Thesis(M.A.)--Case Western Reserve University, 2010 / Title from PDF (viewed on 2010-01-28) Department of Communication Sciences Includes abstract Includes bibliographical references and appendices Available online via the OhioLINK ETD Center

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

The works contained in this dissertation were motivated by a desire to better understand the variability of patient performance on videofluoroscopic assessments of swallowing. Specifically, the variation present in kinematic and temporal measures of swallowing was investigated in three main phases: narrative literature review, healthy swallowing, and disordered swallowing. The primary goals were to identify which factors explain (or do not explain) variation, to develop methods to control for variation and to investigate the association between swallowing physiology and swallowing impairment. The literature reviews revealed wide ranges of variation for kinematic (Chapter 2) and temporal (Chapter 3) measures of swallowing in the existing literature on healthy deglutition. The kinematics (Chapter 4) and timing (Chapter 5) of swallowing were investigated in a prospectively collected sample of young healthy participants stratified by height. One main objective was to investigate the impact of participant size on physiological parameters of swallowing. Finally, kinematic and temporal measures of swallowing were investigated in a sample of patients referred for swallowing assessment (Chapter 6) to explore associations between swallowing physiology and impairment. The findings of this dissertation make several unique contributions to the dysphagia literature. It has demonstrated that inherent variation appears to exist in physiological measures of both healthy and disordered swallowing. Further, when certain sources of variation are controlled (such as participant size), men and women do not demonstrate significant differences for any of the parameters tested. Importantly, this work has demonstrated that participant size impacts the expected extent of hyoid excursion and that this variation can be controlled through normalization of hyoid movement to internal anatomical scalars. Two temporal variables trended toward detecting functional swallowing impairment. Finally, this dissertation provides the first set of normative reference values for parameters of swallowing with an ultra-thin liquid barium. Limitations are acknowledged and future work is suggested.

The works contained in this dissertation were motivated by a desire to better understand the variability of patient performance on videofluoroscopic assessments of swallowing. Specifically, the variation present in kinematic and temporal measures of swallowing was investigated in three main phases: narrative literature review, healthy swallowing, and disordered swallowing. The primary goals were to identify which factors explain (or do not explain) variation, to develop methods to control for variation and to investigate the association between swallowing physiology and swallowing impairment. The literature reviews revealed wide ranges of variation for kinematic (Chapter 2) and temporal (Chapter 3) measures of swallowing in the existing literature on healthy deglutition. The kinematics (Chapter 4) and timing (Chapter 5) of swallowing were investigated in a prospectively collected sample of young healthy participants stratified by height. One main objective was to investigate the impact of participant size on physiological parameters of swallowing. Finally, kinematic and temporal measures of swallowing were investigated in a sample of patients referred for swallowing assessment (Chapter 6) to explore associations between swallowing physiology and impairment. The findings of this dissertation make several unique contributions to the dysphagia literature. It has demonstrated that inherent variation appears to exist in physiological measures of both healthy and disordered swallowing. Further, when certain sources of variation are controlled (such as participant size), men and women do not demonstrate significant differences for any of the parameters tested. Importantly, this work has demonstrated that participant size impacts the expected extent of hyoid excursion and that this variation can be controlled through normalization of hyoid movement to internal anatomical scalars. Two temporal variables trended toward detecting functional swallowing impairment. Finally, this dissertation provides the first set of normative reference values for parameters of swallowing with an ultra-thin liquid barium. Limitations are acknowledged and future work is suggested.

Aim: The aim of this research was to measure functional intraoral pressures using a newly developed method; specifically, three areas were examined. Firstly, this new approach to measurement allowed the equilibrium theory of tooth position to be re-addressed. Secondly, it allowed investigation the patterns of pressure change in the palatal midline during water swallowing. Lastly, this approach allowed a preliminary investigation of the affect of the viscosity of the food ingested on the pressures generated in the mouth. Methods: The participants were 6 healthy volunteers (4 males, 2 females) recruited from the post-graduate students at the University of Otago, School of Dentistry. The age range was 25 to 35 years. All had full permanent dentitions, Angle Class I occlusions (normal) with acceptable overbite and overjet relationship, and none of them had a history of previous orthodontic treatment. For each of the subjects a cast chrome-cobalt baseplate was constructed to house 8 miniature strain gauge pressure transducers (Precision Measurement Co. Michigan). The location of the sensors were standardised as follows: Three sensors were paired on the buccal and lingual surfaces of the central, canine and first molar. Two palatal vault sensors were placed in the midline of the palate, one at level of the distal of the first premolar, and the second slightly anterior to the junction of the hard and soft palate. Simultaneous recordings were taken during a set of tasks including water swallows, saliva swallows and food ingestion. Results: The results showed that swallowing was a highly complex wellcoordinated event, and that each individual had their own unique signature pattern of swallowing, characterised by pressure changes of high frequency, in excess of �1000 kPa/s. Conclusions: The analysis of the pressure acting on the teeth showed that although the pattern and magnitude of pressure generated varied among the group, the observation of waveforms would suggest a tendency for no inherent balance between the buccal and the palatal pressures on the teeth during swallowing for any of the individuals tested. This investigation of the pressure in the midline revealed an aspect previously not fully explored; these experiments showed that there were large and persistent negative pressures generated during swallowing, that preceded the positive pressures and which appear important in bolus propulsion The patterns of swallowing and the magnitudes of pressure generated, changed with the different consistency of the various substances ingested. There was a general trend for increased pressures during swallowing of substrates that are more viscous; water showed the lowest pressures, followed by saliva and finally jelly. Keywords: Tongue pressure, Intraoral pressures, Tongue dynamics, Swallowing.

Safe and efficient swallowing requires integrity of both motor and sensory systems. Prior studies have established that motor impairment in individuals with PD frequently manifests as abnormalities in swallowing biomechanics. In contrast, very few studies have investigated the contribution of sensory impairment towards pharyngeal biomechanics and airway protection in this patient cohort. This area should be addressed in light of evidence that the severity of limb motor dysfunction in PD does not reliably predict severity of dysphagia. Emerging data suggests that dysphagia in PD cannot be solely attributed to motor impairment, but may also be influenced by deficits in sensory aspects of airway protection. As an example, silent aspiration in up to 100% has been reported in individuals with PD due to laryngopharyngeal sensory deficits have. Even so, current research lacks information on the integration of both motor and sensory components that make up the swallowing process. The aim of this study was to document changes in airway protection with age, in PD and across severity levels of PD. The project was comprised of two parts. In part one, three parallel studies were conducted to assess a series of both motor and sensory airway mechanism (Chapters 4 to 9). In the first study, 16 young (8 males, age range 21.3 - 32.4) and 16 elder adults (8 males, age range 61.5 - 84.7), were assessed to investigate changes in airway protection that accompany ageing. In the second study, data from individuals diagnosed with PD across severity levels (Hoehn-Yahr 1 - 4, age range 64.2 - 84.5) were age and gender-matched to 16 healthy elders in order to examine the effects of PD on airway protection. In the third, the impact of disease severity was studied with data from 16 individuals in the earlier stages (Hoehn-Yahr ≤ 2, 13 males, age range 51.3 - 82.5, ) compared to 16 individuals in the later stages (Hoehn-Yahr ≥ 2.5, 10 males, age range 61.5 - 78.9). In part two of this project, two smaller, pilot studies were completed to probe the influence of pharmacologic and behavioural treatments on airway protection mechanisms. In the first pilot study, the effect of pharmacotherapy on airway protection was investigated in 10 patients 'on' and 'off' levodopa (Chapter 10). In the second study, 5 patients were assessed before and after completing the Lee Silverman Voice Treatment (LSVT) to document effects of speech rehabilitation on airway protection (Chapter 11). Multimodality assessment elicited data from all participants on both motor and sensory components of airway protection (Chapter 3). Specifically, breathing-swallowing coordination (BSC) and swallowing apnoea (SA) were captured using simultaneous directional nasal airflow and surface electromyography (sEMG). Standard, closed-loop spirometry was used to assess pulmonary function. Swallowing biomechanics were screened using a validated timed test of swallowing efficiency and further evaluated using fibreoptic endoscopic evaluation of swallowing (FEES). Finally, chemo-sensation of the laryngopharynx was determined with the administration of the inhalation cough challenge while mechanosensation was examined using FEES. Results suggest that motor control for airway protection is reasonably robust in PD, although sensory response is impaired. The predominant pattern for swallowing respiratory coordination was mid-expiration for all participants regardless of age and disease severity (Chapter 4). Individuals with PD demonstrated a reduction in average time and volume per swallow, leading to an overall decrease in swallowing capacity (Chapter 5). No difference was found for swallowing efficiency between those in early and later stages of PD. Pulmonary function measures were not significantly different as a function of age, PD or PD severity (Chapter 6). In summary, results from motor assessments contributing to airway protection support the robustness of breathing-swallowing coordination (BSC) and pulmonary function across research groups, but identify a reduction in overall swallowing efficiency in PD. Results from sensory assessments contributing to airway protection revealed that chemosensation was not different between age groups but base of tongue mechano-sensation was diminished in individuals with PD. Natural cough thresholds did not differ between young adults and elders but when asked to stifle coughing, elders were less able to do so compared to young adults (Chapter 7). For the first time, a reduction in mechano-reception at the base of tongue was recorded in individuals with PD (Chapter 8). These patients also demonstrated increased post swallow residual (Chapter 5), which offers an explanation for the complaint of globus in this population. These assessments highlight some compromise to sensory aspects of airway protection in PD. Overall, dysphagia had a negative impact on the quality of life of individuals with PD and even more as disease severity progresses (Chapter 9). Results from part two of the study looking at the effects of therapeutic interventions on airway protection revealed some unexpected findings. In chapter 10, results showed a reduction in pulmonary function when 'on' levodopa, but no differences in swallowing efficiency, BSC, or laryngopharyngeal chemo- and mechano-reception were observed. These results suggested a reduction in pulmonary function with levodopa without any increase in risk of airway protection compromise1. Unexpectedly and documented for the first time, the percentage of post swallow inspiration increased after LSVT (Chapter 11) but as with the levodopa study, this was also not accompanied by any apparent increase in aspiration risk. An increase in submental surface electromyography (sEMG) amplitude across all 5 participants may serve as a proxy measure of improvement in hyolaryngeal excursion. Finally, participants reported an overall improvement in social functioning and communication after LSVT. In conclusion, this study provided evidence that mechano-sensory aspect of airway protection is diminished in individuals with PD, possibly compromising airway protection. Patients not only demonstrated increased residue but the lack of sensation may prevent clearing or spontaneous multiple swallows. Overall, airway protection is maintained in ageing but swallowing efficiency declines in the presence of PD. This study contributes significantly to current research efforts in PD by expanding on existing reports regarding motor aspects of airway protection. Specifically, BSC, swallowing efficiency and evaluation of biomechanics using FEES research have never before been investigated exclusively in the PD population. Finally, the chemo- and mechano-sensation evaluated in this study are an important addition to the limited evidence that sensory impairment in individuals with PD potentially compromises airway protection. Results of the present study will serve as a platform upon which future studies may compare and expand.

Thesis (M.S.L.T.)--University of Canterbury, 2007. / Typescript (photocopy). Includes bibliographical references (p. 30-34). Also available via the World Wide Web.

Diss. (sammanfattning) Göteborg : Göteborgs universitet, 2007. / Härtill 6 uppsatser.

Thesis (M. Sc. Med.)--University of Sydney, 2008. / Title from title screen (viewed 29 July 2008). Submitted in fulfilment of the requirements for the degree of Master of Science in Medicine to the Discipline of Medicine, Faculty of Medicine. Degree awarded 2008; thesis submitted 2007. Includes bibliographical references. Also available in print form.

Thesis (M.S.)--University of Michigan, 1976.