Respiratory-swallow coordination (RSC) is critical for safe and efficient swallowing. In healthy adults, RSC is most frequently characterized by an exhale-swallow-exhale pattern initiated within the mid-lung volume range with a respiratory pause of approximately one second. This combination in RSC behaviors is thought to be most optimal for swallowing-related bolus clearance and airway protection. Deviations from these RSC behaviors are observed at disproportionately higher rates in people with Parkinson’s disease (PD) when compared to non-dysphagic, healthy adults. However, little is known about which variables influence RSC in PD, if the RSC behaviors that are most optimal for swallowing in healthy adults are also most optimal for swallowing in PD, and if respiratory-swallow training can be used to successfully rehabilitate suboptimal RSC, swallowing safety, and swallowing efficiency in PD. This dissertation document includes a series of four studies that address these important clinical research questions. Chapter 1 will begin by reviewing the current body of literature as it relates to dysphagia in PD, RSC in healthy adults and PD, respiratory-swallow training as a skill-based treatment for dysphagia rehabilitation, and motor learning considerations for respiratory-swallow skill training in PD. Chapter 2 will be used to examine the relationships among RSC with patient- and swallowing-specific factors in PD. Chapter 2 will also be used to assess the influence of RSC behaviors on measures of swallowing safety (penetration-aspiration) and swallowing efficiency (pharyngeal residue) in PD. Chapter 3 will then evaluate the effects of verbal cueing on RSC in PD as a method of determining if RSC is stimulable for rehabilitative change. Chapter 4 will explore the effects of respiratory-swallow training on swallowing safety and efficiency rehabilitation in a person with mid-stage PD and severe dysphagia within the context of a single-subject experimental design. Chapter 5 will then examine the effects of respiratory-swallow training on dysphagia and RSC rehabilitation within the context of a cohort study. Chapter 5 will also be used to compare the effects of constant versus variable practice in order to explore how principles of motor learning can be used to enhance respiratory-swallow training outcomes. This document will then conclude by synthesizing the results from Chapters 2-5 and by discussing directions for future research.

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Thesis (MScMedSc)--Stellenbosch University, 2015. / ENGLISH ABSTRACT: Swallowing disorders are prevalent in many elderly individuals and are common amongst individuals suffering from neurological diseases. These individuals are affected from slight swallowing difficulty to total swallowing inability. In severe cases this may cause aspiration pneumonia, dehydration, malnutrition and ultimately death. Swallowing disorders can be diagnosed and treated to increase quality of life. New treatment strategies to understand the pathophysiology and impaired swallowing response are needed. Neuromuscular electrical stimulation is used as rehabilitation method in various disciplines. This method of rehabilitation of physiological dysfunction is used in treating swallowing disorders and has become a focus for current research. To understand the effect of electrical stimulation to the swallowing centre it is proposed to study its mechanism on normal swallowing musculature. The outcome of the effect that electrical stimulation has on healthy individuals may possibly be used to extrapolate to clinical settings and its benefit for modern dysphagia rehabilitation. The purpose of this study was to report on the hyo-laryngeal movement pattern of young healthy, male and female, individuals and to measure the effect of a single neuromuscular electrical stimulation session on the hyo-laryngeal complex of 22 young healthy individuals. Lastly, the aim was to determine the detraining or lasting effect on the hyo-laryngeal swallowing complex of a single neuromuscular electrical stimulation session. The study reported on baseline hyo-laryngeal complex movement patterns by measuring the anterior movement and elevation of the hyo-laryngeal complex through the use of videofluoroscopy swallow study. Analysis of these measurements where done to report on the effect of electrical stimulation on the hyo-laryngeal complex movement pattern pre- and post- electrical stimulation. Significant changes were revealed with elevation of the hyo-laryngeal complex, however no significant effects could be found with anterior movement of