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Recognizing a need for more guidance on the coronavirus disease 2019 (COVID-19) pandemic, members of the Archives of Physical Medicine and Rehabilitation Editorial Board invited several clinicians with early experience managing the disease to collaborate on a document to help guide rehabilitation clinicians in the community. This consensus document is written in a "question and answer" format and contains information on the following items: common manifestations of the disease; rehabilitation recommendations in the acute hospital setting, recommendations for inpatient rehabilitation and special considerations. These suggestions are intended for use by rehabilitation clinicians in the inpatient setting caring for patients with confirmed or suspected COVID-19. The text represents the authors' best judgment at the time it was written. However, our knowledge of COVID-19 is growing rapidly. The reader should take advantage of the most up-to-date information when making clinical decisions.

The COVID-19 pandemic is having a profound impact on the provision of medical care. As the curve progresses and patients are discharged the rehabilitation wave brings a high number of post-acute COVID-19 patients suffering from physical, mental, and cognitive impairments threatening their return to normal life. The complexity and severity of disease in patients recovering from severe COVID-19 infection require an approach that is implemented as early in the recovery phase as possible, in a concerted and systematic way. To address the rehabilitation wave, we describe a spectrum of interventions that start in the ICU and continue through all the appropriate levels of care. This approach requires organized rehabilitation teams including physical therapists, occupational therapists, speech-language pathologists, rehabilitation psychologists/neuropsychologists, and physiatrists collaborating with acute medical teams. Here, we also discuss administrative factors that influence the provision of care during the COVID-19 pandemic. The services that can be provided are described in detail to allow the reader to understand what services may be appropriate locally. We have been learning and adapting real-time during this crisis and hope that sharing our experience facilitates the work of others as the pandemic evolves. It is our goal to help reduce the potentially long-lasting challenges faced by COVID-19 survivors., Highlights • Rehabilitation care of COVID-19 recovering patient can be safely provided starting in the ICU. • Redeployment of outpatient therapy workforce was useful to provide rehabilitation to patients recovering from COVID-19 in the acute medical care. • Objective functional assessments allowed for a tailored rehabilitation approach based on the individual patient’s needs. • Changes in Medicare regulation allowed for the provision of Acute Inpatient Rehabilitation Services outside of the rehabilitation unit. COVID-19 patients were able to receive ACIR level of care while still recovering from the acute infection.

This paper reviews recent evidence concerning the epidemiology, evaluation, and treatment of post-stroke dysphagia. The large variability in dysphagia severity and outcomes after stroke warrant a comprehensive evaluation and treatment approach. Screening, bedside evaluation, and instrumental assessments should be systematically and consistently used based on clinical presentation and available resources. In addition to traditional methods of diet modification and implementation of strategies and exercises, the use of novel treatments such as biofeedback and noninvasive brain stimulation may be effective in treatment, though further research is warranted. Oral hygiene regimens may be instrumental in reducing the incidence of swallowing-related respiratory compromise in patients with dysphagia. Dysphagia after stroke is optimally assessed by timely and appropriately selected screening and evaluation. Treatment depends on pathophysiology, with more research needed to assess the effectiveness of interventions as a part of an individualized treatment plan.

PURPOSE The purpose of this study was to elucidate the effects of the tongue-hold swallow (THS) on the pharyngeal wall by quantifying posterior pharyngeal wall (PPW) anterior bulge during the THS. In addition, the effect of tongue protrusion length on the extent of pharyngeal wall anterior bulge was analysed. METHODS Thirteen healthy subjects (6 males and 7 females, 23-43 years) underwent 320-row area detector CT during saliva swallow (SS) and THS at two tongue protrusion lengths (THS1 protrude the tongue as much as 1/3 of premeasured maximum tongue protrusion length (MTP-L) and THS2 protrude the tongue as much as 2/3 of MTP-L). To acquire images of the pharynx at rest, single-phase volume scanning was performed three times during usual breathing with no tongue protrusion (rest), protrusion of the tongue at 1/3 of MTP-L (rTHS1) and protrusion of the tongue at 2/3 of MTP-L (rTHS2). Length from cervical spine to PPW (PPW-AP) and the volume of pharyngeal cavity was measured and was compared between rest, rTHS1 and rTHS2 and between SS, THS1 and THS2. Correlation between MTP-L and PPW-AP was calculated in three conditions, SS, THS1 and THS2. RESULTS PPW-AP at rest, rTHS1 and rTHS2 was 2.9 ± 0.6 mm, 3.0 ± 0.5 mm and 3.0 ± 0.5 mm, respectively, showing no significant differences across swallows. PPW-AP at the maximum pharyngeal constriction was 8.1 ± 2.0 mm, 9.1 ± 2.4 mm and 8.7 ± 2.0 mm in SS, THS1 and THS2, respectively. Compared to SS, PPW-AP in THS1 was significantly larger (p = 0.04) and PPW-AP in THS2 was not significantly different (p = 0.09). Pharyngeal volume at rest, rTHS1 and rTHS2 was 16.4 ± 5.2 mm3 , 18.4 ± 4.5 mm3 and 21.3 ± 6.2 mm3 , respectively. It was significantly larger during rTHS2 compared with rest or rTHS1 (rTHS2-rest p = 0.007, rTHS2-rTHS1 p = 0.007). Pharyngeal volume was completely obliterated (zero volume) at maximum pharyngeal contraction in all except one subject. There was no correlation between MTP-L and PPW-AP in any of the three conditions (SS, THS1 and THS2). DISCUSSION This study demonstrated that the expanded pharyngeal cavity due to the tongue protrusion was completely obliterated by the increase in anterior motion of pharyngeal wall during THS. It also became clear that the degree of tongue protrusion did not linearly correlate with the movement of PPW during THS. There was no relationship between PPW motion and the MTP-L, suggesting that the effect of tongue protrusion is better determined in each subject by analysing the motion of PPW using imaging tools.

