Publications Related to Lab Projects
Logemann, J.A., Rademaker, A.W., Pauloski, B.R., et al. (in press). What Information Do Clinicians Use in Recommending Oral versus Non-oral Feeding in Oropharyngeal Dysphagic Patients? Dysphagia.
There is little evidence regarding the type(s) of information clinicians use to make the recommendation for oral or non-oral feeding in patients with oropharyngeal dysphagia. This study represents a first step toward identifying data used by clinicians to make this recommendation and how clinical experience may affect the recommendation. Thirteen variables were considered critical in making the oral vs. non-oral decision by the 23 clinicians working in dysphagia. These variables were then used by the clinicians to independently recommend oral vs. non-oral feeding or partial oral with non-oral feeding for the 20 anonymous patients whose modified barium swallows were sent on a videotape to each clinician. Clinicians also received data on the 13 variables for each patient. Results of clinician agreement on the recommendation of full oral and non-oral only was quite high, as measured by Kappa statistics. In an analysis of which of the 13 criteria clinicians used in making their recommendations, amount of aspiration was the highest frequency criterion. Recommendations for use of postures and maneuvers and the effect of clinician experience on these choices were also analyzed.
Pauloski, B.R., Rademaker, A.W., Kern, M., Shaker, R., & Logemann, J.A. (in press). The Feasibility of Establishing Agreement Between Laboratories for Measures of Oropharyngeal Structural Movements. Journal of Medical Speech-Language Pathology.
Kinematic analysis, also commonly referred to as biomechanical analysis, of the swallow is used to measure movement of oropharyngeal structures over time. Two laboratory directors that have used kinematic analysis in their research collaborated to determine the feasibility of establishing agreement between two separate laboratories on measures of structural movements of the swallow. This report describes the process that was followed toward the goal of establishing measurement agreement. Under the direction of the laboratory directors, one research technician from each laboratory participated in a process that included initial meetings, training sessions, and pre- and post-training evaluation of reproducibility. Because agreement on initial measures of structural movement demonstrated weak correlation on some measures, the research technicians trained together for approximately 6 hours. After training, statistical analyses indicated that: a) most Pearson correlations for measures of structural movements were greater than 0.80 and were highly statistically significant; b) most percentages of absolute deviation were under 25%; and c) most concordance coefficients were above .70. These statistics indicate that the two laboratories were able to increase their level of agreement in measuring selected structural movements of the swallow after a brief amount of training. Factors affecting measurement agreement include image quality, establishment of rules for measuring, and the opportunity for regular discussions among research assistants and investigators from both laboratories.
Radiation alone or concurrent chemoradiation can result in severe swallowing disorders. This manuscript defines the swallowing disorders occurring at pretreatment, 3 months and 12 months after completion of radiation or chemoradiation. Forty-eight patients (10 women and 38 men) participated in this study involving videofluorographic evaluation of oropharyngeal swallow at the 3 time points. At baseline patients had some swallow disorders probably related to presence of their tumor. At 3 months post-treatment, frequency of reduced tongue base retraction, slow or delayed laryngeal vestibule closure, and reduced laryngeal elevation increased from baseline. Some disorders continued at 12 months post-treatment. Functional swallow decreased over time in patients treated with chemoradiation but not those treated with radiation alone. Chemoradiation results in fewer functional swallowers than radiation alone at 12 months post-treatment completion.
Oral tongue strength and swallowing ability are reduced in patients treated with chemoradiotherapy for oral and oropharyngeal cancer. Patients with oral or oropharyngeal cancer treated with high dose chemoradiotherapy underwent tongue strength, swallowing and dietary assessments at pre-treatment, one, three, six and twelve months post-treatment. Tongue strength was assessed using the Iowa Oral Performance Instrument (IOPI). Oral and pharyngeal residue was evaluated utilizing videofluoroscopy. Mean maximum tongue strength dropped a nonsignificant amount immediately after treatment, and then increased significantly at 6 and 12 months post-treatment completion. Analyses were adjusted for patient dropout. Tongue strength was not significantly correlated with swallow observations of percentage oral and pharyngeal residue. Ability to eat various diet consistencies was reduced after treatment, but improved over time at a rate similar to changes in oral intake and type of diet. Parallel but not significant changes in oral intake, diet and tongue strength in the first year post chemoradiation therapy need further study in a larger population.
Current research demonstrates that swallow function is impaired after treatment with organ-sparing chemoradiotherapy. Few studies however have related observed swallowing disorders with the patient’s oral intake and diet in a large cohort of patients. Swallowing function was examined using the modified barium swallow procedure in 170 patients treated with radiotherapy ± chemotherapy for cancer of the head and neck at 5 evaluations points: pretreatment and at 1, 3, 6, and 12 months posttreatment. Fisher’s Exact Test was used to examine the relationship between swallow motility disorders and oral intake or diet consistencies. Limitations in oral intake and diet during the first year after cancer treatment were significantly related to reduced laryngeal elevation, reduced cricopharyngeal opening, and rating of non-functional swallow on at least one swallow of any bolus type. Swallow motility disorders had a significant impact on the eating ability of patients after treatment for head and neck cancer with radiotherapy ± chemotherapy.
