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Videofluoroscopic examination of swallowing (VF) is the gold standard in diagnosis and management of dysphagia. During VF, the patient ingests radiopaque foods and liquids, and oral, pharyngeal, and esophageal stages of swallowing physiology are observed and evaluated. Aspiration is defined as passage of materials through the vocal folds, and laryngeal penetration is defined as passage of materials into the larynx, but not through the vocal folds. In this study, we compared the risk of laryngeal penetration or aspiration during VF using various liquid volumes and food consistencies. Between January 2006 and September 2008, 229 patients with suspected dysphagia each were fed at least 2 out of 6 types of liquids or foods during VF in an upright posture without compensatory maneuvers. The 6 types were pudding-thick barium of 4 ml (PD), thin liquid barium of 4 ml (LQ4) and 10 ml (LQ10), one swallow of thin liquid barium from a cup (CUP), corned beef hash (8 g) with barium (CB), and a two-phase mixture of corned beef hash (4 g) with barium and thin liquid barium of 5 ml (MX). The paired comparisons revealed that laryngeal penetration risk increased in the following order: PD, CB, LQ4, LQ10, MX and CUP, while aspiration risk after PD increased in the following order: CB, LQ4, LQ10, CUP and MX. Thus, risk of laryngeal penetration or aspiration varies, depending on food types. In conclusion, risk of aspiration is highest with the two-phase food, and multi-textured foods should be used with caution in individuals with dysphagia.

During feeding, solid food is chewed and propelled to the oropharynx, where the bolus gradually aggregates while the larynx remains open and breathing continues. The aggregated bolus in the valleculae is exposed to respiratory airflow, yet aspiration is rare in healthy individuals. The mechanism for preventing aspiration during bolus aggregation is unclear. One possibility is that alterations in the pattern of respiration during feeding could help prevent inhalation of food from the pharynx. We hypothesized that respiration was inhibited during bolus aggregation in the valleculae. Videofluorography was performed on 10 healthy volunteers eating solid foods with barium. Respiration was monitored concurrently with plethysmography and nasal air pressure. The timing of events during mastication, food transport, pharyngeal bolus aggregation, and swallowing were measured in relation to respiration. Respiratory cycle duration decreased during chewing ( P < 0.001) but increased with swallowing ( P < 0.001). During 66 recordings of vallecular bolus aggregation, there was inspiration in 8%, expiration in 41%, a pause in breathing in 17%, and multiple phases (including inspiration) in 35%. Out of 98 swallows, 47% started in the expiratory phase and 50% started during a pause in breathing, irrespective of bolus aggregation in the valleculae. Plethysmography was better than nasal manometry for determining the end of active expiration during feeding and swallowing with solid food. The hypothesis is rejected in that respiration was not inhibited during bolus aggregation. These findings suggest that airflow through the pharynx does not have a role in preventing aspiration during bolus aggregation in the oropharynx.

Communication and swallowing disorders are common after stroke. Targeted surveillance followed by prompt evaluation and treatment is of paramount importance. The overall goals of rehabilitation for impaired swallowing and communication and swallowing deficits may differ based on the specific deficits caused by the stroke but the main goal is always to improve the patient's everyday interpersonal interactions and optimize participation in society. Fortunately, therapeutic or compensatory interventions can decrease the effects that communication and swallowing deficits have on the quality of life of stroke survivors.