the hyo-laryngeal complex pre- and post- electrical stimulation. It was found that elevation of the hyo-laryngeal complex lowered after a single electrical stimulation session. The hyo-laryngeal complex movement pattern remained similar between genders. Lastly it was found that a single electrical stimulation session showed significant reversibility towards baseline levels. This might be related to muscle fatigue and one would need to take into account muscle recovery for future research. / AFRIKAANSE OPSOMMING: Sluk versteurings is algemeen onder bejaardes asook individue wat ly aan neurologiese siektes. Hierdie individue word geaffekteer deur matige sluk probleme tot totale sluk onvermoë. In ernstige gevalle kan dit aanleiding gee tot aspirasie longontsteking, dehidrasie, wanvoeding en selfs dood. Sluk versteurings kan gediagnoseer en behandel word om die kwaliteit van lewe te verbeter. Dit is daarom noodsaaklik om die patofisiologiese en verswakte sluk reaksie te verstaan om sodoende nuwe behandeling strategieë te ontwikkel. Neuromuskulêre elektriese stimulasie word gebruik as rehabilitasie tegniek in verskeie dissiplines. Hierdie metode van behandeling van fisiologiese disfunksie word ook gebruik in die behandeling van sluk afwykings en geniet tans baie navorsings aandag. Om die effek van elektriese stimulasie op die sluk sentrum te verstaan word dit dus voorgestel dat die meganisme op die normale sluk spierstelsel bestudeer word. Hierdie bevindinge kan dus moontlik toegepas word op persone met sluk afwykings en sodoende meer effektiewe rehabilitasie tegnieke bevorder. Die doel van hierdie studie was om die effek op die hyo-laringeale bewegings patroon van jong, gesonde, manlike en vroulike individue te bestudeer, asook om verslag te doen oor die uitwerking van 'n enkele neuromuskulêre elektriese stimulasie sessie op die hyo-laringeale kompleks van 22 jong, gesonde individue. Laastens was die doel van hierdie studie ook om die blywende effek van 'n enkele sessie neuromuskulêre elektriese stimulasie op die sluk sentrum te bepaal. Die studie het basislyn hyo-laringeale kompleks bewegings patrone gerapporteer deur die voorwaartse asook opwaartse beweging van die hyo-laringeale kompleks te meet deur gebruik te maak van videofluoroskopie sluk studies. Ontleding van hierdie metings is gedoen om die uitwerking van elektriese stimulasie op die hyo-laringeale kompleks bewegings patroon voor en na elektriese stimulasie te bepaal. Beduidende veranderinge is in die opwaartse beweging van die hyo-laringeale kompleks gevind, alhoewel geen veranderinge gevind is in die voorwaartse beweging van die hyo-laringeale kompleks voor en na elektriese stimulasie nie. Daar is vasgestel dat die opwaartse beweging van die hyo-laringeale kompleks verlaag het na 'n enkele elektriese stimulasie sessie. Verder het die hyo-laringeale kompleks bewegings patroon geen beduidende verskille tussen geslagte getoon nie. Laastens is bevind dat 'n enkele elektriese stimulasie sessie beduidende omkeerbaarheid terug na basislyn vlakke van beweging toon. Dit kan verband hou met die uitputting van die hyo-laringeale spiere as gevolg van die elektriese stimulasie en toekomstige navorsing sal dus uitputting, asook die tempo van herstel in ag moet neem.

Relatively little is known about the role of the basal ganglia and their pathways in human deglutition. Deep Brain Stimulation (DBS) is a treatment for Parkinson Disease (PD) that stimulates the subthalamic nuclei and affords us a model for examining deglutition in humans with known impairment of the basal ganglia. The purpose of this study was to examine the effects of DBS in the ON versus Off conditions on the oral and pharyngeal stages of deglutition in participants with PD. It was hypothesized that DBS in the ON condition would yield improvement in the following dependent variables: oral total composite score, pharyngeal total composite score, pharyngeal transit time, and maximal hyoid bone excursion. Statistically significant differences (improvement) were found for the pharyngeal composite score and pharyngeal transit time in the DBS ON condition. Findings of this study demonstrated that DBS in the ON condition helps to alleviate some of the bradykinesia and hypokinesia associated with PD on the pharyngeal stage of deglutition, but not the oral stage. These findings suggest that Parkinsonian swallowing dysfunction is not solely related to nigrostriatal dopamine deficiency which is purported to be the primary means of DBS alleviation of motor signs. Rather, it may be due to an additional non-dopamine related system of deglutition found in the brainstem.