The relationship between type of chemoradiation treatment, site of disease and swallowing function has not been sufficiently examined in head and neck cancer patients treated primarily with chemoradiation. Fifty-three patients with advanced stage head and neck cancer were evaluated before and three months after chemoradiation treatment to define their swallowing disorders, and characterize their swallowing physiology by site of lesion and chemoradiation protocol. One hundred and forty normal subjects were also studied. Most common disorders at baseline and 3 months post treatment were reduced tongue base retraction, reduced tongue strength, and slowed or delayed laryngeal vestibule closure. Frequency of functional swallow did not differ significantly across disease sites post-treatment, though frequency of disorders was different at various sites of lesion. Effects of chemotherapy protocols were small. Site of lesion affects the frequency of occurrence of specific swallow disorders, while chemoradiation protocols have minimal effect on oropharyngeal swallow function.
We examined measures of oral and pharyngeal residue from scintigraphic studies and estimates/observations from videofluorographic (modified barium swallow) studies taken on the same day but not concurrently in 16 dysphagic patients of varying etiologies presenting with oral and/or pharyngeal dysphagia. Oral and pharyngeal residuals following the swallow were quantified scintigraphically and were then compared with measures of residuals obtained from the modified barium swallow. Estimates of oral and pharyngeal residues from the modified barium swallows were generated by a trained observer who was blinded to the scintigraphic data. Positive and significant Spearman correlations between oral and pharyngeal residue measures from scintigraphy and observations of oral and pharyngeal residue from modified barium swallows were found. This supports the validity of observations of oral and pharyngeal residue in clinical studies. Limitations of these observations are discussed.
Head and neck cancer patients treated with chemoradiation have difficulty eating a normal diet. This study was designed to characterize eating ability over 12 months following chemoradiation treatment. Analyses take patient dropout into account. Two hundred and fifty-five patients with head and neck cancer treated with chemoradiation were followed for 12 months. Eating ability was analyzed using generalized linear model methods that accounted for non-ignorable dropout. Eating ability was compromised immediately following treatment, and improved over 12 months to near pre-treatment levels. Ability to eat at most 50% of the diet orally did not return to baseline levels (p<.05). However, the percent of patients eating a normal diet did return to baseline levels. Accounting for dropout modified the results but the pattern of significance was similar. Treatment of head and neck cancer with chemoradiation has a significant effect on eating ability, which improves after 12 months following treatment.
Previous investigators have found permanent changes in saliva production after chemoradiation but have not examined these in relation to swallowing measures, diet changes and patient comfort over time. Thirty patients with advanced stage cancer of the oropharynx treated with chemoradiation were followed with videofluoroscopic swallow studies, a measure of stimulated total saliva production, a questionnaire of their perception of dry mouth and a questionnaire on the nature of their oral intake at pretreatment until 12 months post‑treatment. Saliva declined significantly from pretreatment to 12 months. Swallowing-related complaints increased significantly over the 12 months, especially in patients with lower saliva weights. Diet choices increased over time post treatment except crunchy foods. Swallow measures did not relate to saliva weight. Reduced saliva weight does not correlate with slowed or inefficient swallow. Instead, reduced saliva weight appears to change patients’ perceptions of their swallowing ability and, on that basis, their diet choices.
There has been increasing interest in gender differences in swallowing function and in the effects of aging on swallowing in both genders. This investigation examined the swallowing ability of 8 healthy young women between the ages of 21 and 29 and 8 healthy older women between the ages of 80-93 during two swallows each of 1 ml and 10 ml liquid boluses. Videofluoroscopic studies of these swallows were reviewed in slow motion and real time to confirm the absence of swallowing disorders. Biomechanical analysis of each swallow was completed from which data on temporal, range of motion, and coordination characteristics of the oropharyngeal swallow were taken. Position of the larynx at rest and length of neck were compared between the two groups. None of the younger or older women exhibited any swallowing disorders. Data from this study were compared with previously published data on younger and older men. Interestingly, the older women often utilized increased range of motion as compared to the young women, and to the old men. This increase may indicate a compensation for aging effects not seen in older men.
Background: The relationship between subjective complaints of dysphagia and objective measures of swallow function in patients with cancers of the oral cavity, pharynx, or larynx, treated with radiotherapy chemotherapy has not been well documented in the literature.
