Many articles have addressed effective school-based dysphagia management practices. There is not a defined best practice plan available for speech-language pathologists, as the information is spread among various published articles. Four optimal outcomes and the most relevant management suggestions to help guarantee achievement of these outcomes are described. Sufficient information found from published articles describes the areas of referral, team responsibilities, assessment, Individualized Education Plan formulation, and treatment in school-based dysphagia management. This information, along with additional suggestions not frequently mentioned in the articles was added to a proposed school-based dysphagia management model. This model is intended for use as a guide for speech-language pathologists in the schools who do not have a management plan available for use. / text

Background: The prevalence of neonatal dysphagia is increasing, as medical advances contribute to the survival of critically ill and preterm infants. Additional factors such as low birth weight (LBW), gastroesoephageal reflux disorder (GERD), failure to thrive (FTT) and exposure to HIV may increase the complexity of dysphagia symptoms. Knowledge of context-specific risk factors for dysphagia in the neonatal intensive care unit (NICU) may lead to an effective pathway of diagnosis and management in vulnerable neonates. Objective: The objective was to describe the feeding characteristics and categories of underlying medical conditions in 24 to 42 week gestational age infants while still in the NICU and who were referred for feeding and swallowing assessment. Method: The study was a retrospective investigation of 231 purposively selected medical and speech-language therapy records. Participants had a mean stay of 28.5 days in the NICU of a peri-urban public hospital and all had feeding concerns. An existing seven-category framework for the classification of suspected dysphagia was used. Results: Feeding characteristics of the participants demonstrated that 65.0% had previous enteral tube (NGT/OGT) feeding, and only 15.6% were referred for instrumental assessments such as a VFSS by doctors or speech-language therapists (SLTs). The majority of participants used a mixed manner of feeding such as cup and breastfeeding, or cup and syringe feeding. Only 29.7% of participants was able to breastfeed exclusively which was an indication of feeding difficulties as the hospital where the study was conducted promotes exclusive breastfeeding. Results indicated that the majority of participants (90.04%) presented with multiple medical conditions. Underlying neurological conditions (48.48%) and feeding difficulties secondary to systemic illness (65.80%) contributed mostly to suspected dysphagia in the sample. It was found that 70.99% of infants presented with feeding difficulties secondary to other conditions such as LBW and prematurity, highlighting the need for an expanded dysphagia classification framework. Conclusion: The results are in agreement with the outcomes of previous research and confirm the need for a unique classification framework for dysphagia in South Africa. Neonatal dysphagia is a complex condition and frequently associated with multiple risk factors. / Dissertation (M Communication Pathology)--University of Pretoria, 2016. / Speech-Language Pathology and Audiology / MCommunication Pathology / Unrestricted

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This master’s report collected the available literature regarding the multiple treatment approaches for oropharyngeal dysphagia and the efficacy of each approach in the remediation of swallowing deficits. A variety of traditional intervention techniques are described and their efficacy data is presented, as well as limitations and contraindications to intervention. Efficacy data for modern oropharyngeal dysphagia intervention techniques such as Vitalstim and E-stim is also presented, and the differences between the two techniques are discussed. Ethical decision-making in dysphagia treatment is also discussed. / text

Rationale: Lower respiratory tract infections (LRTI) are a common cause of morbidity and mortality in children. Swallowing problems are also common in children. Aspiration is one outcome of swallowing dysfunction that may be a contributing factor to LRTI. Methods: Retrospective review of children undergoing videofluoroscopic swallow study was done to identify the prevalence and correlates of aspiration and LRTI. Results: Aspiration prevalence was 36.6%. Significant factors on univariate analysis included: developmental delay, LRTI, pneumonia, digestive tract anomalies, indigenous heritage, cough and congestion. With logistic regression, congestion and LRTI correlated with aspiration. Prevalence of LRTI was 42%. Using univariate analysis pneumonia, aspiration and indigenous heritage were significant. With logistic regression, respiratory issues and indigenous heritage correlated with LRTI. Conclusion: The etiology of LRTI is complex and multifactoral. Understanding the relationship between all factors is imperative given that current interventions are invasive and the untreated outcome can be progressive lung injury.

