It

Treatment of Oropharyngeal Dysphagia

Running head: TREATMENT oF oRopHARyNGEAL DyspI{AGIA

Effectiveness of Thermal Stimulation versus Deep Pharyngeal Neuromuscular Stimulation

in Improving Neurogenic Oropharyngeat Dysphagia

Secondary to Cerebrovascular Accident in Older Adults Carol McKee

University of South Florida

SPA 6805 Research Procedures

Dr. Ruth Bahr

Summer,2000

Treatment of Oropharyngeal Dysphagia 2

Dysphagia" or the inability to swallow, affects vp to 59oA of those who have suffered a cerebrovascular accident (Lugger,1994). Abnormalities may involve the oral, pharyngeal, or esophageal stage of the swallowing sequence (Sellers, Campbell, Stott, Stewart, & Wilsorq

1999). The oral stage of swallowing includes the transfer of material from the mouth to the oropharynx. The pharyngeal stage includes the highly coordinated transport of material away
from the oropharymq around an occluded laryngeal vestibule, and through a relaxed
cricopharyngeus muscle into the upper esophagus. The esophageal stage includes the transport

of material along the esophagus into the gastric cardia (Groher, 1997).
Impairment in swallowing ranges from delay in transfer to absence of transfer and
includes misdirection of transference, as in airway penetration or aspiration (Groher, 1997). It is
a common and potentially fatal complication of acute stroke associated with poor nutritional

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

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

tract, is a complex phenomenon that may occur before, during, or after the swallow.
Generaiiy, aspiration before the swallow is caused by damaged tongue function and a
delayed or absent triggering of the swallow reflex. Aspiration during the swallow relates to reduced laryngeal closure. Aspiration after the swallow may result from a variety of causes

including reduced pharyngeal peristalsis, unilateral pharyngealdysfunction, reduced laryngeal elevation, or cricopharyngeal dysfunction. It can also be caused by certain anatomical abnormalities, such as fistulae or diverticulae, because food tends to collect in these areas and
then be inhaled when the swallow is completed. fupiration in patients recovering from stroke

Treatment of Oropharyngeal

Dysphagia

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

of the etiology, i.e., the anatomical and physiological reason for the dysfunction, is the key to
effective management or treatment of dysphagra.

Although swallowing therapy is associated with successful outcomes, recovery from

dysphagia is not guaranteed. Appropriate diagnosis and effective treatment of swallowing disorders is challenging. Swallowing therapy begins with definition of the patient's anatomic
and physiologic swallowing disorder (Logemann, 1999). This usually involves a radiographic

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

Radiographic studies point toward a specific swallowing disorder. For example, residue in the
valleculae indicates reduced tongue base movement or reduced pharyngeal wall contraction.

Thus, it is incumbent upon the dysphagia clinician to identify the etiology of the dysphagia in order to devise appropriate and effective treatment.

A variety of treatments have been developed for improving dysphagia in stroke patients.
Typically, swallowing therapy in patients with neurogenic dysphagia takes nvo basic forms:
direct and indirect (Neumaru1 Bartolome, Buchholz, & Prosiegel, 1995). Direct therapy
emphasizes compensatory techniques to help cope

with sensorimotor impairment of the oral

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

compensatory techniques include postural adjustment, double swallowing, supraglottic

swallowing, and the Mendelsohn maneuver. On the other hand, indirect therapy attempts to overcome sensorimotor impairment through stimulation techniques and exercises to enhance the swallowing reflex, alter muscle tone, and improve the function of voluntary orofacial, lingual,
and laryngeal muscles. It is based on the principle that recovery of lost neurological functions

Treatment of Oropharyngeal Dysphagia 4

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

those functions. This principle underlies many established neurologic rehabilitation strategies. One of the most extensively utilized indirect treatments for oropharyngeal dysphagia is

thermal stimulation (Logemann, 1983, 1986, 1999). Cold stimulatioq or sensitizatiorq is performed by stroking the base of the anterior faucial pillars with a laryngeal mirror. This
technique was designed to heighten oral awareness and provide an alerting sensory stimulus to the cortex and brainstem such that, when the patient initiates the oral stage of swallow, the pharyngeal swallow will trigger more rapidly (Kaatze-McDonald, Post, & Davis, 1996).

