); likelihood ratios; and post-test probabilities for a variety of signs in isolation and in combinations are reported. These data, if judiciously selected and interpreted contribute to the clinician's knowledge about whether to follow a CSE with a VFSE and about what to expect if the VFSE is completed. Learning outcomes: (1) Clinicians will learn how to use EBM principles in conjunction with clinical assessments of swallowing to enhance patient care. (2) Clinicians will learn how to identify combinations of patient signs during he CSE to predict VFSE performance.
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Diagnostic Accuracy of Bedside Swallow Evaluation Versus Videofluoroscopy to Assess Dysphagia in Individuals With Tetraplegia
Article
  • Apr 2012
To assess the accuracy of bedside swallow evaluation (BSE) compared with videofluorosopic swallow study (VFSS) in diagnosing dysphagia in individuals with tetraplegia due to spinal cord injury (SCI). A prospective diagnostic accuracy study according to STAndards for the Reporting of Diagnostic accuracy studies (STARD) criteria. A county hospital with acute inpatient SCI unit. Thirty-nine subjects with SCI and tetraplegia were enrolled. All of the subjects underwent BSE, and 26 subjects completed the VFSS. Individuals with SCI underwent a BSE followed by a VFSS within 72 hours of the BSE. The subjects were diagnosed as having dysphagia if they had positive findings in either BSE or VFSS. Sensitivity, specificity, and positive and negative predictive values were calculated by using VFSS as the criterion standard. Fifteen subjects (38%) were diagnosed as having dysphagia based on the BSE results. Among the subjects who completed the VFSS, 11 were diagnosed with dysphagia (42%) and 4 were diagnosed with aspiration (10%). Of the 26 subjects who completed both BSE and VFSS, only 1 subject was diagnosed differently compared with BSE (3.8%). Different diet recommendations were made in 4 cases after VFSS versus BSE. Different liquid recommendations were made in 8 cases after VFSS versus BSE. Sensitivity of BSE was 100% (95% confidence interval [CI], 71.5%-100%), specificity was 93.3% (95% CI, 68.1%-99.8%). A positive predictive value of BSE was 91.7% (95% CI, 61.5%-100%), and the negative predictive value was 100% (95% CI, 76.8%-100%). Dysphagia is present in approximately 38% of individuals with acute tetraplegia. Because only one of the 21 subjects was diagnosed differently based on VFSS, we believe that BSE is an appropriate screening tool for dysphagia for individuals with cervical SCI. However, VFSS provided additional information on diet and liquid recommendations, so there appears to be an important clinical role for the VFSS.
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Predicting Aspiration After Hemispheric Stroke from Timing Measures of Oropharyngeal Bolus Flow and Laryngeal Closure
Article
  • Feb 2009
  • Dysphagia
Deglutitive aspiration is common after stroke, affecting up to 50% of patients and predisposing them to pneumonia, yet it is virtually impossible to predict those patients at greatest risk. The aim of this study was to develop a robust predictive model for aspiration after stroke. Swallowing was assessed by digital videofluoroscopy (VF) in 90 patients following hemispheric stroke. Lesion characteristics were determined by computerized tomography (CT) brain scan using the Alberta Stroke Programme Early CT Score (ASPECTS). Aspiration severity was measured using a validated penetration-aspiration scale. The probability of aspiration was then determined from measures of swallowing pathophysiology and lesion location by discriminant analysis. Aspiration was observed in 47 (52%) patients, yet despite disrupted swallowing physiology, intrasubject aspiration scores were variable. The best discriminant model combined pharyngeal transit time, swallow response time, and laryngeal closure duration to predict 73.11% of those aspirating (sensitivity = 66.54, specificity = 80.22, p > 0.001). The addition of lesion location did not add anything further to the predictive model. We conclude that the pathophysiology of poststroke aspiration is multifactorial but in most cases can be predicted by three key swallowing measurements. These measurements, if translatable into clinical bedside evaluation, may assist with the development of novel measurement and intervention techniques to detect and treat poststroke aspiration.
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Biomedical measurement to characterize the oral phase of dysphagia
Article
  • May 1990
Dysphagia is a disorder of the swallowing mechanism and presents a major problem in the rehabilitation of stroke patients and head injured patients. The authors have identified several biomechanical parameters that characterize the oral musculature and have developed techniques to quantify these parameters in normal and dysphagic patients. These parameters include lip closure pressure, lip interface shear force, tongue thrust, and swallow pressure. Significant differences were found in each of these parameters measured in normal and dysphagic patients. The quantitative measurements may aid the physician in choosing the appropriate therapy during the course of recovery.
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