Objective To determine differences between continuous videofluoroscopic swallow studies (VFSS) with a pulse rate and frame rate of 30 and the same swallows reduced to 15 frames per second (fps) on measures of swallowing function in patients after acute ischemic stroke. Design Blinded comparison. Setting Acute hospital. Participants Patients after ischemic stroke (N=20). Interventions Not applicable. Main Outcome Measures Single and sequential sips of thin liquids, single sips of nectar liquids, pudding, and cookie boluses were rated on measures of timing of swallowing events, Modified Barium Swallowing Impairment Profile component scores, and Penetration-Aspiration Scale scores. The ratings for videos at 15 fps and 30 fps were compared by Wilcoxon signed rank tests. Results Pharyngeal transit time was longer and bolus entry into the hypopharynx was later for 30 fps than for 15 fps. Components of Oral Residue and Pharyngoesophageal Segment Opening ratings were more severe for 15 fps than 30 fps, whereas Bolus Transport and Initiation of Pharyngeal Swallow were rated as more severe for 30 fps than for 15 fps. There was no difference between 30 fps and 15 fps on the remaining measures, including Penetration-Aspiration Scale scores. Conclusion Continuous VFSS recorded at 30 fps and their down-sampled 15 fps duplicates yielded contrasting results on certain durational and functional measures of swallowing, though not on others. VFSS should be administered continuously or at 30 pulses per second for valid assessment of swallowing while using other methods to reduce radiation exposure.

To explore how sponsorship functions as a professional relationship in academic medicine.The authors conducted semistructured interviews with Johns Hopkins University School of Medicine faculty in 2016: department chairs (sponsors) and faculty participants of an executive leadership development program (protégés). Using editing analysis style, the authors coded interview transcripts for thematic content; a coding framework and themes were derived using an iterative process.Five themes were identified from 23 faculty interviews (12 sponsors, 11 protégés): (1) Mentorship is different: Sponsorship is episodic and focused on specific opportunities; (2) Effective sponsors are career-established and well-connected talent scouts; (3) Effective protégés rise to the task and remain loyal; (4) Trust, respect, and weighing risks are key to successful sponsorship relationships; (5) Sponsorship is critical to career advancement. Sponsorship is distinct from mentorship, though mentors can be sponsors if highly placed and well connected. Effective sponsors have access to networks and provide unequivocal support when promoting protégés. Effective protégés demonstrate potential and make the most of career-advancing opportunities. Successful sponsorship relationships are based on trust, respect, mutual benefits, and understanding potential risks. Sponsorship is critical to advance to high-level leadership roles. Women are perceived as being less likely to seek sponsorship but as needing the extra support sponsorship provides to be successful.Sponsorship, in addition to mentorship, is critical for successful career advancement. Understanding sponsorship as a distinct professional relationship may help faculty and academic leaders make more informed decisions about using sponsorship as a deliberate career-advancement strategy.

Purpose This study aimed to describe recovery of dysphagia after stroke. We determined the proportion of stroke survivors with dysphagia on admission, discharge, and 6 months after stroke. Additionally, the factors affecting oral feeding 6 months after stroke were explored. Methods A total of 427 acute stroke patients were recruited prospectively. Presence of dysphagia was evaluated on admission, weekly until recovery was achieved, and at discharge. We compared stroke survivors with dysphagia who had complete recovery, who had dysphagia but achieved oral feeding, and who required tube feeding. Patient-reported eating ability was evaluated at 6 months. Patients who achieved oral feeding by 6 months were compared to those who had persistent tube feeding need. Results Fifty-five percent of stroke survivors had dysphagia on initial evaluation (3.1 ± 1.4 days after admission) and 37% at discharge (21.1 ± 12.4 days). At 6 months, 5% of patients required tube feeding. Among those who had dysphagia at initial evaluation, 32% had resolution of dysphagia within two weeks, 44% had dysphagia but started oral feeding before discharge, and 23% required alternative means of alimentation (nasogastric tube feeding, percutaneous endoscopic gastrostomy, parental nutrition) throughout hospitalization. At 6 months, 90% of stroke survivors who achieved oral feeding by discharge continued with oral feeding. Patients who achieved oral feeding after discharge had less cognitive impairments on admission and a higher speech therapist intervention rate after discharge. Conclusions More than half of stroke survivors had dysphagia but the vast majority were able to return to oral feeding by 6 months. Cognitive function and dysphagia rehabilitation interventions were associated with return to oral feeding after hospital discharge.

Videofluoroscopy and videoendoscopy dramatically changed the evaluation and management of swallowing disorders. Later advancements in techniques for the instrumental evaluation of swallowing were limited by technique and positioning. The advent of 320-row area detector CT solved previous challenges and allowed for the study of swallowing physiology and dysphagia in greater detail. In this summary, we describe the history and evolution of CT technology and describe research and clinical applications for the evaluation of swallowing physiology and pathophysiology.

Background Kidney disease and dialysis significantly impact cognitive function across the age spectrum. Cognitive training (CT) and/or exercise training (ET) are promising approaches to preserve cognitive function among community-dwelling older adults, but have not been tested for cognition preservation in hemodialysis patients of all ages. In this manuscript, we summarize the protocol for the Interventions Made to Preserve Cognitive Function Trial (IMPCT). Methods We will perform a 2 × 2 factorial randomized controlled trial (RCT) of eligible adult (≥18 years) hemodialysis initiates (n = 200) to test whether intradialytic CT (brain games on a tablet PC), ET (foot peddlers) and combined CT + ET while undergoing hemodialysis preserves executive function compared to standard of care (SC). Participants will engage in the interventions to which they are randomized for 6 months. The primary objective is to compare, among interventions, the 3-month change in executive function measured using the Trail Making Test A (TMTA) and B (TMTB); specifically, executive function is calculated as TMTB-TMTA to account for psychomotor speed. This primary outcome was selected based on findings from our pilot study. The secondary objectives are to compare the risk of secondary cognitive outcomes, ESKD-specific clinical outcomes, and patient-centered outcomes at 3-months and 6-months. All data collection and interventions are conducted in the dialysis center. Discussion We hypothesize that receiving intradialytic CT or ET will better preserve executive function than SC but receiving combined CT + ET, will be the most effective intervention. The current trial will be an important step in understanding how intradialytic interventions might preserve cognitive health. Trial Registration Clinicaltrials.Gov (Date: 8/6/18): # NCT03616535. Protocol Version: 10 (April 2020). Funding: NIDDK R01DK114074.

Contains fulltext : 229044.pdf (Publisher’s version ) (Closed access) Postextubation dysphagia may impose a substantial burden on intensive care unit patients and healthcare systems. Approximately 517,000 patients survive mechanical ventilation during critical care annually. Reports of postextubation dysphagia prevalence are highly variable ranging between 3% and 93%. Of great concern is aspiration leading to the development of aspiration pneumonia when patients resume oral feeding. Screening for aspiration with a water swallow test has been reported to be positive for 12% of patients in the intensive care unit after extubation. This review aims to increase awareness of postextubation dysphagia and provide an updated overview of the current knowledge regarding prevalence, pathophysiology, diagnostic modalities, and treatment options.

Older adults may evidence changes in swallowing physiology. Our goals were to identify dysphagia risk in community-dwelling older adults with no history of dysphagia, and to compare swallowing physiology and safety between older and younger adults. Thirty-two older adults with no history of dysphagia were prospectively recruited and completed the Dysphagia Handicap Index (DHI), two trials of a 3 oz. swallow screen, and videofluoroscopy (VFSS). Self-ratings of swallowing function were compared to published norms by paired t tests, and multivariate logistic regression models were generated to determine whether these ratings and VFSS analysis of swallowing function were associated with failure of one or both swallow screen trials. Archived VFSS of 33 younger adults were compared to older adults with Wilcoxon rank-sum tests. The DHI scores of older adults were higher than published non-dysphagic adults but lower than dysphagic adults. Older participants with greater Oral Residue scores were more likely to fail both swallow screen trials. Older adults received higher median MBSImP™© scores for select pharyngeal components than younger adults. The two age groups did not differ on Penetration-Aspiration Scale scores, and no aspiration was observed. Measures of swallowing in older individuals may reflect age-related sensory and motor changes in the context of functional swallowing and adequate airway protection.

Introduction Cognitive decline is common and increases mortality risk in hemodialysis patients. Intradialytic interventions like cognitive training (CT) and exercise training (ET) may preserve cognitive function. Methods We conducted a pilot randomized controlled trial of 20 hemodialysis patients to study the impact of 3 months of intradialytic CT (tablet-based brain games) (n = 7), ET (foot peddlers) (n = 6), or standard of care (SC) (n = 7) on cognitive function. Global cognitive function was measured by the Modified Mini Mental Status Exam (3MS), psychomotor speed was measured by Trail Making Tests A and B (TMTA and TMTB), and executive function was assessed by subtracting (TMTB − TMTA). Lower 3MS scores and slower TMTA and TMTB times reflected worse cognitive function. P values for differences were generated using analysis of variance, and 95% confidence intervals (CIs) and P values were generated from linear regression. Results Patients with SC experienced a decrease in psychomotor speed and executive function by 3 months (TMTA: 15 seconds; P = 0.055; TMTB: 47.4 seconds; P = 0.006; TMTB − TMTA; 31.7 seconds; P = 0.052); this decline was not seen among those with CT or ET (all P > 0.05). Compared with SC, the difference in the mean change in 3MS score was −3.29 points (95% CI: −11.70 to 5.12; P = 0.42) for CT and 4.48 points (95% CI: −4.27 to 13.22; P = 0.30) for ET. Compared with SC, the difference in mean change for TMTA was −15.13 seconds (95% CI: −37.64 to 7.39; P = 0.17) for CT and −17.48 seconds (95% CI: −41.18 to 6.22; P = 0.14) for ET, for TMTB, the difference was −46.72 seconds (95% CI: −91.12 to −2.31; P = 0.04) for CT and −56.21 seconds (95% CI: −105.86 to −6.56; P = 0.03) for ET, and for TMTB – TMTA, the difference was −30.88 seconds (95% CI: −76.05 to 14.28; P = 0.16) for CT and −34.93 seconds (95% CI: −85.43 to 15.56; P = 0.16) for ET. Discussion Preliminary findings of our pilot study suggested that cognitive decline in psychomotor speed and executive function is possibly prevented by intradialytic CT and ET. These preliminary pilot findings should be replicated.

Objective This study investigated the effects of bolus consistency on pharyngeal volume during swallowing using three-dimensional kinematic analysis. Methods Eight subjects (2 males and 6 females, mean ± SD 44 ± 10 years old) underwent a 320-row area detector scan during swallows of 10 mL of honey-thick liquid and thin liquid. Critical event timing (hyoid, soft palate, UES) and volume of pharyngeal cavity and bolus were measured and compared between two swallows. Results The pharynx is almost completely obliterated by pharyngeal constriction against the tongue base for both consistencies. There were no significant differences in maximum volume, minimum volume and pharyngeal volume constriction ratio values between thick and thin liquids. However, the pattern of pharyngeal volume change (decrease) was different. For thick liquids, the air volume started to decrease before the onset of hyoid anterosuperior movement and decreased rapidly after onset of hyoid anterosuperior movement. During thin liquid swallowing, air volume remained relatively large throughout the swallow and started to decrease later when compared to swallowing thick liquids. At onset of UES opening, the bolus volume was not significantly different between thin and thick liquids; however, air volume was significantly larger when swallowing thin liquids, which made the total volume of the pharyngeal cavity larger. Conclusion This difference between the two consistencies is associated with differences in tongue motion to propel the bolus and clear the pharynx from possible residue.

Chapter 12 introduces a broad range of considerations, alternatives, and coordination of nonpharmacologic pain management. Rehabilitation approaches to pain include somatic, biopsychosocial, and changes in neurochemical pathways in response to exercise, psychological interventions, and other therapeutic aspects. Rehabilitation occurs after injury, trauma, disease, or dysfunction leads to pain and the need for functional restoration. Prehabilitation is now being used in anticipation of planned procedures to reduce the impact of decreased activity in the operative setting and to increase the likelihood of successful return to function. Complementary and alternative therapies are often incorporated into rehabilitative pain management plans. In the process of providing clinical care for patients with persistent or disabling pain-associated conditions, questions of impairment, disability, and pending legal action may arise, and these are discussed. Applications in outpatient pain care address the coordination of pharmacologic and nonpharmacologic approaches and the challenges of planning and organizing effective evidence-based pain self-management plans in the outpatient setting.

STUDY DESIGN: This study is a retrospective review examining the prevalence of drugs commonly used in the management of spinal cord injury (SCI) which may influence bone health. OBJECTIVE: The aim of our study was to examine the role commonly prescribed medications play in post-SCI bone health. SETTING: We included all males 21 years of age and older who were evaluated over a 10-year period at an SCI-specialized center for a trauma-induced SCI. METHOD: We compared characteristics of individuals with normal bone mass to those with low bone mass according to their dual-energy X-ray absorptiometry (DXA) scan. Medication lists were reviewed for the presence of drugs considered to either positively or negatively affect bone metabolism. RESULTS: Comparing individuals with normal bone mass (n = 68) to those with low bone mass (n = 211), only “Time after Injury” and “Level of Injury” were found to influence the likelihood of having low bone mass. Multivariate analysis failed to demonstrate significant associations between bone mass and the sum of drugs which either positively or negatively affect bone metabolism. When medications were reviewed individually, only bisphosphonates and anticonvulsants were found to be significantly associated with bone mass. CONCLUSIONS: Although 76% of our cohort was found to have low bone mass, the only major risk factors were “Time after Injury” and “Level of Injury”. Anticonvulsant use was more common in individuals with low bone mass compared to those with normal bone mass. Given the retrospective methodology of this work, our findings underline associations that warrant further investigation.

Background Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration. Methods Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines. Results Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration. Conclusions Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.

Changes in both swallowing and taste commonly occur in advanced age, though the relationship between the two is unknown. This study examined the association between a water swallow screen test and taste identification and intensity rating. Participants included 47 community-dwelling women aged 85&ndash, 94 years. Participants completed three trials of a water swallow screen and were observed for signs of aspiration, which, if present, indicated failure. Four pure taste stimuli at low and high concentrations and water were presented, and participants selected one of five taste labels and rated their intensity on the generalized Labeled Magnitude Scale. Ratios of intensity ratings were computed for each taste stimulus to compare the perception of low and high concentrations. The association between water swallow screen failure, correct taste identification, and taste intensity ratio was evaluated with logistic regression modeling, with mediating factors of frailty and number of comorbidities. Failure of three water swallow screen trials was associated with a higher taste intensity ratio for caffeine (bitter) and a lower taste intensity ratio for sucrose (sweet). Correct identification of taste, frailty, and number of comorbidities were not associated with failure of any number of water swallow screen trials. Intensity ratings of certain tastes may be associated with swallowing in old-old women. Heightened vigilance in this population may be necessary to prevent complications related to dietary intake.

Objective The goal was to examine the outcomes of an existing swallow screen protocol in comparison to results from a formal videofluoroscopic protocol. Design Prospective cohort study. Setting Acute hospital. Participants Patients after acute stroke (N=48). Interventions Not applicable. Main Outcome Measures The Johns Hopkins Hospital Brain Rescue Unit 3 oz Swallow Screen was implemented by nursing staff upon admission. Videofluoroscopy was conducted within 72 hours of diagnostic neuroimaging and initial swallow screen. Predictive values of the bedside swallow screen (pass/fail) for clinical judgment of dysphagia on videofluoroscopy (presence/absence) were calculated. Overall impairment scores from the Modified Barium Swallowing Impairment Profile were analyzed with respect to swallow screen results. Results Thirteen participants failed the swallow screen, and 35 passed. Of the 35 patients who passed the swallow screen, 15 were clinically diagnosed with dysphagia on videofluoroscopy. Although pass/fail of the swallow screen was not a significant predictor of presence/absence of dysphagia, a logistic regression model including components of Laryngeal Elevation, Laryngeal Vestibule Closure, and Anterior Hyoid Excursion, and sex was statistically significant for swallow screen outcome. Conclusion The results of this study suggest that a swallow screen of aspiration risk can identify patients with the most need for videofluoroscopic evaluation and dysphagia management. Additionally, patients who fail a swallow screen are more likely to present with physiologic impairments related to airway protection on videofluoroscopy.

Pharyngeal residue, the material that remains in the pharynx after swallowing, is an important marker of impairments in swallowing and prandial aspiration risk. The goals of this study were to determine whether the 2D area of post-swallow residue accurately represents its 3D volume, and if the laterality of residue would affect this association. Thirteen patients with dysphagia due to brainstem stroke completed dynamic 320-detector row computed tomography while swallowing a trial of 10 ml honey-thick barium. 3D volumes of pharyngeal residue were compared to 2D lateral and anterior–posterior areas, and a laterality index for residue location was computed. Although the anteroposterior area of residue was larger than the lateral area, the two measures were positively correlated with one another and with residue volume. On separate bivariate regression analyses, residue volume was accurately predicted by both lateral (R2 = 0.91) and anteroposterior (R2 = 0.88) residue areas, with limited incidence of high residuals. Half of the sample demonstrated a majority of pharyngeal residue lateralized to one side of the pharynx, with no effect of laterality on the association between areas and volume. In conclusion, the area of post-swallow pharyngeal residue was associated with volume, with limitations in specific cases. Direct measurement of pharyngeal residue volume and swallowing physiology with 3D-CT can be used to validate results from standard 2D instrumentation.

This study investigated the effects of three different volumes of honey-thick liquid on the temporal characteristics of swallowing. Twenty-six healthy subjects (15 males, 11 females) underwent 320-row area detector CT scan while swallowing 3, 10 and 20 mL of honey-thick liquid barium. Three-dimensional images were created at 10 images/s. Kinematic events involving six structures (velopharynx, hyoid bone, epiglottis, laryngeal vestibule (LV), true vocal cords (TVC), upper esophageal sphincter (UES)) and timing of bolus movement were timed using frame by frame analysis. The overall sequence of events did not differ across three volumes; however, increasing bolus volume significantly changed the onset and termination of events. The bolus head reached to pharynx and esophagus earlier and the duration of bolus passing through UES was significantly longer in 10 and 20 mL compared to 3 mL (P < .05). Consequently, the onset of UES opening was significantly earlier with increased volume (P < .05). LV and TVC closure occurred later in 20 mL compared to 3 mL (P < .05). These changes in motion of pharynx and larynx appeared to promote swallow safety by preventing aspiration, suggesting that anatomical structure movements adapt in response to bolus volume. Our findings also suggest that the pharyngeal swallow behaviours may be modified by afferents in the oral cavity. The three-dimensional visualization and quantitative measurements provided by 320-ADCT provide essential benchmarks for understanding swallowing, both normal and abnormal.

Endotracheal intubation is associated with postextubation swallowing dysfunction, but no guidelines exist for postextubation swallowing assessments.We evaluated the prevalence, patient demographic and clinical factors, and intensive care unit (ICU) and hospital organizational factors associated with swallowing assessment after oral endotracheal intubation and mechanical ventilation in patients with acute lung injury (ALI).We performed a secondary analysis of a prospective cohort study in which investigators evaluated 178 eligible patients with ALI who were mechanically ventilated via oral endotracheal tube. The patients were recruited from 13 ICUs at four teaching hospitals in Baltimore, Maryland. Patient demographic and clinical factors, types of ICU, and hospital study sites were evaluated for their association with completion of a swallowing assessment both in the ICU and after the ICU stay before hospital discharge. Factors significantly associated with a swallow assessment were evaluated in a multivariable logistic regression model.Before hospital discharge, 79 (44%) patients completed a swallowing assessment, among whom 59 (75%) had their assessments initiated in ICU and 20 (25%) had their assessments initiated on the hospital ward. Female sex (odds ratio [OR] = 2.01; 95% confidence interval [95% CI] = 1.03-3.97), orotracheal intubation duration (OR = 1.13 per day; 95% CI = 1.05-1.22), and hospital study site (Site 3: OR = 2.41; 95% CI = 1.00-5.78) were independently associated with swallowing assessment. Although Site 3 had a twofold increase in swallowing assessments in the ICU, there was no significant difference between hospitals in the frequency of swallowing assessments completed after ICU discharge (P = 0.287) or in the proportion of patients who failed a swallowing assessment conducted in the ICU (P = 0.468) or on the ward (P = 0.746).In this multisite prospective study, female sex, intubation duration, and hospital site were associated with postextubation swallowing assessment. These results demonstrate variability in practice patterns between institutions and highlight the need to determine the appropriate timing and indications for swallowing assessment and to more fully understand swallowing dysfunction after intubation.

Swallowing dysfunction is common after stroke. More than 50% of the 665 thousand stroke survivors will experience dysphagia acutely of which approximately 80 thousand will experience persistent dysphagia at 6 months. The physiologic impairments that result in post-stroke dysphagia are varied. This review focuses primarily on well-established dysphagia treatments in the context of the physiologic impairments they treat. Traditional dysphagia therapies including volume and texture modifications, strategies such as chin tuck, head tilt, head turn, effortful swallow, supraglottic swallow, super-supraglottic swallow, Mendelsohn maneuver and exercises such as the Shaker exercise and Masako (tongue hold) maneuver are discussed. Other more recent treatment interventions are discussed in the context of the evidence available.

Objective: Nurses should be educated in pain management because they are more likely than other healthcare professionals to educate patients about their pain. The authors sought to identify the knowledge gaps in postoperative pain management among postsurgical nursing staff and the existence of institutional policies and educational programs to support them in delivering optimal pain management services. Setting: Academic hospital. Participants: Two hundred seventy-seven registered nurses, nurse practitioners, nurse managers, physician assistants, and other health professionals. Interventions: Nurses participated in an online, anonymous survey that consisted of 43 questions in two broad categories: (1) knowledge and attitudes about pain management and (2) institutional pain management and assessment. Main Outcome Measure: Knowledge base of surgical nursing staff regarding postoperative pain management. Results: The overall mean knowledge score was 44.84 percent, with the highest percent of correct answers in the cancer pain category (54.03 percent). Recognition of signs and symptoms of pain had the lowest correct response rate (40.91 percent). Forty-nine percent of respondents reported that pain management protocols tailored to the specific population treated were available, 42 percent reported that patient pain education was always performed, 29 percent reported that they received regular training about pain management, and 17 percent had access to national pain management guidelines. Conclusion: The survey results demonstrate general gaps in pain management knowledge among nurses, particularly in recognizing signs and symptoms of pain. This work may guide the development of programs that improve postoperative pain management by increasing the frequency of nurses' pain education and improving the availability of pain-related policies and protocols.

Objectives To determine whether symptoms and clinical signs of swallowing dysfunction could be easily identified in community-dwelling elderly adults and to examine the association between self-report and direct observation of symptoms and signs of swallowing dysfunction. Design Physiological substudy conducted as a home visit within an observational cohort study. Setting Baltimore City and County, Maryland. Participants Community-dwelling elderly women without history of dysphagia or neurological disease aged 85 to 94 enrolled in the Women's Health and Aging Study II (N = 47). Measurements Three trials of the 3-ounce water swallowing test, swallowing function questionnaire, and frailty status. Results Thirty-four (72%) subjects demonstrated swallowing dysfunction in at least one swallowing trial and 16 (34%) in all three trials. The most common signs of dysfunction were throat clear and wet voice. Conversely, participants reported few symptoms of dysphagia on a swallowing function questionnaire. The most common symptom, reported by approximately 15% of participants, was the sensation of the food going “down the wrong way,” 8.5% or fewer participants reported other symptoms. Conclusion Signs of swallowing dysfunction were present in a large majority of community-dwelling old-old women, but they were largely unrecognized and reported. Formal evaluation of swallowing function in community-dwelling elderly adults is necessary to determine the clinical consequences of these findings.