The primary aim of this pilot study was to evaluate the effects of a novel dysphagia rehabilitation approach: skill training on swallowing in individuals who have dysphagia secondary to Parkinson’s disease. The secondary objective was to assess skill retention following treatment termination. This within-subject study involved 10 patients with Parkinson’s disease who met the inclusionary criteria. All participants underwent two baseline data collection sessions, conducted two weeks apart. Data collected included the water swallow test, Test of Mastication and Swallowing Solids (TOMASS), ultrasound measurement of hyoid movement and cross-sectional area of submental muscles, surface electromyography (sEMG) of submental muscles, and swallowing-related quality of life questionnaire (SWAL-QOL). Patients then underwent 10 sessions over two weeks of skill training therapy using custom-designed sEMG software. The focus of the treatment was producing swallowing tasks with defined and adjustable temporal and amplitude precision. The skill training treatment phase was followed by an immediate post-intervention assessment session and two weeks later by a retention assessment session. All outcome measures were administered at each data collection point. The study consisted of a total of 14 laboratory sessions, conducted over a six-week period per subject. Results revealed significant improvements in swallowing efficiency for liquids, reduced durational parameters on sEMG, such as pre-motor time (PMT), pre-swallow time (PST), and duration of submental muscle contraction. There was a functional carry-over effect seen from dry swallows, which were the focus of training, to water swallows, which were not directly trained. Additionally, improvements in swallowing-related quality of life were demonstrated. In conclusion, the skill training approach evaluated in this research is able to produce functional, biomechanical, and swallowing-related quality of life improvements in patients with Parkinson’s disease. This indicates the potential effectiveness of this novel approach for dysphagia rehabilitation in this population. However, replication with a larger number of patients with Parkinson’s disease is needed before findings can be generalised to the larger population

Rationale: Lower respiratory tract infections (LRTI) are a common cause of morbidity and mortality in children. Swallowing problems are also common in children. Aspiration is one outcome of swallowing dysfunction that may be a contributing factor to LRTI. Methods: Retrospective review of children undergoing videofluoroscopic swallow study was done to identify the prevalence and correlates of aspiration and LRTI. Results: Aspiration prevalence was 36.6%. Significant factors on univariate analysis included: developmental delay, LRTI, pneumonia, digestive tract anomalies, indigenous heritage, cough and congestion. With logistic regression, congestion and LRTI correlated with aspiration. Prevalence of LRTI was 42%. Using univariate analysis pneumonia, aspiration and indigenous heritage were significant. With logistic regression, respiratory issues and indigenous heritage correlated with LRTI. Conclusion: The etiology of LRTI is complex and multifactoral. Understanding the relationship between all factors is imperative given that current interventions are invasive and the untreated outcome can be progressive lung injury.

Swallowing is an important physiological function leading to nourishment of the organism, controlled by complicated interactions between the muscles, the cranial nerves and multiple brain structures. Swallowing impairments, also called dysphagia, are a major health burden for patients with neurological diseases such as stroke, Parkinson’s disease as well as community dwelling elderly individuals. It has been shown that activation of undamaged swallowing motor cortex compensates for the initial lost swallowing function in stroke patients. Non-invasive brain stimulation provides a tool to explore excitability within the areas of the motor cortex responsible for swallowing muscles. Repetitive transcranial magnetic stimulation (rTMS) is one such technique, with defined frequency parameters, however the underlying reasons for the heterogeneity is responses to low (1Hz) and high (5Hz) frequencies is unclear. These physiological interactions affecting the neurological control of swallowing may be influenced by multiple genes and proteins. Insights into the molecular basis of swallowing through genetic interactions could provide a source of information which can be further used in understanding and treating swallowing impairments. Existing evidence is limited in terms of candidate proteins, genes and pathways which might drive the neural control of swallowing. The aim of my doctoral research was to explore genes which might be involved in swallowing neurophysiology and pathophysiology. My hypothesis is that swallowing due to its complicated physiology is most likely affected by multiple genes and interactions between genes and proteins. To study this hypothesis I used two experimentally distinct study designs. Firstly I explored a number of single nucleotide polymorphisms (SNPs) and potential candidate genes presented in the existing literature. Then, I performed a SNP- and gene-based Genome-Wide Association Study (GWAS) of self-reported swallowing impairments compared with over 500,000 single nucleotide changes. For GWAS I used a group of 555 community dwelling individuals from the Dyne Steel Cohort from the areas of Manchester and Newcastle. Further research involved replication of selected genes and SNPs from literature screening and GWAS using two rTMS paradigms on the largest to date cohort of healthy young volunteers. Forty one volunteers (were assessed for corticobulbar excitability after single-pulse TMS. Repeated measurements of motor evoked potentials from the pharynx and the hand were recorded after the interventions of 1Hz and 5Hz rTMS. The subjects’ individual responses were grouped according to multiple criteria and then associated with factors such as gender, ethnicity, time of day of the stimulation and individual genetic information. GWAS analysis for association with swallowing impairment identified one SNP rs17601696 which achieved genome-wide significance (P-value=5×10(-8)) within a non-coding region of chromosome 10. Gene-based analysis did not result in any genome-wide significant association. In replication of these findings and following a priori selected genes from the literature (BDNF, COMT, TRKB, APOE, DRD2, GRIN2B and GRIN1) from neurophysiological studies applying TMS, two main conclusions were formed. Firstly, rTMS paradigms showed high variability in responses which made the phenotype more complicated. Secondly the result from GWAS could not be confirmed. By contrast, SNP rs6269 from the COMT gene was associated with responsiveness of the pharyngeal MEPs after delivering 1Hz paradigm and rs1800497 from the DRD2 gene with responsiveness after 5Hz rTMS.Lack of replication of the findings between two experiments might be caused by high variability in responsiveness with complex molecular networks of swallowing control where multiple genes with small genetic effects are involved. Although our findings support the hypothesis that molecular markers can be associated with swallowing, more studies are needed to understand the individual factors that determine responsiveness and effectiveness of treatment therapies of swallowing impairments.

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Background: Non-obstructive Dysphagia (NOD) is one of the most common symptoms evaluated using esophageal manometry. Although manometry is considered the gold standard, many NOD patients have normal evaluations. Esophageal function testing with combined multichannel intraluminal impedance and esophageal manometry (MII-EM) is performed using ten 5-mL swallows of a liquid and a viscous material and provides supplemental information about bolus transit. The aim of this study was to evaluate esophageal function using combined MII-EM in patients with NOD who had normal evaluations with liquid manometry. Methods: Multichannel intraluminal impedance and esophageal manometry was performed in consecutive patients presenting for evaluation of NOD. Patients were excluded if any abnormality was detected during liquid manometry. Viscous manometry and liquid and viscous impedance data were analyzed to detect manometric or bolus transit abnormalities. Patients referred for GERD evaluation without any swallowing complaints were used as patient controls and were subject to the same exclusion criteria as the NOD group. All swallow evaluations were performed with 10 liquid and 10 viscous swallows. Key Results: Data from 240 patients were evaluated, 129 with NOD and 111 patient controls. In the NOD group, 9% (12/129) had abnormal liquid impedance and 29% (37/129) had abnormal viscous impedance. In the control group, 4% (4/111) had abnormal liquid impedance and 16% (18/111) had abnormal viscous impedance. Chi-square analysis showed a significant difference between the two study groups for viscous impedance (P = 0.02) but not for liquid impedance (P = 0.12). Conclusions and Inferences: Our data support our belief that a normal liquid manometry with an abnormal viscous impedance analysis in a patient with NOD indicates abnormal esophageal motility. Therefore, viscous impedance should be performed on all patients during the evaluation of NOD.