Methods: Swallowing function in 132 patients with various lesions was evaluated using videofluoroscopy and analyzed by patient complaint of dysphagia grouping.
Results: Patients with complaints of dysphagia demonstrated significantly worse swallow function as indicated by lower oropharyngeal swallow efficiency (OPSE), longer transit times, larger residues, and more swallows with aspiration. Patients with complaints of dysphagia also tended to take less of their nutrition by mouth and less variety of food consistencies in their diet as compared to those without complaint.
Conclusions: Patients were able to perceive decrements in their swallowing function as dysphagia and may have limited their oral intake in response to that perception. The ability to accurately perceive swallowing function may be useful for self-monitoring changes in dysphagia status during a course of swallow therapy.
The objective of this study was to define the effects of Lee Silverman Voice Treatment (LSVT) on swallowing and voice in eight patients with idiopathic Parkinson’s Disease. Each patient received a modified barium swallow (MBS) in addition to voice recording before and after 1 month of LSVT. Swallowing motility disorders were defined and temporal measures of the swallow were completed from the MBS. Voice evaluation included measures of vocal intensity, fundamental frequency, and the patient’s perception of speech change. Before LSVT, the most prevalent swallowing motility disorders were oral phase problems including reduced tongue control and strength. Reduced tongue base retraction resulting in residue in the vallecula was the most common disorder in the pharyngeal stage of the swallow. Oral transit time (OTT) and pharyngeal transit time (PTT) were prolonged. After LSVT, there was an overall 51% reduction in the number of swallowing motility disorders. Some temporal measures of swallowing were also significantly reduced as was the approximate amount of oral residue after 3 ml and 5 ml liquid swallows. Voice changes after LSVT included a significant increase in vocal intensity during sustained vowel phonation as well as during reading. LSVT seemingly improved neuromuscular control of the entire upper aerodigestive tract, improving oral tongue and tongue base function during the oral and pharyngeal phases of swallowing as well as improving vocal intensity.
The purpose of this study was to quantify the reduction in normal tissue complications resulting from the aggressive management of advanced Head and Neck Cancers (AHNC), utilizing Intensity Modulated Radiotherapy (IMRT). Thirty-nine patients with AHNC were treated on an intensive Chemotherapy + Radiation regimen. Twenty-one of 39 patients were treated using IMRT (IM group), the remaining 18 patients were radiated without IMRT (NIM group). Acute and chronic toxicities and swallowing and speech function were assessed. The IM group had a smaller radiation dose gradient across the entire treatment volume. Unscheduled treatment breaks were required in 11% of IM patients as compared to 43% of NIM group (p=.04). The IM group had lower grade 3 or 4 acute and chronic toxicities and lower SOMA scores. At 3 months post treatment, patients in the IM group had better oral intake, lower pharyngeal residue, and better oropharyngeal swallow efficiency, and were able to swallow more bolus types. Patients in the IM group also had better articulation. Use of IMRT resulted in reduced treatment-related interruptions, decreased acute and chronic toxicities, and better speech and swallowing functions. Techniques to improve radiation dose conformality around the target tissues while decreasing the radiation dose to the normal tissues should be an integral part of aggressive combined modality therapy.
As the U.S. population ages, there is increasing need for data on the effects of aging in healthy elderly individuals over age 80. This investigation compared swallowing ability of 8 healthy younger men ages 21 to 29 and 8 healthy older men ages 80 to 94 during two swallows each of 1 ml and 10 ml liquid. Videofluoroscopic studies of these swallows were analyzed to confirm the absence of swallowing disorders. Biomechanical analysis of each swallow was completed from which data on temporal, range of motion and coordination characteristics of the oropharyngeal swallow were taken. Position of the larynx at rest, length of neck and pattern of hyoid bone movement were also compared between the two groups. None of the younger or older men exhibited any swallowing disorders. The C2 to C4 distance of older men was significantly shorter than for younger men, and laryngeal position at rest was lower than in younger men but not significantly so. Older men had a significantly longer pharyngeal delay than younger men and significantly faster onset of posterior pharyngeal wall movement in relation to first cricopharyngeal opening. The older men exhibited significantly reduced maximum vertical and anterior hyoid movement as compared to the younger men even when accounting for the difference in C2 to C4 distance in older men. These data support the hypothesis of reduced muscular reserve in the swallows of older men as compared to younger men. Older men also exhibited less width of cricopharyngeal opening than younger men at 10 ml volume, indicating less upper esophageal sphincter flexibility in the swallows of older men. The potential for exercise to improve reserve is discussed. Significant changes in extent of hyoid elevation and duration of cricopharyngeal opening were seen as liquid bolus volume increased.
Background: Postsurgical oral and oropharyngeal cancer patients may experience pharyngeal clearance problems after completion of postoperative radiotherapy.
Methods: Swallowing was examined in six patients using videofluoroscopy for up to one year after surgery. Biomechanical analysis was used to mark movement of the tongue base and posterior pharyngeal wall during swallowing.
Results: The majority of patients experienced increased problems with pharyngeal clearance at or after their 6 month posthealing evaluation, generally 18 to 22 weeks after completion of radiotherapy. Pharyngeal residue was associated with a disruption in either tongue base or posterior pharyngeal wall movement.
Conclusions: Increased fibrosis of the pharyngeal musculature after completion of radiotherapy may have a negative impact on pharyngeal clearance in addition to any pharyngeal clearance problems resulting from surgical resection. Tongue base to posterior pharyngeal wall contact is essential but not sufficient for effective pharyngeal clearance. Sufficient duration of tongue base to posterior pharyngeal wall contact is also needed to provide adequate pharyngeal bolus driving pressure.
Background: After radiotherapy to the head and neck, many patients experience swallowing difficulties. Preliminary work indicates that these patients benefit from the super-supraglottic swallow maneuver.
Methods: Lateral videofluoroscopic studies examined oropharyngeal swallowing in 9 patients who suffered from dysphagia after radiation to the head and neck. Each patient completed two swallows each of 1 mL or 3 mL liquid barium without a voluntary swallow maneuver and with the super-supraglottic swallow designed to close the entrance to the airway early. The videotape of each swallow was digitized and the location of pharyngeal structures marked throughout the swallow. Movement over time plots were generated to measure changes in structural movement resulting from the maneuver.
Results: The super-supraglottic swallow resulted in changes in airway entrance closure and hyolaryngeal movement. One patient who aspirated without the maneuver stopped aspirating with the maneuver. Two others had aspiration reduced to a trace with the maneuver. Fewer swallow disorders were observed with the maneuver.
The purpose of this study was to examine changes in the biomechanics of pharyngeal swallow after surgery in eight patients (six men and two women) with anterior tongue and floor of mouth resections with distal flap reconstruction. Eight normal age-matched subjects were also studied. Swallowing performance was assessed following a standardized protocol with videofluoroscopy preoperatively and at one and three months postoperatively for the oral cancer patients. The normal subjects received a single videofluoroscopic study. Computer assisted biomechanical analysis was used to mark the movements of specific oropharyngeal structures over time throughout the swallow of calibrated boluses. Statistical analyses revealed that tongue base, pharyngeal wall, hyoid, laryngeal, and cricopharyngeal movements during the swallow were altered significantly after surgery for the cancer patients. Some oropharyngeal structural movements differed from those of normal control subjects before surgery. In this study, biomechanical measures indicated that there was recovery in some aspects of the pharyngeal swallow in this patient group. The duration of tongue base to pharyngeal wall contact, which was significantly reduced preoperatively and at one month after surgery, increased significantly to within normal levels by the three month postoperative evaluation. Duration of laryngeal closure and the onset of laryngeal closure relative to cricopharyngeal opening also improved significantly to within normal levels by the three month postoperative evaluation.
Rademaker, A. W., Pauloski, B. R., Logemann, J. A., & Shanahan, T. K. (1994). Oropharyngeal swallow efficiency as a representative measure of swallowing function. Journal of Speech and Hearing Research, 37, 314-425. [pdf]
The purpose of this investigation was to correlate oropharyngeal swallow efficiency (OPSE), a summary measure of swallowing function, with its component variables. Videofluorographic assessment of oropharyngeal swallow resulted in the measurement of multiple measures of swallow function in the five patient populations and a group of normal volunteers. In total, 759 swallows were studied in 149 persons. Specific dimensions of impairment were identified in the patient groups. Multiple regression analyses were used to relate multiple component variables to OPSE. In patient groups with distinct swallow impairments, OPSE was shown to be representative of the dimensions of impairment. In patient groups with limited impairment and in normal volunteers, the strongest correlates of OPSE were bolus transit times. In all groups, at least four variables were significantly related to OPSE and the squared multiple correlation coefficients ranged from 76% to 89%. We conclude that oropharyngeal swallow efficiency is a representative summary measure of swallowing function across populations characterized by a wide range of swallowing impairment.
Measurement of movements of oral pharyngeal structures from videoradiographic studies is extremely time-consuming and difficult. Each video frame must be traced, and specific points of interest must be identified. Measurements from a single frame can take 30-60 minutes, making such analyses infeasible. To facilitate the biomechanical analysis of the pharyngeal swallow, the Video Analysis Laboratory at Northwestern University, Department of Communication Sciences and Disorders, developed an interactive computer program to digitize, enhance, and plot movement of anatomic structures in the oral cavity and pharynx from the onset through the termination of the swallow. This report describes the application of this program to the biomechanical analysis of swallowing.