Resumo: O aumento da expectativa de vida preocupa os profissionais de saúde quanto à qualidade da mesma em idosos. Entre os problemas que surgem com o envelhecimento estão aqueles relacionados com as condições orais e os distúrbios da deglutição. Os distúrbios da deglutição orofaríngea em idosos, particularmente naqueles institucionalizados, causam desnutrição, desidratação e disfagia, aspiração e pneumonia. A dificuldade para deglutir pode ser avaliada inicialmente por testes clínicos fonoaudiológicos da deglutição, os quais apresentam grande heterogeneidade quanto aos sinais clínicos observados e às consistências e volume de alimentos usados. Objetivo: Caracterizar e classificar a deglutição orofaríngea do idoso institucionalizado. Pacientes e Métodos: Foram estudados 47 moradores de uma casa de repouso que ingeriram 4 consistências de alimentos e foram observados quanto à presença de 7 sinais clínicos sugestivos risco de disfagia e de aspiração. As condições oral e nutricional foram determinadas, foram estabelecidas correlações entre consistências e presença de alterações clínicas e foi criada classificação das alterações segundo grau de severidade. Resultados: Foram encontrados 43 indivíduos desdentados, 40% deles com prótese dentária, 38 dos quais com alteração à mastigação para sólido entre 78 alterações nas 4 consistências. Dos 47 indivíduos, cerca de 69% apresentaram alterações à mastigação de sólidos, enquanto que alteração na elevação da laringe e alteração na qualidade vocal foram apresentados, cada uma, por 15,6% deles. Na consistência pastoso grosso cerca de 19% dos idosos apresentavam deglutições múltiplas, enquanto que alteração na elevação da laringe e da qualidade vocal estiveram presentes, cada uma, em 13%. Foram classificados como portadores de alteração de grau leve a moderado... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: The increase in life expectancy concerns health care professionals with regard to the quality of life of the elderly population. Problems arising from ageing include those related to oral condition and deglutition disorders. Oropharyngeal swallowing disorders particularly in institutionalized elderly individuals, cause malnutrition, dehydration, aspiration and pneumonia. Swallowing impairment can be initially evaluated by clinical tests, which present great heterogeneity regarding the clinical signs observed and the consistency and volume of the food used. Objective: To characterize and classify oropharyngeal deglutition in institutionalized elderly individuals by means the bedside clinical evaluation. Patients and methods: Forty-seven nursing home residents were evaluated during ingestion of foods of four consistencies. They were assessed for the presence of 7 clinical signs suggestive of risk dysphagia. Oral and nutritional conditions were determined; correlations between the consistencies and the presence of clinical changes were established and a classification of the alterations according to levels of severity was done. Forty-three toothless individuals were found, of whom 40% had dental prostheses and 38 presented alteration in mastication for solid food among the 78 alterations found for the 4 consistencies. Of the 47 individuals, approximately 69% showed alteration for solid food and impairment of larynx elevation and of vocal quality were each found in 15.6% of the subjects. In thick consistency 19% of the elderly showed repetitive swallowing and alteration in larynx elevation and vocal quality were each present in 13% of the elderly. Seventy-four percent of the individuals were classified as presenting mild to moderate alteration, and 38% of them were malnourished, without differences between age ranges. Discussion: The presence... (Complete abstract click electronic access below) / Orientador: Onivaldo Bretan / Coorientador: Roberta Gonçalves da Silva / Banca: José Vicente Tagliarini / Banca: Giédre Berretin-Félix / Mestre

Várias são as propostas para reabilitação da disfagia orofaríngea, sendo a eletroestimulação neuromuscular (EENM) uma nova modalidade de tratamento. Poucos são os trabalhos que comprovam a eficácia deste tratamento na reabilitação da disfagia e ainda não foram encontrados estudos que verificaram o efeito da EENM em idosos em fase tardia do acometimento vascular encefálico. Assim, o objetivo do presente trabalho foi verificar o efeito, a curto e médio prazo, da terapia da deglutição com EENM sensorial em idosos com sequelas de acidente vascular encefálico (AVE) que foram submetidos à terapia fonoaudiológica convencional sem sucesso, quanto ao nível de ingestão oral, ao quadro de disfagia orofaríngea e à qualidade de vida relacionada à deglutição. Para isto 10 indivíduos idosos, pósacidente vascular encefálico (AVE), que já haviam realizado terapia fonoaudiológica convencional foram classificados quanto ao nível de ingestão oral na escala funcional de