-
Folia Phoniatrica Et Logopaedica :... 2023In the past four to five decades, the field of swallowing science has made significant strides in the evaluation and treatment of swallowing disorders (dysphagia).... (Review)
Review
BACKGROUND
In the past four to five decades, the field of swallowing science has made significant strides in the evaluation and treatment of swallowing disorders (dysphagia). Despite these strides, several gaps in knowledge remain and optimal approaches for dysphagia management have yet to be established. Part of this hindrance stems from our relatively limited understanding of the complex underlying swallowing mechanisms which further limits our ability to examine how these mechanisms may be altered in patients with dysphagia and how to optimally target them in therapy. To overcome this hindrance, it is critical that we develop sensitive new tools and methods that will allow for the precise and personalized examination of patients' complex swallowing control and neurophysiological changes, and for the direct targeting of this control to improve treatment effectiveness.
SUMMARY
Herein, the advantages and limitations of current approaches in the study of swallowing biomechanics and central and peripheral swallowing control mechanisms are first summarized. Then, two examples of recent technological advances developed by the author's multidisciplinary team are described, including an integrative MRI sequence that allows for the simultaneous examination of oropharyngeal swallow and brain activity (SimulScan), and a novel wearable surface electromyography sensor technology (i-Phagia) designed for swallowing rehabilitation monitoring. The current state, limitations, and future applications of both technologies are discussed. Upon optimization and validation, such technological advancements can offer unprecedented opportunities to gain direct and precise insights on the swallowing mechanism. Information gained from these and similar new technologies can act as a catalyst for the future development of optimized personalized dysphagia care. By leveraging advances in current methods, multidisciplinary collaborations, and new digital age technologies, the field of dysphagia can take the next giant leap forward in improving clinical care and patient lives.
KEY MESSAGES
There is a critical need to develop sensitive new tools and methods that will allow for the precise and personalized examination of the complex swallowing mechanism and lead to the development of physiology-based and more effective interventions. The digital age is the ideal time to begin leveraging the technological advancements of fields such as imaging, electrophysiology, wearables, and machine learning to advance dysphagia research and practice. A new integrative MRI sequence and a novel wearable surface electromyography sensor technology developed by the author's team are presented, as examples of recent technological advances that can play an important role in the future of personalized dysphagia care.
Topics: Humans; Deglutition Disorders; Deglutition; Treatment Outcome
PubMed: 37247613
DOI: 10.1159/000531265 -
Biomechanics and Modeling in... Feb 2023A FLIP device gives cross-sectional area along the length of the esophagus and one pressure measurement, both as a function of time. Deducing mechanical properties of...
A FLIP device gives cross-sectional area along the length of the esophagus and one pressure measurement, both as a function of time. Deducing mechanical properties of the esophagus including wall material properties, contraction strength, and wall relaxation from these data are a challenging inverse problem. Knowing mechanical properties can change how clinical decisions are made because of its potential for in-vivo mechanistic insights. To obtain such information, we conducted a parametric study to identify peristaltic regimes by using a 1D model of peristaltic flow through an elastic tube closed on both ends and also applied it to interpret clinical data. The results gave insightful information about the effect of tube stiffness, fluid/bolus density and contraction strength on the resulting esophagus shape through quantitive representations of the peristaltic regimes. Our analysis also revealed the mechanics of the opening of the contraction area as a function of bolus flow resistance. Lastly, we concluded that peristaltic driven flow displays three modes of peristaltic geometries, but all physiologically relevant flows fall into two peristaltic regimes characterized by a tight contraction.
Topics: Deglutition; Muscle Contraction; Esophagus; Peristalsis; Body Fluids
PubMed: 36352039
DOI: 10.1007/s10237-022-01625-x -
Dysphagia Jun 2022Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and associated with reductions in quality of life and health-related outcomes. Despite the...
Dysphagia is common in individuals with amyotrophic lateral sclerosis (ALS) and associated with reductions in quality of life and health-related outcomes. Despite the high prevalence of dysphagia in ALS, functional impairment profiles of swallowing safety and efficiency have not been comprehensively examined. We therefore aimed to determine the relative prevalence of unsafe and inefficient swallowing in a large cohort of individuals with ALS. We further sought to examine the impact of global and bulbar disease progression (Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised "ALSFRS-R" total and bulbar scores, respectively), disease duration, and onset type on swallowing impairment profiles. One hundred individuals with ALS completed a standardized videofluoroscopic swallowing examination Two independent and blinded raters performed validated ratings of safety (Penetration-Aspiration Scale, PAS) and efficiency (Analysis of Swallowing Physiology: Events, Kinematics, and Timing, ASPEKT % residue). Binary classifications of safety (unsafe: PAS ≥ 3), efficiency (inefficient: total residue ≥ 3% of C2-4) and global swallowing status were derived. The ALSFRS-R was completed to derive ALSFRS-R total and bulbar subscale scores. Demographic data (disease duration and onset type) for each participant was also recorded. Descriptives, 2 × 2 contingency tables with Fishers exact test, and independent samples t-tests were performed (α = 0.05). Prevalence of unsafe and inefficient swallowing was 48% and 73%, respectively. Global swallowing profiles were, in rank order: unsafe and inefficient (39%), inefficient but safe (34%), safe and efficient (18%), and unsafe but efficient (9%). There were no differences in global disease progression or disease duration across swallowing impairment profiles. ALSFRS-R bulbar subscale scores were significantly lower in unsafe versus safe swallowers, p < 0.05. Spinal onset patients had a greater proportion of safe swallowers as compared to bulbar onset patients (p = 0.000, Fisher's exact test). Both spinal and bulbar onset patients demonstrated a higher prevalence of inefficient swallowers as compared to efficient swallowers (p = 0.04, Fisher's exact test). Dysphagia was prevalent in this group of individuals with ALS. Approximately half demonstrated safety impairments and two-thirds had impairments in swallowing efficiency. Inefficient swallowing was approximately four times more likely to be the initial functional impairment in patients with one pathophysiologic functional impairment. A longitudinal study is needed to examine the temporal evolution of dysphagia in ALS.
Topics: Amyotrophic Lateral Sclerosis; Deglutition; Deglutition Disorders; Disease Progression; Humans; Quality of Life
PubMed: 34037850
DOI: 10.1007/s00455-021-10315-2 -
Current Gastroenterology Reports Aug 2020In the absence of mucosal or structural disease, the aim of investigating the oesophagus is to provide clinically relevant measurements of function that can explain the... (Review)
Review
PURPOSE OF REVIEW
In the absence of mucosal or structural disease, the aim of investigating the oesophagus is to provide clinically relevant measurements of function that can explain the cause of symptoms, identify pathology and guide effective management. One of the most notable recent advances in the field of oesophageal function has been high-resolution manometry (HRM). This review explores how innovation in HRM has progressed and has far from reached a plateau.
RECENT FINDINGS
HRM technology, methodology and utility continue to evolve; simple additions to the swallow protocol (e.g. eating and drinking), shifting position, targeting symptoms and adding impedance sensors to the HRM catheter have led to improved diagnoses, therapeutic decision-making and outcomes. Progress in HRM persists and shows little sign of abating. The next iteration of the Chicago Classification of motor disorders will highlight these advances and will also identify opportunities for further research and innovation.
Topics: Deglutition; Electric Impedance; Esophageal Motility Disorders; Humans; Manometry; Patient Positioning
PubMed: 32767186
DOI: 10.1007/s11894-020-00787-x -
American Journal of Speech-language... Sep 2022The research aims of this review were to (a) map swallowing rehabilitation approaches to specific swallowing impairments using the Modified Barium Swallow Impairment... (Review)
Review
PURPOSE
The research aims of this review were to (a) map swallowing rehabilitation approaches to specific swallowing impairments using the Modified Barium Swallow Impairment Profile (MBSImP) to develop evidence maps, (b) match desired rehabilitation treatment targets to treatment approaches, and (c) identify gaps in the literature and highlight which rehabilitation approaches require further investigation to support accurate mapping of interventions to physiologic change.
METHOD
A mapping review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Scoping Review extension framework. The databases searched were CINAHL, Ovid Medline, and Ovid Embase. Data extracted included swallowing rehabilitation approach details via the Rehabilitation Treatment Specification System framework, study characteristics, and resulting change in swallowing physiology. The resulting change in swallowing physiology was mapped onto MBSImP components, where applicable, and effect sizes were reported where data were available. Extracted data were summarized in the form of evidence maps.
RESULTS
Forty-three unique articles met the inclusion criteria for this review and were divided into single-approach and multi-approach exercise studies. Within single-approach studies, 13 different exercise approaches were investigated, and 117 outcome measures could be mapped to MBSImP components. Within multi-approach studies, 13 different combinations of exercise approaches were investigated and 60 outcome measures could be mapped to MBSImP components.
CONCLUSIONS
This review supports speech-language pathologists in incorporating current best evidence into their practice, as it found there is potential for improvement in many MBSImP components by using rehabilitative exercises. In the future, more intervention studies are needed to ensure that recommended rehabilitation approaches are beneficial for improving the targeted swallowing physiology.
Topics: Adult; Cineradiography; Deglutition; Deglutition Disorders; Exercise Therapy; Humans; Outcome Assessment, Health Care
PubMed: 35868298
DOI: 10.1044/2022_AJSLP-21-00342 -
Dysphagia Feb 2017Feeding, swallowing, and airway protection are three distinct entities. Feeding involves a process of sequential, neurosensory, and neuromotor interactions of reflexes... (Review)
Review
Feeding, swallowing, and airway protection are three distinct entities. Feeding involves a process of sequential, neurosensory, and neuromotor interactions of reflexes and behaviors facilitating ingestion. Swallowing involves anterograde bolus movement during oral-, pharyngeal-, and esophageal phases of peristalsis into stomach. During these events, coordination with airway protection is vital for homeostasis in clearing any material away from airway vicinity. Neurological-airway-digestive inter-relationships are critical to the continuum of successful feeding patterns during infancy, either in health or disease. Neonatal feeding difficulties encompass a heterogeneous group of neurological, pulmonary, and aerodigestive disorders that present with multiple signs posing as clinical conundrums. Significant research breakthroughs permitted understanding of vagal neural pathways and functional aerodigestive connectivity involved in regulating swallowing and aerodigestive functions either directly or indirectly by influencing the supra-nuclear regulatory centers and peripheral effector organs. These neurosensory and neuromotor pathways are influenced by pathologies during perinatal events, prematurity, inflammatory states, and coexisting medical and surgical conditions. Approaches to clarify pathophysiologic mapping of aerodigestive interactions, as well as translating these discoveries into the development of personalized and simplified feeding strategies to advance child health are discussed in this review article.
Topics: Airway Management; Deglutition; Digestive System Diseases; Gastroenterology; Humans; Infant; Infant, Newborn; Neonatology; Pulmonary Medicine; Respiration
PubMed: 28044203
DOI: 10.1007/s00455-016-9773-z -
Journal of Parkinson's Disease 2023Swallowing impairment, including altered physiology and aspiration, occur across the progression of Parkinson's disease (PD). The phase of respiration during which a... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Swallowing impairment, including altered physiology and aspiration, occur across the progression of Parkinson's disease (PD). The phase of respiration during which a swallow is initiated has been linked to swallowing impairment and aspiration in cohorts with dysphagia following stroke and head and neck cancer treatment, but has been understudied in PD. If similar findings are shown in individuals with PD, the implications for swallowing assessment and treatment are significant.
OBJECTIVE
The aim of this systematic review and meta-analysis of literature was to examine respiratory-swallow coordination measures and potential implications on swallowing physiology in individuals with PD.
METHODS
An extensive search of 7 databases (PubMed, EMBASE, Central, Web of Science, ProQuest Dissertations & Theses, Scopus, and CINAHL) with predetermined search terms was conducted. Inclusion criteria were individuals with PD and the use of objective evaluations of respiratory-swallow coordination.
RESULTS
Of the 13,760 articles identified, 11 met the inclusion criteria. This review supports the presence of atypical respiratory swallow patterning, respiratory pause duration and lung volume at swallow initiation in individuals with PD. The meta-analysis estimated an occurrence of 60% of non-expiration-expiration and 40% of expiration-expiration respiratory phase patterns surrounding swallowing.
CONCLUSION
Although this systematic review supports the occurrence of atypical respiratory-swallow coordination in individuals with PD, the evidence is limited by the variability in the methods of data acquisition, analysis, and reporting. Future research examining the impact of respiratory swallow coordination on swallowing impairment and airway protection using consistent, comparable, and reproducible methods and metrics in individuals with PD is warranted.
Topics: Humans; Parkinson Disease; Deglutition; Deglutition Disorders; Respiration
PubMed: 37393516
DOI: 10.3233/JPD-230057 -
Biomedical Engineering Online May 2024Monitoring of ingestive activities is critically important for managing the health and wellness of individuals with various health conditions, including the elderly,...
Monitoring of ingestive activities is critically important for managing the health and wellness of individuals with various health conditions, including the elderly, diabetics, and individuals seeking better weight control. Monitoring swallowing events can be an ideal surrogate for developing streamlined methods for effective monitoring and quantification of eating or drinking events. Swallowing is an essential process for maintaining life. This seemingly simple process is the result of coordinated actions of several muscles and nerves in a complex fashion. In this study, we introduce automated methods for the detection and quantification of various eating and drinking activities. Wireless surface electromyography (sEMG) was used to detect chewing and swallowing from sEMG signals obtained from the sternocleidomastoid muscle, in addition to signals obtained from a wrist-mounted IMU sensor. A total of 4675 swallows were collected from 55 participants in the study. Multiple methods were employed to estimate bolus volumes in the case of fluid intake, including regression and classification models. Among the tested models, neural networks-based regression achieved an R of 0.88 and a root mean squared error of 0.2 (minimum bolus volume was 10 ml). Convolutional neural networks-based classification (when considering each bolus volume as a separate class) achieved an accuracy of over 99% using random cross-validation and around 66% using cross-subject validation. Multiple classification methods were also used for solid bolus type detection, including SVM and decision trees (DT), which achieved an accuracy above 99% with random validation and above 94% in cross-subject validation. Finally, regression models with both random and cross-subject validation were used for estimating the solid bolus volume with an R value that approached 1 and root mean squared error values as low as 0.00037 (minimum solid bolus weight was 3 gm). These reported results lay the foundation for a cost-effective and non-invasive method for monitoring swallowing activities which can be extremely beneficial in managing various chronic health conditions, such as diabetes and obesity.
Topics: Humans; Electromyography; Deglutition; Male; Female; Automation; Signal Processing, Computer-Assisted; Adult; Neural Networks, Computer; Wireless Technology
PubMed: 38760808
DOI: 10.1186/s12938-024-01241-z -
The Cochrane Database of Systematic... May 2014Adequate upper oesophageal sphincter (UOS) opening is critical to safe and efficient swallowing due to the close proximity of the UOS to the airway entrance. Many people... (Review)
Review
BACKGROUND
Adequate upper oesophageal sphincter (UOS) opening is critical to safe and efficient swallowing due to the close proximity of the UOS to the airway entrance. Many people with neurological conditions, progressive and non-progressive, present with UOS dysfunction. The consequences for the person include difficulty swallowing food with subsequent choking and aspiration (passage of material into the trachea beyond the level of the true vocal cords). Clinical complications include aspiration pneumonia, weight loss, dehydration and malnutrition. Tube feeding is often indicated but is associated with increased mortality. Quality of life is also frequently impacted. A range of interventions exist that aim to improve UOS function and swallowing. These include compensatory strategies, rehabilitation techniques, pharmacological interventions and surgery. Over the last two decades, botulinum toxin has been gaining popularity as an intervention for UOS dysfunction, with some evidence to suggest that it is successful in improving swallow function. Despite a number of studies investigating its efficacy, there is a lack of consensus regarding whether this intervention is effective in improving swallowing for individuals with UOS dysfunction associated with neurological disease.
OBJECTIVES
To establish the efficacy and safety of botulinum toxin use aimed at improving UOS dysfunction in people with swallowing difficulties (dysphagia) associated with non-progressive and progressive neurological disease.
SEARCH METHODS
We searched the following electronic databases for published trials: the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (1950 to 2013); EMBASE (1980 to 2013); AMED (Allied and Complementary Medicine) (1941 to 2013); CINAHL (Cumulative Index to Nursing and Allied Health Literature) (1937 to 2013). We also searched major clinical trials registers: CCT (http://www.controlled-trials.com); Clinical Trials (http://www.clinicaltrials.gov); Chinese Clinical Trial Register (www.chictr.org); ACTR (http://www.actr.org.au/. We examined the reference lists of all potentially relevant studies to identify further relevant trials. We handsearched published abstracts of conference proceedings from both the Dysphagia Research Society and the European Society of Swallowing Disorders. Digestive Disease Week (published in Gastroenterology) was also handsearched. Additionally, we searched ProQuest Dissertations & Theses for dissertation abstracts.
SELECTION CRITERIA
Only randomised controlled trials were sought.
DATA COLLECTION AND ANALYSIS
Independent searches were completed by JR, AM, MC and MW. Two review authors (JR and MW) independently inspected titles, abstracts and key words identified from the literature search.
MAIN RESULTS
No randomised controlled studies were retrieved. Twenty-nine studies were excluded, mainly on the basis of trial design.
AUTHORS' CONCLUSIONS
It was not possible to reach a conclusion on the efficacy and safety of botulinum toxin as an intervention for people with UOS dysfunction and neurological disease. There is insufficient evidence to inform clinical practice. Directions for future research are provided.
Topics: Anti-Dyskinesia Agents; Botulinum Toxins; Deglutition; Deglutition Disorders; Esophageal Sphincter, Upper; Humans; Nervous System Diseases
PubMed: 24801118
DOI: 10.1002/14651858.CD009968.pub2 -
Dysphagia Dec 2022There has been a recent shift towards proactive dysphagia intervention in motor neurone disease (MND) to maintain physiological reserve. Pharyngeal high-resolution... (Review)
Review
There has been a recent shift towards proactive dysphagia intervention in motor neurone disease (MND) to maintain physiological reserve. Pharyngeal high-resolution manometry (PHRM) can quantify swallowing pathophysiology to inform and evaluate proactive dysphagia intervention. This study aims to explore the current use of PHRM as a dysphagia evaluation in adults with MND. A scoping review based on the Joanna Briggs Framework was completed. Four electronic databases (PubMed, EMBASE, CINAHL and Web of Science core) were searched (inception to March 2021) by two independent researchers. Data were analysed according to (i) PHRM protocol and analysis methods and the feasibility of same, (ii) swallow biomechanics data and (iii) dysphagia intervention effects as measured by PHRM. Six studies with 78 people with MND (PwMND) were included. There was considerable variation in PHRM protocol and analysis methods. Five studies reported a 100% completion rate and three studies reported no adverse events. Swallow biomechanics data were reported across all studies. The effects of sensory stimulation, increased bolus consistency, effortful swallow and cricopharyngeal myotomy were evaluated using PHRM with 20 PwMND across four studies with varying effects. Literature on the use of PHRM in PwMND is limited. Variability in PHRM methods restricts comparison of metrics. PHRM appears to be a feasible tool for PwMND. PHRM can provide novel swallow physiology data in PwMND and quantify discrete effects of compensatory and surgical dysphagia interventions not detectable by videofluoroscopy or FEES. Further research on the effects of proactive dysphagia intervention as measured by PHRM is required.
Topics: Adult; Humans; Deglutition Disorders; Deglutition; Manometry; Pharynx; Motor Neuron Disease
PubMed: 35235032
DOI: 10.1007/s00455-022-10418-4