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

swallow. Rather, when the patient initiates the swallow after the stimulatiorq the reflex should
trigger more rapidly. Additionally, effects of thermal stimulation have been reported to continue

for several nonsensitized swallows following the stimulated swallows (Laz,arqLazarus, &
Logemann, 1986).

In thermal stimulatioq a size 00 laryngeal mirror is utilized to sensitize the faucial piiiars
(I-ogemanrg 1983, 1986, i999). The mirror is chilled in ice for 5-10 seconds, and it is then put in contact with the anteriol faucial arch in a stroking motion. After 5-6 strokes on each side of the oral cavity at the faucial hrch, the patient is given a small amount of material, usually a cold,
carbonated beverage, and asked to swallow. When the patient initiates the swallow after

stimulation, the reflex should trigger more rapidly. Thus, swallows after this sensitization are normally faster than swallows that do not follow sensitization (Logemann, 1986). The clinical
acceptance of this technique suggests that the sensitivity of the faucial pillar can be enhanced by

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

Treatment of Oropharyngeal Dysphagia

Another indirect method currently being used in the treatment of oropharyngeal

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

therapeutic program that uses direct neuromuscular stimulation to the pharyngeal musculature to
restore muscle strength, endurance, pharyngeal reflex responses, and pharyngeal reflex

coordination. In this procedure, frozen lemon glycerin swabs are used to stimulate the lingual
base, velar musculature, and pharyngeal constrictors. Stefanakos (2000) suggests using a

minimal number of probes during the first treatment session, with graduated probe progression over treatment sessions. While DPNS adopts the anatomical and physiological bases for applying a cold stimulus

to the faucial pillar, this procedure is only

of 9 sequenced steps designed to provide maximum

sensory input to multiple cranial nerves involved in the swallowing process. Stefanakos (2000) hypothesizes that thermal stimulation to the faucial arches, in isolation, provides minimal

stimulation of the glossopharyngeal nerye, which generally serves to elicit an impaired swallow response. DPNS, on the other hand, provides ma:<imum sensory input to three reflex sites to improve and restore a cbordinated swallow. These sites include: 1) tongue base and bitter taste
buds for improving the tongue base retraction reflex; 2) soft palate musculature for improving the palatal reflex and velopharyngeal closure; and, 3) superior and medial pharyngeal constrictor muscles for improving the pharyngeal constrictor reflex. In stimulating these three reflex sites,

DPNS elicits strong reflexes, which in turn activate muscle group contractions, which then
strengthen the pharyngeal and lingual musculature.

Treatment of Oropharyngeal

Dysphaga

Of greatest concern to the clinicians providing treatment, and the patients receiving the
treatment, is the efficacy of such treatments. Thermal stimulation and deep pharyngeal neuromuscular stimulation are two techniques that are in widespread use in the treatment oropharyngeal dysphagia. Unfortunately, limited data have been presented to support the efficacy of these methods in the management of dysphagia. Thermal Stimulation Thermal stimulation, in published descriptions (Logemann, 1983, L986. 1999), is widely
used in the management of oropharyngeal dysphagia. Data establishing the method's efficacy

of

are limited. The anatomical and physiological bases for the technique are founded in a study by Pommerenke (1928). In that study, Pommerenke reported that mechanical probing of the faucial

pillar evoked swallowing most consistently in the human oropharynx. AJthough the temperature
condition of the rod was not described, it is possible that even a rod at room temperature could transmit some degree of cooling to the pillar mucosa (Kaatze-NlcDonald, Post, & Davis, 1996).

In conclusion, Pommerenke emphasized that, although the faucial pillars evoked the swallowing
most consistently, no single area could be ascribed the exclusive power of causing the

swallowing act because' of individual variability. Over a decade of research has fueled cautious optimism about thermal stimulation's treatment potential. Only a few studies have actually attempted to evaluate the efficacy of cold stimulation as a treatment for dysphagia. In an early study, Lazzar\Lazarus, & Logemann (1986) found that thermal stimulation improved triggering of the swallow reflex in23 of 25 neurologically impaired patients whose reflexes were delayed. Additionally, results from a different protocol with a limited number of these same patients suggested that the ef[ects of a

Treatment of Oropharyngeal Dysphagia 7

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

support for the use of thermal stimulation in improving swallow function for neurologlcally impaired patients. However, since only short-term effects were evaluated, it was suggested that additional studies to evaluate long-term effects be undertaken.