ingestão oral (FOIS), submetidos à avaliação instrumental (videofluoroscopia) da deglutição utilizando-se líquido, alimento na consistência de pudim e sólido, a partir da qual foi analisado o grau da disfagia orofaríngea por meio da escala Dysphagia Outcome and Severity Scale (DOSS), realizada a classificação na escala de penetração e aspiração e na escala de resíduos. Também foi realizada a aplicação do protocolo de qualidade de vida relacionado à deglutição SWAL-QOL e aos procedimentos terapêuticos propostos, sendo que os exames foram repetidos imediatamente e três meses após a reabilitação. As sessões de terapia foram realizadas três vezes por semana e distribuídas em quatro semanas, totalizando 12 sessões. Cada sessão consistiu em duas etapas de 10 minutos de exercício, nas quais os pacientes foram solicitados a deglutirem a saliva com esforço, ou umapequena quantidade de água a cada 10 segundos durante a EENM. imediatamente após e três meses após as 12 sessões de terapia, todos os indivíduos foram submetidos novamente às avaliações iniciais. Os resultados demonstram que houve melhora da classificação da deglutição para 4 dos 10 pacientes imediatamente após a intervenção e, após três meses, um paciente ainda melhorou em mais um nível. Na análise estatística foi confirmada diferença significante na classificação da escala DOSS (0,023) entre os períodos. Além disso, houve diferença estatisticamente significante na somatória dos pontos do questionário de qualidade de vida relacionado à deglutição (p=0,008) entre os períodos pré e pós 3 meses de terapia com EENM. Não foram encontradas diferenças entre os períodos da reabilitação quanto ao nível de ingestão oral, classificação da penetração e aspiração, aos resíduos na faringe e aos tempos de trânsito oral e faríngeo (p>0,005). Portanto, a aplicação da eletroestimulação neuromuscular em nível sensorial em idosos acometidos por AVE resultou em diminuição do grau da disfagia em curto e médio prazo, além de melhora na qualidade de vida relacionada à deglutição após três meses de terapia. / There are several proposals for rehabilitation of oropharyngeal dysphagia, and the neuromuscular electrical stimulation (NMES) is a new type of treatment. There are few studies proving the efficiency of this treatment in oropharyngeal dysphagia, and studies verifying the effect of NMES in the elderly in late stage of cerebrovascular impairment haven´t been found yet. Thus, the objective of this study is to verify the short- and medium-term effect of the deglutition therapy with sensorial NMES in elderly patients with stroke sequelae, who underwent conventional speech therapy with no success, regarding the level of oral intake, the oropharyngeal dysphagia condition and the quality of life related to deglutition. In order to achieve such objective, 10 poststroke elderly patients, who had already undergone conventional speech therapy, were classified regarding the level of oral intake according to the functional oral intake scale (FOIS). They underwent swallowing instrumental assessment (fluoroscopy) with liquid, solid food and food in the consistency of pudding, their level of oropharyngeal dysphagia was analyzed by means of the Dysphagia Outcome and Severity Scale (DOSS), and they were rated by means of the penetration and aspiration scale and the waste scale. The SWAL-QOL outcomes tool was also applied regarding the quality of life in deglutition and the therapeutic procedures proposed. The sessions were performed three times per week for 4 weeks, a total of 12 sessions. One session consisted of two 10 minutes exercises with a 2 minutes rest period provided between exercises. Patients were asked to forcefully swallow their saliva or a small amount of water every 10 seconds during stimulation. The exams were repeated immediately and three months after rehabilitation. The results show there was an improvement in the deglutition rating for 4 out of the 10 patients immediately after the intervention and, after three months, one patient improved in one more level. In the statistical analysis, a significant difference was confirmed in the rating of the scale DOSS (0.023) between the periods. Furthermore, there was a statistically significant difference in the sum of the scores of the quality of life questionnaire related to deglutition (p=0.008) between the periods before and after 3-month therapy with NMES. No differences were found between the rehabilitation periods regarding the level of oral intake, the penetration and aspiration rating, the waste in the pharynx and oral and pharyngeal transit times (p>0.005). Therefore, the application of neuromuscular electrical stimulation in sensory level in elderly patients who had stroke resulted in the lowering of the dysphagia level in short- and long- term, in addition to the improvement in the quality of life related to deglutition after three months of therapy.

