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Kendrea L Garand,1 Charlie Strange,2 Luca Paoletti,2 Theresa Hopkins-Rossabi,3 Bonnie Martin-Harris3 1Department of Speech Pathology and Audiology, College of Allied Health Professions, University of South Alabama, Mobile, AL 36688, USA; 2Division of Pulmonary, Critical Care, and Sleep Medicine, College of Medicine, Medical University of South Carolina, Charleston, SC 29425, USA; 3Department of Communication Sciences and Disorders, School of Communication, Northwestern University, Evanston, IL 60208, USA Background: Swallowing impairment (dysphagia) has been associated with COPD and may contribute to exacerbations of this chronic and progressive disease. Further, risk of mortality increases with concomitant presence of cachexia in the COPD population. The purpose of this prospective study was to depict oropharyngeal swallowing physiology in underweight patients with stable but advanced-stage COPD. Patients and methods: Ten underweight patients with stable but advanced COPD underwent a modified barium swallow study. Analysis of oropharyngeal swallowing function was completed using the standardized Modified Barium Swallow Impairment Profile and the Penetration–Aspiration Scale. Scores from the Dysphagia Handicap Index and 10-item Eating Assessment Tool were collected to assess patient perception of swallowing difficulty. Findings were compared to age- and sex-matched healthy controls. Results: Significantly higher MBSImP oral total scores (P=0.007) were observed in COPD patients compared to matched controls, but no difference was observed in pharyngeal total scores (P=0.105). Patients with COPD had significantly higher maximum PAS scores compared with controls (P=0.030). There was no significant difference in EAT-10 or DHI scores between patients with COPD and controls (P=0.41 and P=0.08, respectively). Conclusion: Underweight patients with severe but stable COPD present with dysphagia that may not be recognized by the patient. Further investigation is needed to elucidate the interaction between the respiratory–swallowing systems, how muscular weakness may contribute to swallowing impairment, and responsiveness to swallowing treatment. Keywords: COPD, swallowing impairment, MBSImP, dysphagia, underweight

The aim of this study was to test reliability, content, construct, and external validity of a new modified barium swallowing study (MBSS) tool (MBSImp) that is used to quantify swallowing impairment. Multiple regression, confirmatory factor, and correlation analyses were used to analyze 300 in- and outpatients with heterogeneous medical and surgical diagnoses who were sequentially referred for MBS exams at a university medical center and private tertiary care community hospital. Main outcome measures were the MBSImp and index scores of aspiration, health status, and quality of life. Inter- and intrarater concordance were 80% or greater for blinded scoring of MBSSs. Regression analysis revealed contributions of eight of nine swallow types to impressions of overall swallowing impairment (p < or = 0.05). Factor analysis revealed 13 significant components (loadings >/= 0.5) that formed two impairment groupings (oral and pharyngeal). Significant correlations were found between Oral and Pharyngeal Impairment scores and Penetration-Aspiration Scale scores, and indexes of intake status, nutrition, health status, and quality of life. The MBSImp demonstrated clinical practicality, favorable inter- and intrarater reliability following standardized training, content, and external validity. This study reflects potential for establishment of a new standard for quantification and comparison of oropharyngeal swallowing impairment across patient diagnoses as measured on MBSS. [ABSTRACT FROM AUTHOR]

Impaired swallowing physiology is a possible, serious complication in the post-lung transplant population particularly in the acute phase of recovery. Much of the literature has focused solely on the presence of laryngeal penetration and/or aspiration or on post-transplant esophageal testing. However, no literature has explored swallowing function across the swallowing continuum (mouth to stomach) within a single cohort. We performed a retrospective cohort study of post-lung transplant patients at the Medical University of South Carolina. All participants received a high-resolution esophageal manometry (HRM) study pre-transplant and a post-transplant Modified Barium Swallow Study (MBSS) using the Modified Barium Swallow Impairment Profile (MBSImP) protocol. Data were collected for MBSImP, Penetration-Aspiration Scale (PAS), Functional Oral Intake Scale, International Dysphagia Diet Standardization Initiative, and temporal variables (e.g., time from transplant to MBSS). We used descriptive statistics to characterize the outcome variables and performed tests of association (Fisher's exact, Wilcoxon Rank Sum, relative risk, and odds ratio) to examine linkages between pre-transplant HRM findings and post-transplant measures of swallowing impairment. Twenty-six patients were included in this post-lung transplant cohort (mean age 57 years [range 27-70], 50% female). Abnormal esophageal clearance was identified in 85% of patients. The odds of having abnormal esophageal clearance post-transplant were 2 times greater (OR = 2.111) for participants who had an abnormal pre-transplant HRM. Participants with abnormal esophageal clearance had a 67% increased risk for abnormal anterior hyoid excursion and were 60% more likely to have a recommendation for modified food consistencies. All the participants who aspirated (PAS 6-8) on their post-lung transplant MBSS had abnormal esophageal clearance. Post-lung transplant patients appear to have high probability for both oropharyngeal and esophageal swallowing impairment. These findings support the value of post-transplant assessment of oropharyngeal and esophageal swallowing function. Early identification and intervention with behavioral therapies known to target these mechanisms may prevent post-operative complications and hasten recovery. [ABSTRACT FROM AUTHOR]

Respiratory-swallow coordination is a critical component of aspiration prevention and efficient swallowing. In healthy adults, swallowing occurs during the expiratory phase of breathing at mid-to-low tidal lung volume. We hypothesize that disruptions to respiratory-swallowing coordination before lung transplant may contribute to post-transplant swallowing complications. The aim of this study was to explore respiratory-swallow patterning and oropharyngeal swallowing in patients referred for lung transplant evaluation. Patients prospectively referred for Modified Barium Swallow Studies (MBSS) were included. The MBSS were conducted using the standardized Modified Barium Swallow Impairment Profile (MBSImP) protocol. Respiratory kinematics, lung volume, and nasal airflow data were synchronized with videofluoroscopic images. MBSImP composite scores of swallowing impairment were calculated. Lung volume at swallow initiation and respiratory phase patterning were determined using standardized methods. Pulmonary function test results were extracted from the electronic medical record. Descriptive statistics were used to characterize the type and frequency of respiratory-swallow patterning and swallowing impairment. Spearman's Rank correlation coefficients were used to evaluate relationships between respiratory-swallow patterning, pulmonary function, and MBSImP scores. Twenty-five patients were included in the cohort. Ten swallows were analyzed per participant. Seventy-two percent (18/25) of patients displayed aberrant respiratory-swallow patterning on ≥ 1 swallows. Only 58% of swallows were initiated at mid-to-low lung volume and most patients (84%, 21/25) initiated swallows above their target lung volume. All patients demonstrated impairment on ≥ 1 MBSImP physiologic swallowing component; however, only 16% of patients (4/25) had laryngeal penetration. Optimal respiratory-swallow patterning was positively correlated with forced vital capacity (FVC) (r s = 0.58, P=0.002) and forced expiratory volume (FEV 1) (r s = 0.55, P=0.004). The presence of suboptimal respiratory-swallow patterning and physiologic swallowing impairments found in this preliminary study support including MBSS as part of the pre-transplant protocol and looking beyond aspiration as an indicator of risk post-transplant. [ABSTRACT FROM AUTHOR]

In September 2008, an article was published in the Journal of the American Medical Directors Association criticizing current dysphagia assessment and management practices performed by speech-language pathologists in Long-Term Care (LTC) settings. In the same issue, an editorial invited dialogue on the points raised by Campbell-Taylor. We are responding to this call for dialogue. We find Campbell-Taylor's interpretation of the literature to be incomplete and one-sided, leading to misleading and pessimistic conclusions. We offer a complementary perspective to balance this discussion on the 4 specific questions raised: (1) Is the use of videofluoroscopy warranted for evaluating dysphagia in the LTC population? (2) How effective are thickened liquids and other interventions for preventing aspiration and do they contribute to reduction of morbidity? (3) Can aspiration be prevented and is its prevention important? and (4) Is there sufficient evidence to justify dysphagia intervention by speech language pathologists? [ABSTRACT FROM AUTHOR]

Background: The high incidence of dysphagia after acute stroke is likely the result of cumulative effects of the stroke and pre-stroke brain health. While cerebral small vessel disease (cSVD) is recognized as a marker of compromised brain health, it's unclear which neuroanatomical pathologies of cSVD impact post-stroke dysphagia. We assessed the relation between cSVD pathologies, i.e., brain atrophy, white matter hyperintensities (WMH), perivascular spaces, as markers for brain integrity at the time of the stroke, and acute post-stroke dysphagia measured with the Modified Barium Swallow Study (MBSS)., Methods: We conducted a retrospective, observational study of 40 individuals with an acute first-ever ischemic stroke. We segmented T1-weighted images into gray matter, white matter, and cerebrospinal fluid (CSF) to derive brain atrophy estimates. We scored the presence and severity of periventricular and deep WMH using the Fazekas scale and counted perivascular spaces in the basal ganglia following standard guidelines. Swallow impairments were determined with the Modified Barium Swallow Impairment Profile (MBSImP), Penetration-Aspiration Scale, and timing measures (oral (OTT), and pharyngeal transit times (PTT)). We performed regression to assess the relation between cSVD pathologies and swallowing while controlling for the stroke overlap with the right and left corticobulbar tracts, stroke volume, and the number of days between the MRI and MBSS., Results: Worse brain atrophy and more severe periventricular WMH were related to more severe MBSImP pharyngeal total scores, and worse deep WMH were related to aspiration events. More severe perivascular spaces in the basal ganglia were related to longer OTT and PTT, with a high explanatory value (27.5% and 25.1%, respectively), even when controlling for chronological age., Conclusions: Our results suggest that several aspects of pre-stroke brain health impact dysphagia severity after acute stroke independent of the stroke site and size. These findings contribute to our understanding of mechanisms underlying the variability of post-stroke dysphagia and emphasize the importance of brain structural integrity before the stroke. Future larger studies are warranted., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: The purpose of the present study was to use a large swallowing database to explore and compare the swallow-physiology impairment profiles of five dysphagia-associated diagnoses: chronic obstructive pulmonary disease (COPD), dementia, head and neck cancer (HNC), Parkinson's disease (PD), and stroke., Method: A total of 8,190 patients across five diagnoses were extracted from a de-identified swallowing database, that is, the Modified Barium Swallow Impairment Profile Swallowing Data Registry, for the present exploratory cross-sectional analysis. To identify the impairment profiles of the five diagnoses, we fit 18 partial proportional odds models, one for each of the 17 Modified Barium Swallow Impairment Profile components and the Penetration-Aspiration Scale, with impairment score as the dependent variable and diagnoses, age, sex, and race as the independent variables with interactions between age and diagnoses and between PD and dementia (in effect creating a PD with dementia [PDwDem] group). For components with > 5% missingness, we applied inverse probability weighting to correct for bias., Results: PD and COPD did not significantly differ on 13 of the 18 outcome variables (all p s > .02). Dementia, stroke, and PDwDem all showed worse impairments than COPD or PD on five of six oral components (all p s < .007). HNC had worse impairment than all diagnoses except PDwDem for nine of 10 pharyngeal components (all p s < .006). Stroke and HNC had worse penetration/aspiration than all other diagnoses (all p s < .003)., Conclusions: The present results show that there are both common and differing impairment profiles among these five diagnoses. These commonalities and differences in profiles provide a basis for the generation of hypotheses about the nature and severity of dysphagia in these populations. These results are also likely highly generalizable given the size and representativeness of the data set., Supplemental Material: https://doi.org/10.23641/asha.27478245.

A clinical swallow evaluation (CSE) is a noninvasive and indirect assessment of the anatomical and physiological integrity of the swallowing mechanism in a natural setting. A CSE goes beyond a screening, a dichotomized indicator of dysphagia risk, by comprehensively examining the patient's swallowing through gaining sensory and motor information of oral and pharyngeal function. Information obtained from CSEs in combination with medical, social, and environmental patient related factors allow clinicians to make critical decisions about patients' health and quality of life. It is essential that we have assessment tools with rigorous methodological quality to optimize the accuracy of our clinical judgement. The purpose of this study is to investigate the diagnostic validity of clinical observations obtained through the Mann Assessment of Swallowing Ability (MASA) to better inform clinicians regarding the confidence that the items are testing what they are intended to test and reflect indication of true physiologic swallowing impairment and airway invasion. Area Under the ROC Curve (AUC) analyses revealed that the MASA's diagnostic validity showed acceptable accuracy levels for detecting oral impairment and aspiration, and poor accuracy for detecting pharyngeal impairment and penetration. In the cross-validation analysis, the AUC accuracy level for aspiration changed from acceptable to poor, but remained the same for oral impairment, pharyngeal impairment and penetration. In our sample, acceptable levels for detecting aspiration but poor levels for detecting pharyngeal impairment indicate that the MASA does an adequate job of identifying risk but not explaining the nature of impairment. These results support the need for videofluoroscopic imaging to identify the nature and severity of swallowing impairment, guide intervention and provide recommendations for safe and efficient oral intake., Competing Interests: Declarations Competing Interests Dr. Martin-Harris report grants from NIH/NIDCD, during the conduct of the study; Royalties from Northern Speech Services through Medical University of South Carolina Foundation for Research Development, outside the submitted work. Dr. Lee and Dr. Alkhuwaiter have nothing to disclose., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Although swallowing impairment is prevalent following lung transplantation, baseline respiratory and swallowing characteristics are often overlooked. Respiratory disease processes may predispose lung transplant candidates to altered respiratory-swallow patterning and swallowing impairment., Methods: This cross-sectional study included patients referred for a Modified Barium Swallow Study during lung transplant evaluation. Swallowing impairment was measured using the Modified Barium Swallow Impairment Profile and Penetration-Aspiration Scale. Respiratory plethysmographic signals synchronized with videofluoroscopy were analyzed to determine phase patterning, pause duration, and rate. Mixed-effects logistic regression was used to identify linkages between respiratory and swallowing measures., Key Results: Fifty patients were included and demonstrated delayed swallow initiation (49/50), oral residue (37/50), incomplete pharyngoesophageal segment opening (35/50), and esophageal retention (43/50). Airway invasion occurred infrequently (10/50). Atypical respiratory patterning was significantly associated with impairment in pharyngeal swallow initiation (OR [95% CI] = 1.76 [1.16, 2.68], p = 0.009), laryngeal elevation (OR [95% CI] = 1.45 [1.01, 2.07], p = 0.044), and laryngeal vestibular closure (OR [95% CI] = 2.57 [1.48, 4.46], p < 0.001). Increased pause duration was associated with impaired initiation (OR [95% CI] = 2.24 [1.20, 4.16], p = 0.011), laryngeal elevation (OR [95% CI] = 1.18 [1.03, 1.36], p = 0.018), laryngeal closure (OR [95% CI] = 1.28 [1.9, 1.50], p = 0.003), and tongue base retraction (OR [95% CI] = 1.33 [1.13, 1.56], p < 0.001)., Conclusions & Inferences: Patients undergoing evaluation for lung transplant demonstrated impaired swallowing and phase patterning. Preliminary findings implicate the need for further evaluation of respiratory-swallow coordination and its potential role in swallowing impairment before and after lung transplantation., (© 2024 The Author(s). Neurogastroenterology & Motility published by John Wiley & Sons Ltd.)

Purpose: The use of noninvasive respiratory support- namely high flow of oxygen delivered via nasal cannula (HFNC), continuous positive airway pressure (CPAP), and noninvasive ventilation (NIV) - has been expanding in recent years. The physiologic mechanisms underlying each of these forms of support are generally well understood. In contrast, the effects on the sensorimotor mechanisms of swallowing movements, and of breathing and swallowing coordination ─ critical elements of airway protection and bolus clearance ─ remain unclear. The purpose of this systematic review is to assess the existing evidence about the impact of noninvasive respiratory support on swallowing mechanics, airway protection, and respiratory-swallowing patterns in adults., Methods: Six databases (PubMed, EMBASE, Web of Science, Scopus, CINAHL and ProQuest Dissertations & Theses) were searched using predetermined terms. Inclusion criteria were: 1) adult humans 2) use of noninvasive respiratory support, and 3) assessment of swallowing., Results: We identified 8727 articles for screening; 15 met the inclusion criteria. Six studies assessed noninvasive respiratory support in healthy adults, and 9 assessed participants with heterogenous respiratory diagnoses including chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), acute respiratory failure, and chronic respiratory failure due to neuromuscular disease. Risk of bias was assessed using a modified NIH Quality Assessment Tool. In healthy adults, results demonstrated mixed effects of HFNC and CPAP on measures of swallowing function, airway protection, and respiratory swallowing patterns. Negative effects on respiratory-swallowing patterns were reported with NIV. In adults with heterogeneous respiratory diagnoses, six studies reported that HFNC, CPAP, or nasal NIV improved measures of swallowing and respiratory-swallowing patterns. HFNC has mixed effects on swallowing measures in ICU patients. NIV increased atypical respiratory-swallowing patterns in patients with stable COPD., Conclusions: Due to small sample sizes and the wide variation in study designs, the impact of noninvasive respiratory support on swallowing, airway protection, and respiratory-swallowing patterns cannot be confidently assessed based on the current evidence. Future studies using standardized, validated, and reproducible methods to assess the impact of noninvasive respiratory support on swallowing physiology and airway protection are warranted., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Oropharyngeal swallowing impairment frequently occurs following lung transplantation, placing patients at risk of aspiration-related complications and mortality. The primary objectives of this study were to characterize swallowing impairment and explore potential risk factors for aspiration after lung transplantation., Methods: A retrospective review of lung transplant recipients treated between January 2018 and December 2022 that received an instrumental swallow study was conducted. Clinical characteristics, post-operative outcomes, and results of swallow studies were evaluated. Airway invasion was classified using the Penetration-Aspiration Scale (PAS). Swallowing physiology was characterized using the Modified Barium Swallow Impairment Profile. Chi-squared, Wilcoxon signed-rank, Kaplan-Meier, Student's t -tests, and regression analyses were conducted., Results: One hundred eighteen patients underwent lung transplantation and had an instrumental swallow study. Fifty-nine percent (70/118) demonstrated airway invasion. Delayed swallow initiation occurred in all patients that had videofluoroscopy (39/118). Body mass index (BMI) and body surface area (BSA) were significantly lower in patients with airway invasion (24.7±4.5 vs. 26.8±4.6 kg/m 2 , P=0.02; 1.8±0.2 vs. 1.9±0.2 m 2 , P=0.02, respectively), and were associated with airway invasion [odds ratio (OR): 0.91, P=0.02; OR: 0.13, P=0.02]. Intra- and post-operative outcomes and long-term survival did not differ significantly in our cohort., Conclusions: Oropharyngeal swallowing impairment and airway invasion occurred with high frequency, and linkages to low BMI or frailty were found. Although the true prevalence of aspiration after lung transplantation might be underestimated by referral patterns in this cohort, the negative impact of aspiration after lung transplantation may be mitigated by appropriate recognition and intervention., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-707/coif). B.M.H. receives grant funding from the National Institutes of Health (2K24DC012801-07, 1R01CA262502- 01, 1R01DK122975-01) and Bracco Diagnostics Inc., royalties from Northern Speech Services and the Medical University of South Carolina Foundation for Research Development, and consulting fees from Bracco Diagnostics Inc. She holds a US Provisional Patent for wearable sensor technology (US 62/710,324). A.B. is supported by the National Institutes of Health, HL145478, HL147290, and HL147575. The other authors have no conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Dysphagia, a common result of other medical conditions, is caused by malfunctions in swallowing physiology resulting in difficulty eating and drinking. The Modified Barium Swallow Study (MBSS), the most commonly used diagnostic tool for evaluating dysphagia, can be assessed using the Modified Barium Swallow Impairment Profile (MBSImP™). The MBSImP assessment tool consists of a hierarchical grouped data structure with multiple domains, a set of components within each domain which characterize specific swallowing physiologies, and a set of tasks scored on a discrete scale within each component. We lack sophisticated approaches to extract patterns of physiologic swallowing impairment from the MBSImP task scores within a component while still recognizing the nested structure of components within a domain. We propose a Bayesian hierarchical profile regression model, which uses a Bayesian profile regression model in conjunction with a hierarchical Dirichlet process mixture model to (1) cluster subjects into impairment profile patterns while respecting the hierarchical grouped data structure of the MBSImP, and (2) simultaneously determine associations between latent profile cluster membership for all components and the outcome of dysphagia severity. We apply our approach to a cohort of patients referred for an MBSS and assessed using the MBSImP. Our research results can be used to inform appropriate intervention strategies, and provide tools for clinicians to make better multidimensional management and treatment decisions for patients with dysphagia., (© 2024 John Wiley & Sons Ltd.)

Modified Barium Swallow Studies (MBSS) are a critical part of the evaluation, treatment planning, and outcome assessment for persons with swallowing disorders. Since MBSSs use ionizing radiation with associated cancer risks, many clinicians have reduced radiation exposure by reducing the fluoroscopic pulse rate. However, by reducing pulse rate, we also decrease the temporal resolution of MBSSs which has been shown in pilot studies to significantly reduce diagnostic accuracy. Two hundred MBSSs from patients routinely undergoing MBSS as standard of care conducted at 30 pulses per second (pps) using the Modified Barium Swallow Study Impairment Profile (MBSImP™) standardized administration protocol were selected. A stratified sampling method ensured that a full range of swallowing impairments (etiology, type, and severity) was represented. Recordings were down sampled from 30 pps to 15, 7.5, and 4 pps. MBSSs were rated using the MBSImP components and Penetration-Aspiration Scale (PAS) score for each swallow. Percent agreement was calculated across raters for MBSImP and PAS scores by bolus type and volume. The Least-Squares Method was used for hypothesis testing. Statistically significant and clinically meaningful changes in scores of swallowing physiology and penetration/aspiration occurred when reducing pulse rate below 30pps. These changes were evident across bolus types and volumes. Given the impact on diagnostic accuracy and the low radiation risks to adults undergoing MBSSs, reducing pulse rate to 15pps or below is not aligned with the As Low As Reasonably Achievable (ALARA) principle and should not be used as a viable method to reduce radiation exposure from MBSSs., (© 2023. The Author(s).)

Purpose: Tongue manometry (i.e., tongue pressure measurement) is a commonly used assessment for patients with suspected oral-motor involvement in swallowing disorders. Availability of lingual manometry has changed in recent years, with the introduction of the Tongueometer device being a more affordable tongue manometry system. The purpose of this study was to test concurrent (criterion) validity of the Tongueometer compared to the current standard reference device, the Iowa Oral Performance Instrument (IOPI)., Method: Adults without dysphagia were recruited for participation in this study. Standard lingual measurements (swallowing-related pressures, maximum isometric pressure [MIP], and maximum isometric endurance) were recorded, with the bulb anteriorly placed, with both devices, in a randomized order. The Bland-Altman method was used to determine concurrent (criterion) validity of these measurements compared to the clinical standard IOPI device. A recently available suggested corrective value by Curtis et al. (2023) was also applied, with comparisons made between devices both with and without the Curtis correction., Results: The final sample included 70 adult participants aged 20-89 years ( M age = 52.3 years). Measures with the Tongueometer device were significantly lower when compared with the same measures taken using the IOPI ( p < .01) for all measures including MIP, endurance, and swallow pressures. The correction suggested by Curtis and colleagues did not ameliorate these differences., Conclusions: The Tongueometer lingual measurements were consistently lower compared to the IOPI. Clinical use of values taken with the Tongueometer device should be compared to normative data published for each specific device. Available features of each device (e.g., display, bulb texture, technology/application) should be considered when selecting which device to use with an individual patient.

Purpose: The purpose of this study was to test the feasibility for quantifying changes in oropharyngeal swallowing impairment in response to alteration in bolus viscosity using a reliable and valid method of observational measurement-the Modified Barium Swallow Impairment Profile (MBSImP)., Method: This retrospective analysis included a heterogeneous cohort of 119 patients with suspected dysphagia that underwent a videofluoroscopic swallowing study as part of clinical care. Using consensus scoring, two expert clinicians assigned MBSImP scores to components related to oropharyngeal swallowing function between two bolus viscosities (thin liquid and pudding): epiglottic movement, laryngeal elevation, anterior hyoid excursion, tongue base retraction, pharyngeal stripping wave, and pharyngoesophageal segment opening (PESO). Comparisons between the two bolus viscosities were investigated for each component., Results: Higher (worse) scores were observed in the thin-liquid trial compared with the pudding trial for the following MBSImP components: anterior hyoid excursion ( p = .03), epiglottic movement ( p < .001), pharyngeal stripping wave ( p < .001), and PESO ( p = .002). Lower (better) scores were observed in the liquid trial compared with the pudding trial for one component-tongue base retraction (Component 15) only ( p < .001)., Conclusion: These findings provide further evidence for positive influences of viscosity on the swallow mechanism, including influences of sensory feedback on the sensorimotor swallow program.

Many studies include functional swallowing ability and quality of life information to indicate a response to a specific swallowing intervention or to describe the natural history of dysphagia across diseases and conditions. Study results are difficult to interpret because the association between these factors and actual swallowing impairment is not understood. We set out to test the associations between components of physiologic swallowing impairment, functional swallowing ability, and swallow-specific quality of life using standardized and validated measurement tools: Modified Barium Swallow Impairment Profile (MBSImP), Functional Oral Intake Scale (FOIS), Eating Assessment Tool (EAT-10), and Dysphagia Handicap Index (DHI). We specifically aimed to understand which factors may contribute to the overall relationships between these measurement tools when analyzed using total scores and item-level scores. This study included a heterogeneous cohort of 273 outpatients who underwent a modified barium swallow study (MBSS). We found significant correlations between MBSImP total scores and FOIS scores and DHI total scores, but not between MBSImP total scores and EAT-10 total scores. Significant correlations were also found between MBSImP item-level component scores and FOIS scores, EAT-10 total scores, and DHI total scores. Detailed item-level analyses revealed the MBSImP components of bolus transport/lingual motion, oral residue, and tongue base retraction were correlated with EAT-10 item-level scores and DHI item-level scores. The clinically modest associations between physiologic swallowing impairment, functional swallowing ability, and swallow-specific quality of life reveal different factors that uniquely contribute to patients' overall dysphagic profile, emphasizing the clinical impact of a comprehensive swallowing assessment., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Swallowing occurs preferentially in the expiratory phase of the quiet breathing cycle and at mid-to-low tidal volume. This coordinative pattern imparts important biomechanical advantages to swallowing and airway protection and facilitate laryngeal elevation, laryngeal vestibular and vocal fold closure, and cricopharyngeal sphincter opening. This preferred coordinative relationship between breathing and swallowing is impaired in a variety of patient populations, including head and neck cancer survivors with dysphagia. We developed a training protocol to re-establish more optimal phasing of swallowing with breathing in these patients with striking outcomes, including reduced swallowing physiological impairments and improved airway protection. This motivated us to continue to refine and expand this training protocol and develop new assistive technologies for swallowing monitoring outside of the lab. In this review, we highlight the origins of our optimal respiratory-swallowing coordination hypothesis, describe the biomechanical advantages it provides, carefully describe our training protocol and findings, and chart a course for the next phase of this work. Our overall goal is to harness technology combined with carefully constructed learning paradigms to improve the lives of patients with impaired respiratory-swallowing coordination consequent to a variety of pathologies including head and neck cancer and degenerative neurological conditions such as Parkinson's disease., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Spinal pathology is very common with advancing age and can cause dysphagia; however, it is unclear how frequently these pathologies affect swallowing function. This study evaluates how cervical spinal pathology may impact swallowing function in dysphagic individuals observed during videofluoroscopic swallowing studies (VFSSs)., Method: A retrospective case-control study was performed on 100 individuals with dysphagia as well as age-/gender-matched healthy controls (HCs) with available VFSS. Spinal anatomy of patients was classified into two predetermined categories, and a consensus decision of whether spinal pathology influenced swallowing physiology was made. Validated swallow metrics, including Modified Barium Swallow Impairment Profile (MBSImP) component scores, Penetration-Aspiration Scale (PAS) maximum scores, and 10-item Eating Assessment Tool (EAT-10) scores, were compared between the spine-associated dysphagia (SAD), non-SAD (NSAD), and HC groups using Kruskal-Wallis one-way analysis of variance., Results: Most patients with dysphagia had spinal pathology. Spinal pathology was judged to be the primary etiology of dysphagia in 16.9% of patients with abnormal spine pathology. Median EAT-10 scores were statistically different among the three groups, with the NSAD group scoring the highest and the HC group scoring the lowest. Similarly, median PAS scores were significantly different between dysphagic groups and HCs. Median MBSImP Oral Total scores were significantly different only between the NSAD group and HCs, whereas Pharyngeal Total score was not significantly different among the groups., Conclusions: Spinal pathology is commonly observed during VFSS and can contribute to dysphagia, resulting in worse swallowing-related outcomes when compared with HCs. Patients judged to have SAD tended to have better outcomes than patients with dysphagia from other etiologies, perhaps due to the progressive nature of spinal disease that allows for compensatory swallowing physiology over time.

The Modified Barium Swallow Study (MBSS) is a videofluoroscopic examination of the anatomy and physiology involved in swallowing. Like other fluoroscopic examinations, the MBSS uses ionizing radiation with related radiation risks. Thus, the procedures and protocols related to MBSSs must balance the benefit of the diagnostic information gained with the risk of radiation exposure. This requires complex decision-making for any given clinician but becomes complicated due to the interprofessional nature of conducting MBSSs, namely the direct involvement of both the speech-language pathologist and radiologist with indirect involvement of the medical physicist and the referring physician. This editorial provides the perspectives of the various stakeholder groups related to radiation use in adult MBSSs, identifies barriers to conducting MBSSs in an evidence-based manner, and suggests areas for improvement., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The elements of impaired swallowing biomechanics are visually assessed and scored by clinicians using a standardized and validated tool for assessing type and severity of physiological impairments using the Modified Barium Swallow Impairment Profile (MBSImP). However, the functional anatomical correlates that underly noted impairments using MBSImP scoring have not been measured. The purpose of this study was to determine whether differences in MBSImP component scores represent differences in underlying swallowing mechanics as measured by computational analysis of swallowing mechanics (CASM) to better define underlying mechanisms of impairment., Method: A retrospective analysis of modified barium swallow studies from physician-referred adult patients with dysphagia was scored using the MBSImP for laryngeal elevation, anterior hyoid excursion, epiglottic movement, pharyngoesophageal segment opening, and tongue base retraction. A canonical variate analysis (CVA) was performed to determine the movement of anatomical landmarks associated with MBSImP component scores using the CASM method. Mahalanobis distances ( D ) were then used to detect differences among MBSImP scores for each component assessed., Results: CVA showed significant differences ( p < .0001) in Mahalanobis distance ( D > 1) between MBSImP component scores of 0-1, 0-2, 0-3, or 0-4, as applicable, depending on the component. Discriminant function analyses revealed concomitant increase/worsening in MBSImP score with changes in anatomical positioning of structures., Conclusions: Ratings of swallowing impairment and physiology using the MBSImP have distinct biomechanical correlates with anatomical movements of swallowing. These data further demonstrate how swallowing mechanics are highly interrelated. Understanding these linkages between anatomical and physiological movement within impaired swallowing biomechanics is essential in more specific characterization and treatment of dysphagia., Supplemental Material: https://doi.org/10.23641/asha.20816788.

Swallowing is a complex neuromuscular activity regulated by the autonomic nervous system. Millions of adults suffer from dysphagia (impaired or difficulty swallowing), including patients with neurological disorders, head and neck cancer, gastrointestinal diseases, and respiratory disorders. Therapeutic treatments for dysphagia include interventions by speech-language pathologists designed to improve the physiology of the swallowing mechanism by training patients to initiate swallows with sufficient frequency and during the expiratory phase of the breathing cycle. These therapeutic treatments require bulky, expensive equipment to synchronously record swallows and respirations, confined to use in clinical settings. This paper introduces a wireless, wearable technology that enables continuous, mechanoacoustic tracking of respiratory activities and swallows through movements and vibratory processes monitored at the skin surface. Validation studies in healthy adults (n = 67) and patients with dysphagia (n = 4) establish measurement equivalency to existing clinical standard equipment. Additional studies using a differential mode of operation reveal similar performance even during routine daily activities and vigorous exercise. A graphical user interface with real-time data analytics and a separate, optional wireless module support both visual and haptic forms of feedback to facilitate the treatment of patients with dysphagia., (© 2022. The Author(s).)

Purpose: The purpose of this study was to extend the assessment of the psychometric properties of the Modified Barium Swallow Impairment Profile (MBSImP). Here, we re-examined structural validity and internal consistency using a large clinical-registry data set and formally examined rater reliability in a smaller data set., Method: This study consists of a retrospective structural validity and internal consistency analysis of MBSImP using a large data set ( N = 52,726) drawn from the MBSImP Swallowing Data Registry and a prospective study of the interrater and intrarater reliability of a subset of studies ( N = 50) rated by four MBSImP-trained speech-language pathologists. Structural validity was assessed via exploratory factor analysis. Internal consistency was measured using Cronbach's alpha for each of the multicomponent MBSImP domains, namely, the oral and pharyngeal domains. Interrater reliability and intrarater reliability were measured using the intraclass correlation coefficient (ICC)., Results: The exploratory factor analysis showed a two-factor solution with factors precisely corresponding to the scale's oral and pharyngeal domains, consistent with findings from the initial study. Component 17, that is, the esophageal domain, did not load onto either factor. Internal consistency was good for both the oral and pharyngeal domains (α oral = .81, α pharyngeal = .87). Interrater reliability was found to be good with ICC interrater = .78 (95% confidence interval [CI; .76, .80]). Intrarater reliability was good for each rater, ICC Rater-1 = .82 (95% CI [.77, .86]), ICC Rater-2 = .83 (95% CI [.79, .87]), ICC Rater-3 = .87 (95% CI [.83, .90]), and ICC Rater-4 = .87 (95% CI [.83, .90])., Conclusions: This study leverages a large-scale, clinical data set to provide strong, generalizable evidence that the MBSImP assessment method has excellent structural validity and internal consistency. In addition, the results show that MBSImP-trained speech-language pathologists can demonstrate good interrater and intrarater reliability.

Modified Barium Swallow Studies (MBSSs) are important tests to aid the diagnosis of swallowing impairment and guide treatment planning. Since MBSSs use ionizing radiation, it is important to understand the radiation exposure associated with the exam. This study reports the average radiation dose in routine clinical MBSSs, to aid the evidence-based decision-making of clinical providers and patients. We examined the MBSSs of 200 consecutive adult patients undergoing clinically indicated exams and used kilovoltage (kV) and Kerma Area Product to calculate the effective dose. While 100% of patients underwent the exam in the lateral projection, 72% were imaged in the upper posterior-anterior (PA) projection and approximately 25% were imaged in the middle and lower PA projection. Average kVs were 63 kV, 77 kV, 78.3 kV, and 94.3 kV, for the lateral, upper, middle, and lower PA projections, respectively. The average effective dose per exam was 0.32 ± 0.23 mSv. These results categorize a typical adult MBSS as a low dose examination. This value serves as a general estimate for adults undergoing MBSSs and can be used to compare other sources of radiation (environmental and medical) to help clinicians and patients assess the risks of conducting an MBSS. The distinction of MBSS as a low dose exam will assuage most clinician's fears, allowing them to utilize this tool to gather clinically significant information about swallow function. However, as an X-ray exam that uses ionizing radiation, the principles of ALARA and radiation safety must still be applied., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

A widely applied metric for identifying airway invasion events is the Penetration-Aspiration Scale (PAS). PAS scores are often included as primary outcome measures in clinical interventional studies, applied to characterize airway protection in a particular disease, used to establish a normal referent for control group comparisons without dysphagia, and as determinants or predictors of clinical outcomes. Despite the widespread use of the PAS, there is variability in scoring condition. One common method used in research studies includes rater scores applied to each single swallow that occurred during a modified barium swallow study (MBSS) of the same patient. A second common method includes raters scoring single swallow segments that have been spliced from full MBSS from different patients. These single swallow segments are then randomly distributed and the rater is blinded to all swallows that occurred during that patient MBSS. The potential effects of different scoring conditions on rater reliability and score accuracy have not been studied and may have high relevance for the conclusion drawn from the result. The primary aim of this investigation is to determine the impact of two scoring conditions on rater reliability and score accuracy: 1. Contextual, unblinded scoring condition and 2. Randomized, blinded condition. Results of the present study show that no statistically significant differences in PAS rater reliability and score accuracy were found between the two scoring conditions. If findings from this pilot study are reproduced in larger sample sizes, the time and intensity involved in splicing and randomizing MBSS for scoring may not be necessary., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: Translate into Brazilian Portuguese and culturally adapt the component scores definition from the Modified Barium Swallow Impairment Profile - MBSImP videofluoroscopy protocol., Methods: This study was conducted based on international guidelines for creation, translation and transcultural adaptation according to domestic publications for the validation of international speech-language pathology tests. A specialist committee was convened with two otorhinolaryngologists and three speech-language pathologists familiar with videofluoroscopy examinations. Translation into Brazilian Portuguese was carried out by two otorhinolaryngologists with subsequent back translation performed independently by two U.S.-born translators. The final Brazilian Portuguese version was written by speech-language pathologists after revision of translations and back translations resolved semantic, idiomatic, conceptual, linguistic and contextual inconsistencies. This version was tested by committee members, who assessed subjects with no disease, with head and neck cancer and with mild cognitive impairment., Results: Translation of the component scores definition from MBSImP was performed independently and translators agreed on a final version. The MBSImP protocol was renamed "Martin-Harris scale for swallowing videofluoroscopy". Some terms were adapted for the final Brazilian Portuguese version. Use of the translated protocol did not reveal any deviations from the original., Conclusion: Translation of the MBSImP fragment into Brazilian Portuguese was consistent with the original version. Approval from specialist committee members refined the protocol adaptation, allowing precise concepts to be accurately translated.

Introduction: Difficulty swallowing (dysphagia) occurs frequently in patients with neurological disorders and can lead to aspiration, choking, and malnutrition. Dysphagia is typically diagnosed using costly, invasive imaging procedures or subjective, qualitative bedside examinations. Wearable sensors are a promising alternative to noninvasively and objectively measure physiological signals relevant to swallowing. An ongoing challenge with this approach is consolidating these complex signals into sensitive, clinically meaningful metrics of swallowing performance. To address this gap, we propose 2 novel, digital monitoring tools to evaluate swallows using wearable sensor data and machine learning., Methods: Biometric swallowing and respiration signals from wearable, mechano-acoustic sensors were compared between patients with poststroke dysphagia and nondysphagic controls while swallowing foods and liquids of different consistencies, in accordance with the Mann Assessment of Swallowing Ability (MASA). Two machine learning approaches were developed to (1) classify the severity of impairment for each swallow, with model confidence ratings for transparent clinical decision support, and (2) compute a similarity measure of each swallow to nondysphagic performance. Task-specific models were trained using swallow kinematics and respiratory features from 505 swallows (321 from patients and 184 from controls)., Results: These models provide sensitive metrics to gauge impairment on a per-swallow basis. Both approaches demonstrate intrasubject swallow variability and patient-specific changes which were not captured by the MASA alone. Sensor measures encoding respiratory-swallow coordination were important features relating to dysphagia presence and severity. Puree swallows exhibited greater differences from controls than saliva swallows or liquid sips ( p < 0.037)., Discussion: Developing interpretable tools is critical to optimize the clinical utility of novel, sensor-based measurement techniques. The proof-of-concept models proposed here provide concrete, communicable evidence to track dysphagia recovery over time. With refined training schemes and real-world validation, these tools can be deployed to automatically measure and monitor swallowing in the clinic and community for patients across the impairment spectrum., Competing Interests: S.X. and J.A.R. hold equity in the company Sonica Health, which makes wearable sensors for medical applications. A patent on the wireless sensor and methods for medical use has been filed by Northwestern University with J.A.R., S.X., B.M-H., L.R.C., A.J., and M.K.O. as inventors. The remaining authors have no conflicts of interest to declare., (Copyright © 2021 by S. Karger AG, Basel.)