In a more recent study, Rosenbek, Robbins, Fishback, & Levine (1991) measured the
effect of thermal application to the anterior faucial pillars on the swallow response in seven
subjects whose dysphagia resulted from multiple strokes. Subjects received two weeks

of

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

month. Three judges completed visual inspections of data plots for eight durational and four
descriptive measures to determine whether daily thermal application influenced the swallowing

of liquid boluses. An operational definition of "influence" was a'!es" judgment by at least two of the three judges. Two of the three judges agreed that fwo subjects demonstrated improvement
in the duration of stage transition (DST) secondary to treatment. Overall, that study failed to reveal strong evidence that thermal application improved dysphagia for patients with multiple

strokes. Had all three judges agreed reliably on the presence of changes in one or more of the
durational or descriptivd measures, that would have been considered strong evidence. Bisch, Logemann, Rademaker, Kahrilas, &Lazarus (199a) conducted a study to examine the efFects of bolus temperature, volume, and viscosity on the durations of pharyngeal stage swallow events and the frequency and nature of oropharyngeal swallowing problems and bolus

transit. They hypothesized that

a cold bolus might have the same

facilitatory effects as those

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

triggering of the pharyngeal swallow on

1 ml boluses

in patients with mild neurogenic

TreatmentofOropharyngealDysphagia

dysphagra" but not in more severely dysphagic patients. Additionally,

it was found that bolus

volume had a greater effect than bolus temperature on improving the speed of triggering of the
pharyngeal swallow. Selinger, Prescott,

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

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

effect of a cold probe upon contact with the oral mucosa. The results indicated that 6 seconds after a probe was lifted from the ice, the temperature of the probe closely approximated
temperatures perceived as warm or at least neutral, but not cold. The warming was affected first by temperature changes resulting from the probe being moved from the ice into room

temperature and, second by the contact to the oral mucosa. The clinical implication of that study
was that stimulation to the faucial pillars with a cold probe may not be what it is believed to be.

According to Selinger, et al., (1994), the only potentially consistent stimulation to the oral cavity
is tactile and that too is not controlled for in terms of time or amount.

In another study, Rosenbek, Roecker, Wood, & Robbins (1996) examined swallowing
variability and short-term effects of thermal application by comparing two durational measures

for l0 untreated swallows and 10 treated swallows. The recommended treatment for cold
thermal stimulation was followed by icing a 00 laryngeal mirror and subsequently stroking each faucial pillar three times. The results of that study showed that thermal stimulation reduced the duration of stage transition and total swallow duration. Although those findings were interpreted
as having a therapeutic effect,

it was emphasized that demonstrating a method's enduring effects

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

Treatment of Oropharyngeal Dysphagia 9

Deep Phar.vneeal Neuromuscular Stimulation

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

deep pharyngeal neuromuscular stimulation (Stefanakos,

2000). Although no studies on the

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

1.

The pharyngeal phase of the swallow is reflexive.

There are multiple receptors in the tongue, epiglottis, and larynx which are additional receptors for the elicitation of the swallow reflex.

2.

3. It has been hypothesized

that sensory endings in the posterior oral cavity, innervated

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

formation in the brainstem to stimulate various reflexive actions as tongue base retraction refle:; palatal reflex triggering gag reflex, and the swallow reflex.

4.

Contact of food material in the pharynx, or at the top of the larynx, may occasionally trigger a swallow reflex via the superior laryngeal nerye of the vagus nerve (CN

D.

5.

In the normal individual, the sensory input for the triggering of the swallow reflex
comes predominantly via the glossopharyngeal nerve (CN

D0

However,

a.

Velopharyngeal closure (palatal reflex) is accomplished by means

of

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

(cN

x)

b.

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

c. LaryngeaVairway

protection (elevation of the larynx, and closure of the

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

Treatment of Oropharyngeal

Dysphagia l0

d.

Closure of the laryna by means of the adductor mechanisms of the true and
false vocal folds and aryepiglottic folds, is innervated by the spinal accessory nerve

(CIll)il)

and the vagus nerve (CN X).

e.

The cricopharyngeus muscle and pharyngoesophageal segment relaxation for bolus transfer to the esophagus is accomplished through the vagus nerve (CN

x)

6. 7.

AII pharyngeal reflexes provide direct input into the brainstem, specifically, the
reticular formation within the medulla oblongata. Swallow function is severely impaired when pharyngeal reflexes and pharyngeal
muscle strength are diminished.

A number of related studies support the anatomical and physiological DPNS. For example, Miller (1986),
a variety as

bases underlying

part of his effort to lay the physiological groundwork for

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

are to evoke

swallowing. Criteria were based on previous investigations that identified which to touctr/pressure, or to both

sensory fibers in the oral cavity responded only to temperature, only

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

kinds of sensory fibers. DPNS provides thermal, gustatory, and tactile stimulation to a wide
range of sensory fibers. Another criterion was that the sensations most likely to influence

swallowing with the lowest threshold travel along the superior laryngeal nerve (SLN). The anterior faucial pillars, which are the primary site for traditional thermal stimulatiorg are primarily innervated by the glossopharyngeal nerye (CN IX), which has a higher threshold to
evoke swallowing. Another criterion was that the application of the stimulus be dynamic rather

Treatment of Oropharyngeal

Dysphagia

11

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

from the oral cavity, if it is to influence the swallow, must synapse in the dorsal region of the
brainstem swallowing center. This dorsal region includes the nucleus tractus solitarius CItmS)
and the surrounding reticular

region. Presumably, NTS receives input from the trigeminal

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

The anatomical and physiological information provided by Miller appears to support the
use of DPNS over thermal srimulation. This information is important as a rationale

for continued

experimentation with sensory stimulation in the management of dysphagia. More importantly, it provides a rationale for clinical researchers to compare types of stimulation and to identify the most efficient and efficacious program.

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

Pauloski, Colangelo, Lazarus, Fujiu, & Kahrilas (1995) examined the use of a cold sour stimulus in the treatment of dysphagia. It was hypothesized that a cold sour bolus may provide
heightened sensory input to the brainstem and the cortex since the stimuli incorporated both temperature and taste. That study showed that a cold sour bolus reduced the pharyngeal delay

time, reduced oral and pharyngeal transit times, and improved oropharyngeal swallow efficiency. The study further supporied earlier findings that the degree of sensory input was crucial in improving swallow function (Miller, 1986).

Although data establishing DPNS's efficacy are not yet published, Stefanakos (2000)
reported, in a patient study, thatg3Yo (57 out of 61) of cerebrovascular accident patients showed improvement within 2-l2weeks of treatment. Those improvements, determined in pre/post videofluoroscopic evaluations, were significant enough to warrant diet upgrades. That study

Treatment of Oropharyngeal

Dysphagia

12

provided strong support for the use of DPNS in the treatment of oropharyngeal dysphagra. However, further research to corroborate these findings would provide additional support for the
use of this technique.

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

of deep pharyngeal neuromuscular stimulation versus thermal gustatory stimulation to determine

which treatment technique was more beneficial to the dysphagic patient. Six subjects were
treated for four consecutive days with an alternating treatment design. Willis evaluated swallow

initiation time and degree of lingual movement at the beginning and end of each treatment
session. The outcomes of that study did not reveal that one treatment was significantly more effective than another in treating oropharyngeal dysphagia. Howeveq alarge effect size was
noted, which suggested that DPNS may be more effective than thermal stimulation. Rationale for the Cunent Study

Despite the limited number of efficacy studies to support or refute the use of thermal stimulation and deep pharyngeal neuromuscular stimulation, these two techniques are in
widespread use in the treatment of orpha4mgeal dysphagia. According to Logemann (1999), clinicians working in dysphagia should be knowledgeable about the literature supporting each treatment procedure used. Before applying a new treatment procedure, clinicians should be aware of the existing data published in peer-reviewed journals regarding the efficacy and outcomes of the procedure. That is the basis of evidence-based practice. Therapy procedures

..

that have no such published evidence should not be utilized. Unfortunately, data on thermal stimulation and DPNS are in short supply. It remains for clinical researchers to compare types
treatment and identily the most efificient and efficacious methods.