INTRODUÇÃO: A deglutição é um processo complexo que requer a coordenação precisa de mais de 25 músculos, seis pares de nervos cranianos e os lobos frontais. O comprometimento neste processo, denominado de disfagia, pode aumentar a taxa de morbidade dos pacientes e também o risco para a aspiração, retardando a administração de uma nutrição adequada por via oral. A intubação orotraqueal prolongada, definida na literatura como período superior a 48 horas de intubação, poderá causar alterações na deglutição e ocasionar a disfagia após a extubação. O objetivo deste estudo foi verificar as variáveis independentes da avaliação fonoaudiológica da deglutição que são preditoras do risco de disfagia após intubação orotraqueal prolongada nas Unidades de Terapia Intensiva. MÉTODOS: Foi realizado um estudo transversal observacional. Participaram deste estudo 148 pacientes submetidos à avaliação em beira de leito da deglutição, no período entre setembro de 2009 e setembro de 2011. Todos os pacientes apresentavam histórico de intubação orotraqueal prolongada e foram admitidos em uma das Unidades de Terapia Intensiva de um grande hospital escola brasileiro. Os critérios de inclusão adotados foram: estabilidade clínica e respiratória; pontuação na Escala de Coma Glasgow acima de 14 pontos; idade acima de 18 anos; ausência de traqueostomia; ausência de doenças neurológicas; ausência de disfagia esofágica; ausência de procedimentos cirúrgicos envolvendo a área de cabeça e pescoço. Além disso, os pacientes deveriam ser submetidos à avaliação em beira de leito da deglutição no prazo de 48 horas após a extubação. A análise estatística incluiu a correlação entre os resultados obtidos no teste de deglutição de água e a pontuação do nível da deglutição. RESULTADOS: Os resultados indicaram que a presença de tosse e alteração da ausculta cervical durante a deglutição de água são variáveis preditoras independentes do risco de disfagia para o grupo testado. CONCLUSÃO: O estudo apontou as variáveis preditoras do risco de disfagia em pacientes submetidos à intubação orotraqueal prolongada. / INTRODUCTION: Swallowing is a complex process, that require the precise timing and coordination of more than 25 muscles, six cranial nerves and frontal lobes. Compromise of this process, or dysphagia, can result in profund morbidity, increasing the changes of aspiration and delaying the admistration of proper oral nutrition. It is know that an orotracheal tube might disturb these intricately choreographed events and cause post-extubation dysphagia. Prolonged intubation, typically defined as longer than 48 hours in the literature, is thought to contribute to swallowing dysfunction. The objective of this study is to elucidated independent factors that predict the risk of dysphagia after prolonged orotraqueal intubation in Intensive Care Units patients. METHODS: A cross-sectional, observational study design was used. Participants were 148 consecutive patients who underwent clinical bedside swallowing assessment, from September 2009 to September 2011. All patients presented a history of prolonged orotraqueal intubation and were admitted in one of the several Intensive Care Units of a large Brazilian school hospital. The adopted inclusion criteria were: to present clinical and respiratory stability, to present more than 14 points on the Glasgow Coma Scale; age above 18 years; absence of tracheostomy; absence of neurologic diseases, absence of esophageal dysphagia; absence of surgical procedures involving the head and neck. Also, to be included in the study, patients had to undergo a clinical swallowing assessment within 48 hours after extubation. The statistical analysis included the correlation of the results obtained on a water swallow test and the risk level for dysphagia. RESULTS: Results indicated that altered cervical auscultation and presence of cough during water swallow tests increase the likelihood of dysphagia in patients who underwent prolonged orotracheal intubation. CONCLUSION: The results of the study indicate factors that predict the risk of dysphagia after prolonged orotraqueal intubation.