Objective: Superior hypogastric plexus neurolysis (SHP-N) has been shown in uncontrolled studies to provide intermediate-term benefit in a majority of patients with pain secondary to genitourinary, gynecologic, and colorectal cancers. The purpose of this is to determine factors associated with treatment outcome. Materials and Methods: Patients who underwent SHP-N after a positive prognostic block were identified based on diagnostic classification and procedural codes from databases at 2 large teaching hospitals. A host of demographic, clinical, and treatment factors were examined for their association with treatment success, which was defined as ≥50% pain relief lasting ≥1 month. Results: A total of 53.1% of 32 patients with sufficient medical records for analysis experienced a positive outcome. Those with a positive outcome were older (mean age 59.6 y, SD 13.1 vs. 47.8, SD 15.6; P=0.03), less likely to have pelvic pain (36.8% success rate, P=0.04), and more likely to have bladder cancer (88.9% success rate; P=0.01) than those with a negative outcome. In stratified analysis, female were more likely to have positive outcome if they did not have pelvic pain compared to those that did (P=0.008). This difference was not significant for males. Discussion: Selecting patients based on demographic and clinical variables may improve treatment outcomes for SHP-N. Larger, prospective studies are needed to confirm our results and better refine selection criteria better.

OBJECTIVE Quantifying pain intensity is challenging, particularly for patients with chronic pain. The visual analog scale (VAS) is limited by ceiling effects that often leave patients with no ability to quantify worsening pain. The goal of this study was to determine whether the general Labeled Magnitude Scale (gLMS) can be feasibly used to measure pain clinically while overcoming limitations of the VAS. DESIGN Eighty patients (mean age, 53.7 yrs) scheduled for evaluation of a painful complaint were asked to rate their current pain using the gLMS and the VAS. The time necessary to administer the gLMS was recorded to determine feasibility. The difference in rating between the two scales (VAS and gLMS) was the main outcome measure. RESULTS After scaling and rounding off the gLMS scores for direct comparison, it was found that the gLMS scores were significantly lower than the corresponding VAS scores by a mean of 1.78 (P < 0.001). The mean time to administer the gLMS was 2.66 mins. CONCLUSIONS These results suggest that the gLMS has great potential and can be feasibly used to measure pain intensity clinically. The gLMS scores were consistently lower than the VAS scores, thus reducing the ceiling effect and allowing range at the high end of the scale for rating worsening pain.

Objective To evaluate language deficits after acute stroke and their association with post–acute care at a setting other than home. We hypothesized that deficits in language comprehension would be associated with discharge to a setting other than home after adjustment for physical/occupational therapy (PT/OT) needs. Design Secondary analysis of prospectively collected data. Discharge location, demographic characteristics (age, sex, race), and the presence of PT/OT recommendations were abstracted from the medical record. Setting Acute stroke unit at a tertiary medical center. Participants Left hemispheric stroke patients (N=152) within 24 hours of event. Interventions The following tasks were administered: (a–b) oral and written naming of pictured objects, (c) oral naming with tactile input (tactile naming), (d–f) oral reading, oral spelling, and repetition of words and pseudowords, (g) written spelling to dictation, (h) spoken word-picture verification (ie, auditory comprehension), and (i) written word-picture verification (ie, written word comprehension). Main Outcome Measure Discharge to a setting other than home. Results Of 152 cases, 88 were discharged home and 64 to another setting. Among stroke subjects discharged to a setting other than home, 63.6% had auditory comprehension deficits compared with 42.9% of those discharged home ( P =.03). Deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a setting other than home after adjustment for age and PT/OT recommendations. Conclusions Cases with deficits in auditory comprehension, reading comprehension, and oral spelling to dictation had increased odds of being discharged to settings other than home. Early evaluation of these language deficits and prompt treatment may allow patients who would otherwise be discharged to an institution to go home. Further research is needed to design and evaluate individualized treatment protocols and their effect on discharge recommendations.

When chewing solid food, part of the bolus is propelled into the oropharynx before swallowing; this is named stage II transport (St2Tr). However, the tongue movement patterns that comprise St2Tr remain unclear. We investigated coronal jaw and tongue movements using videofluorography. Fourteen healthy young adults ate 6 g each of banana, cookie, and meat (four trials per foodstuff). Small lead markers were glued to the teeth and tongue surface to track movements by videofluorography in the anteroposterior projection. Recordings were divided into jaw motion cycles of four types: stage I transport (St1Tr), chewing, St2Tr, and swallowing. The range of horizontal tongue motion was significantly larger during St1Tr and chewing than during St2Tr and swallowing, whereas vertical tongue movements were significantly larger during chewing and St2Tr than during swallowing. Tongue movements varied significantly with food consistency. We conclude that the small horizontal tongue marker movements during St2Tr and swallowing were consistent with a "squeeze-back" mechanism of bolus propulsion. The vertical dimension was large in chewing and St2Tr, perhaps because of food particle reduction and transport in chewing and St2Tr.

The onset of encephalopathy may be difficult to detect on the rehabilitation floor for a variety of reasons. The rehabilitation patient’s premorbid cognition may be unknown making it difficult to detect decline or subtle changes in a patient’s mental status may be masked by their acute illness (e.g., cognitive slowing after stroke may mask a metabolic deficiency). However, there are several causes of encephalopathy which may be elucidated through laboratory analysis. This chapter is intended to assist clinicians in the diagnosis of reversible causes of encephalopathy using basic laboratory findings.

Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration.Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines.Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration.Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.

The purpose of this short chapter is to introduce the reader to basic data analysis principles that can be helpful in exploring data, determining the significance of findings, and deriving conclusions.

Purpose To determine the clinical performance characteristics of the Mann Assessment of Swallowing Ability (MASA) for predicting aspiration (determined by videofluoroscopic swallowing study [VFSS]) in a mixed population. Method We selected 133 cases clinically evaluated using MASA and VFSS from January through June 2007. Ordinal risk rating (ORR) and total numeric score (TNS) were evaluated as predictors of aspiration on VFSS. To account for missing items, the maximum possible score was determined and a weighted percentage score calculated for each patient. We used receiver operating characteristic (ROC) analysis to compare the sensitivity and specificity of ORR and TNS for predicting aspiration. Results VFSS identified 51 (38.4%) aspirators, while ORR identified 54 (40.6%) as probable or definite aspiration and TNS 19 (14.3%) as moderate to severe aspiration risk. ROC analysis demonstrated an area under the curve of 0.74, 95% CI [0.66, 0.82], for ORR and 0.51, 95% CI [0.41, 0.61], for TNS. These ROC scores suggest that the MASA ORR is better at predicting aspiration on VFSS than the numeric score. Conclusion In this sample, the subjective ORR had good predictive ability, while the percentage TNS failed to predict aspiration on VFSS. The MASA ORR assessment was a better predictor for a patient’s aspiration risk in this population.

Gonzalez-Fernandez M, Davis C, Molitoris JJ, Newhart M, Leigh R, Hillis AE. Formal education, socioeconomic status, and the severity of aphasia after stroke. Objective To determine the role of education and socioeconomic status on the severity of aphasia after stroke. Design Cross-sectional study. Setting Stroke units of 2 affiliated medical centers. Participants Stroke patients (n=173) within 24 hours of symptom development and hospitalized controls (n=62) matched for age, education, and socioeconomic status (SES) with normative brain magnetic resonance imaging. Interventions Not applicable. Main Outcome Measures Percent error on 9 language tasks (auditory and written comprehension, naming [oral, written, and tactile], oral reading, oral spelling, written spelling, and repetition). Education was recorded in years and dichotomized as less than 12 years or 12 years and above for data analysis. Demographic characteristics (age, sex, race) and stroke volume were recorded for adjustment. SES was obtained from census tract data as 2 variables: mean neighborhood household income and family income. Results The percentage of errors for participants with 12 or more years of education was significantly lower for auditory and written comprehension, written naming, oral reading, oral spelling, and written spelling of fifth grade vocabulary words, even after adjusting for age, sex, stroke volume, and SES. Conclusions These findings suggest that even once learned, access to written word forms may become less vulnerable to disruption by stroke with increasing years of education.

Prehabilitation is the process of enhancing preoperative functional capacity to improve tolerance for the upcoming stressor; it was associated with improved postoperative outcomes in a handful of studies, but never evaluated in transplantation. Kidney transplant (KT) candidates may be uniquely suited for prehabilitation because they experience a profound loss of functional capacity while waiting years on dialysis. To better understand the feasibility and effectiveness of prehabilitation in KT, we conducted a pilot study of center-based prehabilitation for candidates; this intervention consisted of weekly physical therapy sessions at an outpatient center with at-home exercises. We enrolled 24 participants; 18 participated in prehabilitation (75% of enrolled; 17% of eligible). 61% were male, 72% were African American, and mean age = 52 (SD = 12.9); 71% of participants had lower-extremity impairment, and 31% were frail. By 2 months of prehabilitation, participants improved their physical activity by 64% (P = 0.004) based on accelerometry. Participants reported high satisfaction. Among 5 prehabilitation participants who received KT during the study, length of stay was shorter than for age-, sex-, and race-matched control (5 vs 10 days; RR = 0.69; 95% CI:0.50-0.94; P = 0.02). These pilot study findings suggest that prehabilitation is feasible in pretransplant patients and may potentially be a strategy to improve post-KT outcomes.

Objective. To assess demographic and clinical factors associated with celiac plexus neurolysis outcomes. Design. Retrospective clinical data analysis. Setting. A tertiary care, academic medical center. Patients. Forty-four patients with terminal visceral (mostly pancreatic) cancer who failed conservative measures. Interventions. Fifty celiac plexus alcohol neurolytic procedures done for pain control after a positive diagnostic block. Outcome Measures. A successful treatment was predefined as >50% pain relief sustained for ≥1 month. The following variables were analyzed for their association with treatment outcome: age, gender, duration of pain, origin of tumor, opioid dose, type of radiological guidance used, single- vs double-needle approach, type of block (e.g., antero- vs retrocrural), immediate vs delayed neurolysis, volume of local anesthetic employed for both diagnostic and neurolytic blocks, and use of sedation. Results. Those variables correlated with a positive outcome included lower opioid dose and the absence of sedation. Strong trends for a positive association with outcome were found for the use of computed tomography (vs fluoroscopy), and using