of

Treatment of Oropharyngeal Dysphagia

13

Thus, the present study was designed to examine the effectiveness of thermal stimulation versus deep pharyngeal neuromuscular stimulation in improving neurogenic oropharyngeal dysphagia secondary to cerebrovascular accident in older adults. Specifically, this study was
designed to answer two questions. First, does treatment approach improve oropharyngeal

swallow efficiency? Second, is the relationship between treatment approach and improvement in
oropharyngeal swallow efficiency influenced by the amount of liquid barium utilized during the

MBS study?
This study differs from the Willis study in several ways. Specifically, this study is a group design that employs two different treatments to fwo different groups over a four week period of time. The Willis study was a multiple single subject design that employed an ABAB
alternating.treatment design within all subjects over four consecutive days. Furthermore, the present study measures oropharyngeal swallow efficiency; whereas, the Willis study measured

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

it compares the effectiveness of thermal stimulation versus deep pharyngeal neuromuscular

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

Treatment of Oropharyngeal

Dysphagia

1,4

Method
Participants

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

following criteria: (1) at least 60 years of age; (2) presence of a single left anterior hemispheric
stroke verified by magnetic resonance imaging; (3) presence of stroke-caused dysphagia
characterized by reduced lingual motility and delayed pharyngeal swallow evidenced by

videofluoroscopic examination; (4) duration of dysphagia between one and four weeks; (5)
medical stability as judged by a referring neurologist; and, (6) ability to cooperate with the

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

if they are (1) tracheotomized; (2) suffering from dysphagia from a cause other than stroke,
determined.by consultation with a referring neurologist; and/or, (3) treated with any other

as

version of the experimental therapy within two weeks of enrollment in the present study.
Once a patient's eligibility is established, randomizationto
be accomplished. Each group

I of 2 treatment

groups will

will include l0 parricipants.

Treatment Protocols Thermal stimulatiorq in published descriptions (Logemann i983, 1986,Ig99), will be
administered to all participants in Group

A.

A 00 laryngeal mirror will be chilled in a cup of

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

mirror will be put in contact, in a vertical stroking motion, with the anterior faucial arch. After five strokes on each side of the oral cavity at the faucial arches, the patient will be grven a small
amount of water and asked to swallow This procedure will constitute one complete trial. Trials

Treatment of Oropharyngeal

Dysphagta l5

will

be repeated

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

times a week for four weeks. Deep pharyngeal neuromuscular stimulation, as described by Stefanakos (2000), will be administered to all participants in Group

B.

Frozen lemon glycerine swabs will be placed in an

iced chest to maintain temperature. Stimulation techniques will be applied first to the weaker
side, then to the stronger side as

follows: (1) glide swab across the palatal pharyngeal

musculature firmly for

l-3

seconds; (2) moving anteriorly-posteriorly from nasal spine region,

stimulate bilaterally on soft palate, then straight down the uvula along the palatal raphe for
seconds; (3) glide swab firmly across bitter taste buds 1-3 seconds;

l-2

( ) holding tongue with

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

for 2-4 seconds; (5) moving posterior to anterior, stimulate lingual apex along lingual septum
while depressing lingual base with gloved hand for 2 seconds, (6) holding tongue with glove,
stimulate posterior pharyngeal wall firmly for 7-2 seconds; (7) holding tongue with gauze, stimulate straight down the ulula; (8) stimulate distal palatopharyngeus area across soft palate

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

will constitute

one complete

trial. Trials will be repeated for a period of 30 minutes

each day.

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

Instrumentation
Standardized videofluoroscopic evaluations of the oropharyngeal stages of deglutition

will be obtained one day prior to the initial treatment session and one day following the final
treatment session. Studies will be completed in the hospital's videbfluoroscopic suite using a
Sony VO-5800 video recorder at a rate of 30 frames per second. A specially designed timer

Treatment of Oropharyngeal

Dysphagia

16

(Thalner Electronics, Ann Arbor, MI) will encode an analog time signal in hundredths of a
second (accurate to 0.01) on the video image. Slow motion and frame by frame analysis will be
used to measure oropharyngeal swallow efficiency (OPSE) for each participant. OPSE is a measure developed by Logemann, Kahrilas, Kobara,

& Vikal (1989) to quantifr the ability of the

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

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

More specifically,
OPSE

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

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

obtained from the videofluorographic assessment. OPSE has been found to be a representative summary measure of swallowing function in various groups of dysphagic patients (Rademaker,

Pauloski, Logemann, & Shanaha 199$.