INTRODUCÃO: O objetivo da reabilitação em disfagia orofaríngea é estabilizar o aspecto nutricional e eliminar os riscos de aspiração laringotraqueal e consequentes complicações associadas. Um estudo sistemático que permita estabelecer o processo de reabilitação fonoaudiológica da disfagia orofaríngea, bem estruturado com base e em evidências e demonstração dos indicadores de qualidade, ainda se faz necessário para nortear a atuação clínica. O objetivo da pesquisa foi a aplicação da primeira fase de um ensaio clínico, onde o PTFDO foi avaliado em seu efeito terapêutico. A medida de efeito adotada foi a manifestação da alteração funcional considerada como mudança benéfica positiva (segurança para deglutição do alimento, por via oral, após a aplicação do tratamento). MÉTODO: Este foi um estudo longitudinal de efeito de tratamento, determinado por medidas comparativas entre pré e pós teste. A população alvo do estudo alvo foram pacientes adultos, encaminhados ao Ambulatório de Disfagia, HCFMUSP, para avaliação e tratamento fonoaudiológico. O período de seleção dos participantes foi de 24 meses, sendo avaliados para elegibilidade todos os pacientes encaminhados pelas equipes médicas do Instituto Central do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Para avaliação clínica fonoaudiológica da deglutição foram aplicados protocolos clínicos padronizados, PARD e PITA. Após a avaliação inicial, foram compostos 3 grupos de alocação, com base no padrão funcional da deglutição. A alocação dos participantes foi realizada com base na classificação do paciente segundo a Escala Funcional ASHA NOMS. Todos os participantes, independente do grupo de alocação, realizaram o mesmo programa terapêutico, composto por número de sessões fechadas, com técnicas especificas, bem como sua frequência e intensidade. As técnicas realizadas nas sessões presenciais, também foram repetidas diariamente pelos participantes. RESULTADOS: Foram incluídos de acordo com os critérios pré-estabelecidos um total de 138 participantes. Nos três grupos existe uma redução significativa dos sinais para disfagia, tendo em comum no pós tratamento a presença de deglutições múltiplas em todos os grupos CONCLUSÃO: Os dados obtidos demonstram efetividade na reabilitação da disfagia orofaríngea por meio da terapia tradicional, utilizando sessões presenciais e orientações em casa, num período de quatro semanas / INTRODUCTION: The aim of rehabilitation in oropharyngeal dysphagia is to stabilize the nutritional aspect and eliminate the risk of tracheal aspiration and subsequent complications associated. A systematic study to establish the process of voice rehabilitation of oropharyngeal dysphagia, well structured and based on evidence and statement of quality indicators are still needed to guide clinical practice. The research objective was the implementation of the first phase of a clinical trial where the PTFDO was valued at its therapeutic effect. The adopted measure of effect was the manifestation of the functional alteration considered positive beneficial change (for food safety swallowing orally, after application of the treatment). METHODS: This was a longitudinal study of treatment effect, determined by comparative measurements between pre and post test. The target study target population been adult patients referred to the Clinic of Dysphagia, HCFMUSP for evaluation and speech therapy. The period of selection of participants was 24 months, being evaluated for eligibility all patients referred by medical personnel of the Central Institute of the Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo. For clinical examination of swallowing were applied standardized clinical protocols, PARD and PITA. After the initial assessment, it was made 3 allocation groups, based on functional pattern of swallowing. The allocation of participants was based on patients\' classification according to Functional Scale ASHA NOMS. All participants, regardless of the allocation group, underwent the same treatment program, consisting of number of closed sessions, with specific techniques as well as their frequency and intensity. The techniques used in classroom sessions were also repeated daily by the participants. RESULTS: We included according to pre-established criteria a total of 138 participants. In all three groups there is a significant reduction in the signs for dysphagia, in common post treatment the presence of multiple swallows in all CONCLUSION groups: The data demonstrate effectiveness in the rehabilitation of oropharyngeal dysphagia through traditional therapy using classroom sessions and guidelines at home, over a four week period

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences