The videofluorographic swallowing study (VFSS) is the definitive test to identify aspiration and other abnormalities of swallowing. When a VFSS is not feasible, nonvideofluorographic (non-VFG) clinical assessment of swallowing is essential. We studied the accuracy of three non-VFG tests for assessing risk of aspiration: (1) the water swallowing test (3 ml of water are placed under the tongue and the patient is asked to swallow); (2) the food test (4 g of pudding are placed on the dorsum of the tongue and the patient asked to swallow); and (3) the X-ray test (static radiographs of the pharynx are taken before and after swallowing liquid barium). Sixty-three individuals with dysphagia were each evaluated with the three non-VFG tests and a VFSS; 29 patients aspirated on the VFSS. The summed scores of all three non-VFG tests had a sensitivity of 90% for predicting aspiration and specificity of 71% for predicting its absence. The summed scores of the water and food tests (without X-ray) had a sensitivity of 90% and specificity of 56%. These non-VFG tests have limitations but may be useful for assessing patients when VFSS is not feasible. They may also be useful as screening procedures to determine which dysphagia patients need a VFSS.

Three tests for predicting aspiration without videofluorography

OBJECTIVE: Powered exoskeletons promise to increase the quality of life of people with lower-body paralysis or weakened legs by assisting or restoring legged mobility while providing health benefits across multiple physiological systems. Here, a systematic review of the literature on powered exoskeletons addressed critical questions: What is the current evidence of clinical efficacy for lower-limb powered exoskeletons? What are the benefits and risks for individuals with spinal cord injury (SCI)? What are the levels of injury considered in such studies? What are their outcome measures? What are the opportunities for the next generation exoskeletons? APPROACH: A systematic search of online databases was performed to identify clinical trials and safety or efficacy studies with lower-limb powered exoskeletons for individuals with SCI. Twenty-two studies with eight powered exoskeletons thus selected, were analyzed based on the protocol design, subject demographics, study duration, and primary/secondary outcome measures for assessing exoskeleton's performance in SCI subjects. MAIN RESULTS: Findings show that the level of injury varies across studies, with T10 injuries being represented in 45.4% of the studies. A categorical breakdown of outcome measures revealed 63% of these measures were gait and ambulation related, followed by energy expenditure (16%), physiological improvements (13%), and usability and comfort (8%). Moreover, outcome measures varied across studies, and none had measures spanning every category, making comparisons difficult. SIGNIFICANCE: This review of the literature shows that a majority of current studies focus on thoracic level injury as well as there is an emphasis on ambulatory-related primary outcome measures. Future research should: 1) develop criteria for optimal selection and training of patients most likely to benefit from this technology, 2) design multimodal gait intention detection systems that engage and empower the user, 3) develop real-time monitoring and diagnostic capabilities, and 4) adopt comprehensive metrics for assessing safety, benefits, and usability. Language: en

https://iopscience.iop.org/article/10.1088/1741-2560/13/3/031001/pdf

Powered exoskeletons for bipedal locomotion after spinal cord injury

Many screening tests for dysphagia can be given at bedside. However, they cannot accurately screen for silent aspiration (SA). We studied the usefulness of a cough test to screen for SA and combined it with the modified water swallowing test (MWST) to make an accurate screening system. Patients suspected of dysphagia (N = 204) were administered a cough test and underwent videofluorography (VF) or videoendoscopy (VE). Sensitivity of the cough test for detection of SA was 0.87 with specificity of 0.89. Of these 204 patients, 107 were also administered the MWST. Fifty-five were evaluated as normal by the screening system, 49 of whom were evaluated as normal by VF or VE. Sixteen were evaluated as "SA suspected" by the screening system; seven of them were normal, and seven were evaluated as having SA by VF or VE. Nineteen were evaluated as aspirating with cough, 14 of whom had aspiration with cough as shown by VF or VE. Seventeen were evaluated as having SA, 15 of whom had SA shown by VF or VE. The cough test was useful in screening for SA. Moreover, a screening system that included MWST and a cough test could accurately distinguish between the healthy who were safe in swallowing and SA patients who were unsafe.