Procedures

Trial Therapy. Prior to the first treatment session, each participant will receive an
orientation and trial therapy session for each of the two procedures. First, each method will be
described to each subject, and each will be shown the simple tools necessary to provide the

treatment. Next, each subject will receive ten minutes of thermal stimulation followed by ten
minutes of deep pharpgeal neuromuscular stimulation to determine tolerance for the procedures. Tolerance for both procedures will be required for inclusion in the study.

Treatment Procedure. Treatment will be administered by an experienced speech

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

Treatment of Oropharyngeal

Dysphagia

17

pharyngeal neuromuscular stimulation. Treatment sessions will be scheduled for five consecutive days per week with a two-day rest period befween each five-day treatment period.

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

will

be required during the originally scheduled two-day rest period

Videofluoroscopic Procedure. Participants will be seated in the lateral plane and given
standardized instructions. The fluoroscopic camera will focus on the lips anteriorly, the posterior pharyngeal wall posteriorly, the hard palate superiorly, and the cervical vertebra inferiorly. Participants will be given one, 1-ml thin liquid barium bolus on a spoon by an experienced speech-language pathologist and instructed to hold the material in the mouth until the command

"swallow" is given. The procedure will be repeated with one, 3-rnl thin liquid barium bolus.
The formula for mixing the liquid barium will be maintained constant for all subjects. Data Collection

AII videofluoroscopic swallowing examinations will be analyzed by an experienced

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

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

to determine the following measures: (a) oral transit time (OTT) - the time (in seconds) from the
onset of bolus movement'in the mouth until the head of the bolus reaches the point where the

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

the time

(in seconds) from the arrival of the bolus head at the point where the lower rim of the mandible
crosses the tongue base until first laryngeal elevation; (c) pharyngeal response time (PRT)

the

time (in seconds) from first laryngeal elevation until the bolus tail passes through the cricopharyngeal region; (d) oral residue (ORES) - the approximate percent of the bolus

Treatment of Oropharyngeal Dysphagia

18

remaining in the oral cavity, (e) pharyngeal residue (PRES)

the approximate percent of the

bolus remaining in the pharyngeal region after completion of the first swallow of the bolus; (f)
aspiration before the swallow (ASPB) - the approximate percent of bolus aspirated before a

swallow; and, (g) aspiration during the swallow (ASPD)

the approximate percent of the bolus

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

previously defined, to obtain the OPSE ratio. Ten percent of the swallows will be reanalyzed by the same observers to determine intrajudge and interjudge reliability.
Proposed Data Analysis Oropharyngeal swallow efficiency (OPSE) scores will be meaned for each of the two

groups. A 3-way analysis of variance (ANOVA) will be utilized to determine the relationships, if any, between the following variables:

(l)

type of treatment (thermal stimulation and deep

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

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

Effect sizes will be calculated to determine clinical significance.

Conclusion
Based on hypo,thetical data obtained, a significant main effect will show that deep pharyngeal neuromuscular stimulation is more efilective than thermal stimulation in treating neurogenic oropharyngeal dysphagia secondary to cerebrovascular in older adults (Appendix A).

No other significant main effects will be present. Such data will support the Stefanakos (2000)
finding that deep pharyngeal neuromuscular stimulation has shown that more stimulation input, via multiple cranial nerve tracts within the pharyrx, improves swallow function significantly.

Treatment of Oropharyngeal

Dysphagia

19

References

Bisctq E.M., Logemanrg J.A., Rademaker, A.W., Kahrilas, PJ., & Lazarus, C.L. (1994)'
Pharyngeal effects of bolus volume, viscosity, and temperature in patients with dysphagia

resulting from neurologic impairrnent and in normal subjects. Journal of Speech and Hearing
Reseqrch, 37, 104l-1049.

Groher, M.E. (1997). Dysphagta: Diagnosis and Management (3'd ed.). Boston:
B

utterwo rth-Heinemann.