Few studies have examined the intensity of muscle activity during swallowing in healthy humans. We examined selected hyoid muscles using fine wire intramuscular electromyography (EMG) during swallowing of four food consistencies. Thirteen healthy adults were studied using videofluorography and EMG of the anterior belly of digastric (ABD), geniohyoid (GH), sternohyoid (SH), and masseter (MA; surface electrodes) while ingesting thin liquid (three trials) and solid food of three consistencies (banana, tofu, and cookie, three trials each). After rectification, integration, and normalization, peak EMG amplitudes for each muscle in each trial were measured. Hyoid displacements were measured in two dimensions. Data were analyzed using repeated measures ANOVA with Bonferroni correction. GH had the highest adjusted amplitude for both solids and liquid. For MA and ABD, amplitude was highest with triturated cookie. For ABD, amplitude was lowest with liquid. There were no significant food consistency effects for GH or SH. Hyoid displacements were greatest for cookie and the lowest for liquid. EMG amplitude varied with initial food consistency. The high peak EMG amplitude of GH is consistent with its essential role in opening the upper esophageal sphincter. High MA amplitude with hard solid foods is likely due to the higher tongue-palate pressure with triturated solids. The higher ABD amplitude with solid food is associated with greater hyoid displacement. These findings support the existence of a central pattern generator that modifies the level of muscle activity during pharyngeal swallowing in response to input from mechanoreceptors in the oral cavity.

Dysphagia affects the vast majority of acute stroke patients. Although it improves within 2 weeks for most, some face longstanding swallowing problems that place them at risk for pneumonia, malnutrition, dehydration, and significantly affect quality of life. This paper discusses the scope, the disease burden, and the tools available for screening and formal evaluation of dysphagia. The most common and recently developed treatment interventions that might be useful in the treatment of this population are discussed.

Although the goal of dysphagia rehabilitation is the same, population needs, clinical practice patterns, availability of resources, and dysphagia research varies greatly around the world. The goal of this review is to introduce the reader to the context in which dysphagia rehabilitation is practiced, to describe practice patterns, and to highlight the dysphagia research being performed in three distinct regions of the world: North America, New Zealand and Australia, and Japan.

Few studies have reported the activation sequence of the swallowing muscles in healthy human participants. We examined temporal characteristics of selected hyoid muscles using fine wire intramuscular electromyography (EMG). Thirteen healthy adults were studied using EMG of the anterior belly of digastric (ABD), geniohyoid (GH), sternohyoid (SH), and masseter (MA, with surface electrodes) while ingesting thin liquid, banana, tofu, and cookie (3 trials each). Onset timing was measured from rectified and integrated EMG. Data were analyzed using repeated-measures ANOVA with Bonfer- roni correction. When drinking thin liquid, MA, GH, and ABD were activated almost simultaneously, but SH was activated later (using GH onset as 0 s, MA -0.07 (-0.20 to 0.17) second (median (interquartile range)); ABD 0.00 (-0.10 to 0.07) second; SH 0.17 (0.02 to 0.37) second; P \ 0.01). With solid foods, MA contraction preceded GH and ABD; SH was last and delayed relative to liquid swallows (GH 0 s; MA -0.17 (-0.27 to 0.07) second; ABD 0.00 (-0.03 to 0.03) second; SH 0.37 (0.23 to 0.50) second; P \ 0.01). The role of the MA differs between solids and liquids so the variation in its timing is expected. The synchronous contraction of GH and ABD was con- sistent with their role in hyolaryngeal elevation. The SH contracted later with solids, perhaps because if the longer duration of the swallow. The consistent pattern among foods supports the concept of a central pattern generator for pharyngeal swallowing.

Upper extremity prosthetic technology has significantly changed in recent years. The devices available and those under development are more and more able to approximate the function of the lost limb; however, other challenges remain. This article provides a brief perspective on the most advanced upper limb prostheses available and the challenges present for continued development of the technology.

Stage II transport (St2Tr) is propulsion of triturated food into the pharynx for storage before swallowing via tongue squeeze-back against the palate. To clarify the phenomenology of St2Tr, we examined the effects of food consistency and the number of chewing cycles on the number of St2Tr cycles in a chew-swallow sequence. We recorded chew-swallow sequences in lateral projection with videofluoroscopy of 13 healthy volunteers eating 6 g of hard (shortbread cookie), and soft foods (ripe banana and tofu) with barium. We counted the number of chewing and St2Tr cycles from food intake to terminal swallow. We used the Friedman test for bivariate analyses and negative binomial regression for multivariable analyses. On bivariate analysis, food consistency had a positive association with the number of chewing cycles (P = 0.013), but not with the number of St2Tr cycles (P = 0.27). Multivariable analysis, however, revealed a greater number of St2Tr cycles with hard than soft food (P ≤ 0.01) and a trend toward negative correlation between the numbers of St2Tr and chewing cycles (P = 0.083). The number of chewing cycles needed to clear the mouth differs among food consistencies as demonstrated previously. Greater numbers of both St2Tr and chewing cycles were elicited with the hard than with the soft foods. Given the trend toward negative correlation, the association between the number of St2Tr cycles and that of chewing cycles deserves further study.

Lean Six Sigma (LSS) process analysis can be used to increase completeness of discharge summary reports used as a critical communication tool when a patient transitions between levels of care. The authors used the LSS methodology as an intervention to improve systems process. Over the course of the project, 8 required elements were analyzed in the discharge paperwork. The authors analyzed the discharge paperwork of patients (42 patients preintervention and 143 patients postintervention) of a comprehensive integrated inpatient rehabilitation program (CIIRP). Prior to this LSS project, 61.8% of required discharge elements were present. The intervention improved the completeness to 94.2% of the required elements. The percentage of charts that were 100% complete increased from 11.9% to 67.8%. LSS is a well-established process improvement methodology that can be used to make significant improvements in complex health care workflow issues. Specifically, the completeness of discharge documentation required for transition of care to CIIRP can be improved.

The purpose of this study was to determine if well-understood, positive reinforcement performance improvement models can successfully improve compliance by resident physicians with medication reconciliation in an outpatient clinical setting. During the preintervention phase, 36 anesthesiology residents who rotate in an outpatient pain clinic were instructed in the medication reconciliation process. During the postintervention phase, instruction was given, and then improvement was recognized publicly. Data on physician compliance were collected monthly. The authors performed a secondary analysis of the audit database, which contained 1733 patient charts. The data were divided into preintervention and postintervention phases for comparison. A 4-fold increase in compliance was found. When logistic regression was used to adjust for adaptation of resident physicians over time and year, the odds of reconciling were 82% higher postintervention. By the consistent application of this effective tool, the authors have demonstrated that sustained performance of a tedious but important task can be achieved.

The hyoid bone and larynx elevate to protect the airway during swallowing. However, it is unknown whether hyolaryngeal movements during swallowing can adjust and adapt to predict the presence of a persistent perturbation in a feed-forward manner (adaptive motor learning). We investigated adaptive motor learning in nine healthy adults. Electrical stimulation was administered to the anterior neck to reduce hyolaryngeal elevation, requiring more strength to swallow during the perturbation period of this study. We assessed peak hyoid bone and laryngeal movements using videofluoroscopy across thirty-five 5-ml water swallows. Evidence of adaptive motor learning of hyolaryngeal movements was found when (1) participants showed systematic gradual increases in elevation against the force of electrical stimulation and (2) hyolaryngeal elevation overshot the baseline (preperturbation) range of motion, showing behavioral aftereffects, when the perturbation was unexpectedly removed. Hyolaryngeal kinematics demonstrates adaptive, error-reducing movements in the presence of changing and unexpected demands. This is significant because individuals with dysphagia often aspirate due to disordered hyolaryngeal movements. Thus, if rapid motor learning is accessible during swallowing in healthy adults, patients may be taught to predict the presence of perturbations and reduce errors in swallowing before they occur.

In this study, the relationship between patients' perceptions of pain control during hospitalization and their overall satisfaction with care was examined. Satisfaction data were collected from the federally mandated Hospital Consumer Assessment of Healthcare Providers and Systems survey for 4349 adult patients admitted to any surgical unit over an 18-month period. Patients' perceptions of pain control and staff's efforts to control pain were associated with their overall satisfaction scores. These perceptions varied widely among services and nursing units. Interestingly, patient satisfaction was more strongly correlated with the perception that caregivers did everything they could to control pain than with pain actually being well controlled. The odds of a patient being satisfied were 4.86 times greater if pain was controlled and 9.92 times greater if the staff performance was appropriate. Hospitals may improve their patients' satisfaction by focusing on improving the culture of pain management.

Background. In addition to its conventional use as a treatment for refractory neuropathic extremity pain, spinal cord stimulation (SCS) has recently emerged as a possible treatment for visceral and arthritic pain. But concurrent with the expansion of possible conditions amenable to SCS, other studies have questioned the long-term efficacy of SCS for traditional indications. These disparate findings argue strongly for the refinement of selection criteria. The purpose of this study is to identify correlates of outcome for SCS. Methods. Data were retrospectively collected on 244 patients who underwent a SCS trial at two academic medical centers. Success was predefined as ≥50% pain relief sustained for ≥6 months. Variables analyzed for their association with outcome included demographics, location of pain, diagnosis, presence of coexisting diseases, pain descriptors, opioid and adjuvant medication use, duration and pain relief during trial, and complications. Results. The presence of allodynia and/or hyperalgesia correlated with both a positive SCS trial (P = 0.01) and long-term implantation outcome (P = 0.05). History of substance abuse was associated with a negative permanent SCS outcome (P = 0.05) but bore no relationship to trial results. The variable most strongly associated with an SCS outcome was experiencing

Background The study prospectively assessed the functional impairments and rehabilitation needs of Africans admitted to a regional trauma center. It also acts as a pilot study to demonstrate the practical use of the Language Independent Functional Evaluation (L.I.F.E.) software in an acute hospital setting. Methods A 5 page questionnaire was used to gather demographic data (age, sex, medical diagnosis, education, housing type, place of residency, occupation), cause of disability/injury, severity of disability or functional impairment, and rehabilitation treatment received (types of rehab, frequency of treatment, duration of therapy, follow up therapy, equipment). Functional status on discharge was evaluated with the L.I.F.E. scale. Results 84 consecutive consenting subjects were recorded. The predominant disability/injury of respondents involved the lower extremities (70%), followed by upper extremities (23%). The mechanisms of injury were largely related to auto accidents (69%). Falls made up 17% of these injuries and 14% were related to violence. Eleven subjects had disability measured using L.I.F.E and all were classified as having major disabilities. Only 14 patients (17%) received any rehabilitation therapy which consisted of only physical therapy provided at a frequency of once a day for less than one week duration. Conclusion This study found that most persons admitted to a sophisticated trauma unit in Ghana are discharged without adequate rehabilitation services, and that the level of disability experienced by these people can be measured, even while they are still sick and in the hospital, using L.I.F.E. The implications are clear: African trauma systems must measure the long term outcomes from their treatments and provide the inpatient medical rehabilitation services that are a standard of care for trauma victims elsewhere in the world.

Swallowing is an intricate, yet fundamental process which is often interrupted by neurologic disease and senescence and has a major impact on the overall health, quality of life, and nutritional status of those affected. A number of neurologic conditions are associated with dysphagia including Parkinson’s disease (PD), amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), dementia, and traumatic brain injury (TBI). Of these, stroke is the most common. Although swallowing problems may be exclusive to one phase of swallowing, deficits can be seen in multiple stages – oral, pharyngeal, and/or esophageal. The health risk is enormous, particularly in the elderly, and includes aspiration pneumonia, malnutrition, dehydration, and weight loss. There are several challenges when caring for these individuals who often are socially estranged and besieged by other medical conditions, physical impairments, cognitive dysfunction, immune system deficiencies, and poor nutrition at baseline which together complicate medical decision making often causing further decline. Age-related changes, whether anatomic, physiologic, or psychologic, also accompany normal swallowing and are not considered to be pathologic. As the number of individuals 65 years of age and older increases, the ability to diagnose and manage swallowing disorders will be of extreme importance. For the most part, treatment focuses on dietary modification, compensatory, and rehabilitative techniques. When swallowing is not permissible, consideration of enteral feeding via percutaneous endoscopic gastrostomy tube or, for short-term purposes, with use of oral or nasogastric feeding tubes is necessary. With a better knowledge and awareness of the swallowing process, including its relation to the existing disease state, complication risk, and importance of rehabilitation services, care can be coordinated effectively to improve overall health, wellbeing, and quality of life.

Bussell SA, Gonzalez-Fernandez M. Racial disparities in the development of dysphagia after stroke: further evidence from the Medicare database. Objective To describe the relationship between minority race/ethnicity and dysphagia after stroke in a national sample. Unlike the multiple studies that have examined racial disparities in stroke incidence, risk factors, outcomes, and quality of care, the influence of race or ethnicity on dysphagia after stroke has been understudied. We hypothesized that the odds of dysphagia would be higher for Asians compared with Caucasians in the United States given the results of a previous study in the U.S. Design Observational study. Setting Conducted using the U.S. National Medicare Medical Provider Analysis and Review Data. Participants Medicare beneficiaries admitted in 2007 with a stroke diagnosis. Intervention We selected 382,959 cases with cerebrovascular disease codes with self-identified race/ethnicity of Caucasian, African American, Asian, Hispanic, Native American, or other/unknown. Cases had a diagnosis of cerebrovascular disease, defined as International Classification of Disease, Ninth Revision codes 430 to 438.9. Self-reported race/ethnicity was recorded in the following categories: Caucasian, African American, Asian, Hispanic, Native American, and other/unknown. Main Outcome Measure Dysphagia after stroke as coded in the data. Results The adjusted odds ratio (OR) for poststroke dysphagia was higher for Asians and other minority groups compared with Caucasians (Asian: OR, 1.73; 95% confidence interval [CI], 1.60–1.88; Hispanic: OR, 1.50; 95% CI, 1.39–1.63; African American: OR, 1.42; 95% CI, 1.37–1.47; unknown/other: OR, 1.27; 95% CI, 1.16–1.38; Native American; OR, 1.44; 95% CI, 1.22–1.69). Conclusions Our findings confirm previous research suggesting an association between Asian race and dysphagia after stroke while adding evidence for increased odds in other racial/ethnic minority groups.

Heterotopic ossification is a common complication in disabled populations that can significantly affect hip range of motion, cause pain, and limit functional mobility. The most common musculoskeletal injuries among amputee athletes are sprains and strains to the lumbar spine and sacroiliac joint on the uninvolved side. Athletes with cerebral palsy typically experience lower extremity injuries that involve the patellofemoral joint which are due to muscle spasms of the surrounding muscles. Wheelchair athletes are at a greater risk of long bone fractures due to osteoporosis. Disabled athletes require sport- and disability-specific equipment to minimize injury.

To better define patients appropriate for opiate management for chronic pain syndromes.Retrospective study of 65 patients with noncancerous pain syndromes who were on or being considered for opiates and who were transitioned into a structured outpatient clinic with close monitoring and management. Noncompliance with this outpatient pain management program was the primary outcome. Noncompliance was defined as (1) receipt of prescriptions from providers outside of this clinic, (2) increase in medication dosage without proper approval, (3) refusing toxicology screening on entrance into the program, (4) negative toxicology tests for prescribed medications, (5) positive toxicology tests for psychoactive medications not prescribed, or (6) discovery on toxicology tests of the presence of illicit substances.There were 24 cases of noncompliance (37%), with age56 yrs old demonstrating significant (P = 0.02) association with persons who were noncompliant with the outpatient program. Forty-three percent of those younger than 56 yrs were noncompliant with program, yet no patient older than 56 yrs was noncompliant. Working status approached significance (P = 0.07) with those patients out of work demonstrating a greater likelihood of noncompliance. There were no correlations found between other patient characteristics and the level of compliance with the program.When considering opiates as a treatment option, pain clinics should have a heightened suspicion for younger and unemployed patients. Although these findings should be examined in larger studies, they suggest that nonmedical factors play a substantial role regarding success in such a structured opiate pain program.

Dysphagia is a common problem in neurologic disease. The authors describe rates of dysphagia in selected neurologic diseases, and the evaluation and treatment of dysphagia in this population. Applicable physiology and aspects of neural control are reviewed. The decision-making process to determine oral feeding versus alternative means of alimentation is examined.

The aim of this study was to determine the accuracy of dysphagia coding using the International Classification of Diseases version 9 (ICD-9) code 787.2. We used the administrative database of a tertiary hospital and sequential videofluorographic swallowing study (VFSS) reports for patients admitted to the same hospital from January to June 2007. The VFSS reports were abstracted and the hospital’s database was queried to abstract the coding associated with the admission during which the VFSS was performed. The VFSS and administrative data were merged for data analysis. Dysphagia was coded (using code 787.2) in 36 of 168 cases that had a VFSS. Of these, 34 had dysphagia diagnosed by VFSS (our gold standard) and one had a prior history of dysphagia. Code 787.2 had sensitivity of 22.8, specificity of 89.5, and positive and negative predictive values of 94.4 and 12.9, respectively. Dysphagia was largely undercoded in this database, but when the code was present those individuals were very likely to be dysphagic. Selection of dysphagic cases using the ICD-9 code is appropriate for within-group comparisons. Absence of the code, however, is not a good predictor of the absence of dysphagia.

Gonzalez-Fernandez M, Kuhlemeier KV, Palmer JB. Racial disparities in the development of dysphagia after stroke: analysis of the California (MIRCal) and New York (SPARCS) inpatient databases. Objectives To determine whether the proportion of patients with stroke experiencing dysphagia differs among racial groups and whether this relation can be explained by stroke type or severity. Design Case-control study using California's Medical Information Reporting and New York's Statewide Planning and Research Cooperative System databases for 2002. Cases had primary diagnosis of cerebrovascular disease ( International Classification of Disease, 9th Revision [ICD-9] codes 430–438.9, excluding transient [435–435.9] and late-effects [438–438.9]), and self-identified race was white, black, or Asian. Two comparison groups were selected: (1) Parkinson's disease (ICD-9 codes 332–332.1) and (2) oral cancer (ICD-9 codes 141–149). Setting Inpatient admissions in the respective states. Participants Cases with primary diagnosis of cerebrovascular disease whose self-identified race was white, black, or Asian. Interventions Not applicable. Main Outcome Measure Dysphagia, defined by ICD-9 codes 787.2 (dysphagia), 507.0 (aspiration pneumonia), or presence of a feeding tube in the absence of a diagnosis of coma (Current Procedural Terminology codes 432.46 or 437.50 without ICD-9 code 780.01). Results In the stroke group, the adjusted odds ratio (OR) with 95% confidence interval (CI) for dysphagia was significantly higher for Asians than whites in New York (OR=1.64; 95% CI, 1.50–1.79) and California (OR=1.69; 95% CI, 1.34–2.13). The adjusted OR was slightly but significantly higher for blacks than whites in New York (OR=1.15; 95% CI, 1.03–1.28), but not in California (OR=1.08; 95% CI, 0.97–1.19). No statistically significant differences among racial groups were found in patients with Parkinson's disease or oral cancer. Other factors strongly associated with dysphagia included hemiplegia (OR=2.19; 95% CI, 2.07–2.32) and aphasia (OR=1.97; 95% CI, 1.83–2.11). Conclusions Asians were more likely to have dysphagia after stroke. This association was statistically significant after adjusting for age, sex, stroke severity indicators, comorbidities, and stroke type.

Purpose The authors write this letter to clarify some of the points raised by Dr. Giselle Carnaby about their article titled “Clinical Experience Using the Mann Assessment of Swallowing Ability (MASA) for Identification of Patients at Risk for Aspiration in a Mixed-Disease Population” (González-Fernández, Sein, & Palmer, 2011). The intention of this letter is to ensure that the reader has a balanced perspective and the information necessary to interpret the results of the original publication.

See related article, pages 1501–1507. According to the World Health Organization (WHO), approximately 15 million people experience a stroke each year, of which one third die and one third are permanently disabled. It was not until the mid-nineties that the advent of tissue plasminogen activator (tPA) offered a treatment option. One of the most important factors limiting the use of tPA is the 3-hour window of administration (up to 4.5 hours in select cases) recommended to prevent hemorrhagic complications. Because of the importance of seeking immediate medical care for tPA to be a treatment option, public health campaigns, such …