Kaatzke-McDonald, M.N., Post, E., & Davis, P.J. (1996). The effects of cold, touctg and
chemical stimulation of the anterior faucial pillar on human swallowing. Dysphagra, I 206.

l,

198-

lazzayl,G.D., Lazarus, C., &.Logemann, J.A. (1986). Impact of thermal stimulation on the
triggering of the swallowing reflex. Dysphagra,

l,

73-77

Logemann, J.A. (1983). Evahtation and treatment of *vallotving disorders' San Diego:

College-Hill Press.
Logemann, J.A. (1986). Treatment for aspiration related to dysphagia: An overview.

Dysphogta, t,34-38.
Logemann, J.A. (1999). Behavioral management for oropharyngeal dysphagia' Folia

Phoniatrica et Logopaedica, 51, L99-212.

Logemann, J.A., Kahrilas, P.J., Kobara, M.,

& vakil, N.B. (19S9). The benefit of head

rotation on pharyngoesophageal dysphagia. Archives of Physical Medicine and Rehobilitation,

70,767-771.

Treatment of Oropharyngeal Dysphagia 20

Logemann, J.A., Pauloski, 8.R., Colangelo L.,Lazarus, C., Fujiu, M., & Kahrilas, p.J.

(1995). Effects of a sour bolus on oropharyngeal swallowing measures in patients with

neurogenic dysphagia. Journal

of

Speech and Hearing Research, 38, 556-563.

Lugger, K.E. (1994). Dysphagia in the elderly stroke patient. Journal of Neuroscience Nursing, 26,78-84.
lvfi.ller,

A.I. (1986). Neurophysiological

basis of swallowing. Dysphagia,

/, 9l-100.

Neumann, S., Bartolome, G., Buchholz, D., & Prosiegel,

M. (1995).

Swallowing therapy

of

neurologic patients: Correlation of outcome with pretreatment variables and therapeutic methods. Dysphagia, 10,

l-5.

Pommerenke, W.T. (1928). A study of the sensory areas eliciting the swallowing reflex.

American Journal of Physiologt, 81(I),36-41.

Rademaker, A.w., Pauloski, B.R., Logemann, J.A., Shanahan,

T.K. (L994). oropharyngeal

swallow efficiency as a representative measure of swallowing function. Jounwl of Speech and

Hearing Research, 37, 314-325.

Rosenbek, J.c., Robbins, J., Fishback, B., & Levine,

R.L. (1991). Effects of thermal

31, 1257-1268.

application on dysphagia after stroke. Journal

of Speech and Hearing Research,

J. (1996).

Rosenbek, J.C., Roecker, E.B., Wood, J.L., &. Robbins,

Thermal application

reduces the duration of stage transition in dysphagia after stroke. Dysphagra, I Selinger, M., Prescott, T.E., &

l,

225-233.

Hoffinan,I. (1994). Temperature acceleration in cold oral

stimulation. Dysphosra, 9, 83-87.

Sellers, C., Campbell, A.M., Stott, D.J., Stewart, M.,

& Wilson, J.A. (1999). Swallowing

abnormalities after acute stroke: A case control study, Dysphagia, 11,212-218.

Treatment of Oropharyngeal

Dysphagia 2l

Stefanakos,

K.H. (2000, February). Deep pharyngeal neuromuscalar stimulation: E/fective

treatment of pharyngeat dysphagia. Symposium on Deep Pharyngeal Neuromuscular Stimulation, Atlanta, Georgia.

Willis, M.H. (1997). Effectiveness of deep pharyngeal neuromuscular stimulation versus

thermal gustatory stimulation in decreasing tength of swallow initiation and improving lingual movements. Unpublished master's thesis, University of South Florida" Tampa.

Treatment of Oropharyngeal Dysphagia 22

APPENDIX A

TMPROVEMENT rN OROPHARYNG EAL SWALLOW EF FICIENCY

a o

[ort---l

(u +J F

(n
o

o lo

[*r-i

CL

UJ

a oo
1 mr Lroulp 3 ml LIQUID 1 ml LIQUID 3 ml LIQUID PRE.TEST PRE.TEST POST-TEST POST.TEST

Swallow Condition