Screening test for silent aspiration at the bedside.

Objective: To identify a most useful and simple clinical screening tool to predict videofluoroscopic aspiration in patients with stroke. Design: Factor analysis of multiple dysphagia variables and sensitivity and specificity testing with chi-square test. Patients: Sixty-one consecutive stroke patients with symptoms suggestive of dysphagia admitted to a university hospital and its 4 affiliated hospitals in Japan. Methods: Factors were extracted from 6 oromotor examinations (lip closure, tongue movement, palatal elevation, gag reflex, voice quality and motor speech function), 2 swallow screen tests (saliva swallowing test and our modified water swallowingtestusing30 mlofwater)and4parameters evaluated with a videofluoroscopic swallow study. Sensitivity and specificityofeachdysphagia-relatedvariablewasdetermined against aspiration in a videofluoroscopic swallow study. Results: Factor analysis revealed that cough/voice change in the water swallowing test and aspiration on videofluoroscopic swallow study belonged to the same factor. Chi-square analysis showed that cough/voice change in the water swallowing test was the only variable that was significantly associated with aspiration on videofluoroscopic swallow study, with a sensitivity of 72% (95% CI: 61‐83%) and a specificity of 67% (CI: 55‐79%) as a predictor of aspiration (p < 0.05). Conclusion: We recommend our modified 30 ml waterswallowing test as a useful single task-screening tool to detect aspiration.

/pdf/identification-of-a-simple-screening-tool-for-dysphagia-in-d54v7ecv40.pdf

Identification of a simple screening tool for dysphagia in patients with stroke using factor analysis of multiple dysphagia variables.

Background: Although poststroke dysphagia is an important issue for determining prognosis, the pathophysiology of oral-phase dysphagia has yet to be clarified due to a lack of adequate devices and protocols. The present study investigated the relationships between swallowing pressure production by the tongue and dysphagia in stroke patients using a newly developed method of tongue pressure measurement with a sensor sheet system. Methods: Subjects were 64 stroke patients, including 30 patients with dysphagia. A T-shaped sensor sheet with 5 measuring points was attached to the hard palate to record tongue pressure while swallowing 5 ml of water. The average maximal magnitude and incidence of abnormalities such as asynchronous and/or polyphasic patterns in tongue pressure waves in 5 locations were compared between patients with and without dysphagia. Results: The average maximal tongue pressure was significantly smaller in patients with dysphagia than in those without dysphagia. Asynchronous and polyphasic patterns showed a sensitivity of 63 and 87%, and a specificity of 91 and 71%, respectively, for identifying patients with dysphagia. Conclusion: Tongue pressure production during swallowing appears closely related to poststroke dysphagia. Tongue pressure measurement appears useful for evaluating the pathophysiology of oral-phase dysphagia in stroke patients.

Relationship between tongue pressure and dysphagia in stroke patients.

131名の機能的嚥下障害患者の「反復唾液嚥下テスト」(the Repetitive Saliva Swallowing Test: RSST)と嚥下ビデオレントゲン造影(videofluorography:VF)所見を比較し,RSSTの妥当性を検討した.RSSTはVF所見と相関が高く,カットオフ値として3回/30秒間が妥当であると思われた.誤嚥の有無の判別に関する感度と特異度は,0.98,0.66と,感度が非常に高かった.摂食・嚥下障害の診断・評価としては,まずRSSTでスクリーニングを行い,3回/30秒間未満の場合はさらに詳細な病歴,身体所見をとり,必要と判断されればVFを行い,治療方針を決定するのが適当である.

https://www.jstage.jst.go.jp/article/jjrm1964/37/6/37_6_383/_pdf

The Repetitive Saliva Swallowing Test(RSST)as a Screening Test of Functional Dysphagia(2)Validity of RSST

Although oropharyngeal and laryngeal structures are essential for swallowing, the three-dimensional (3D) anatomy is not well understood, due in part to limitations of available measuring techniques. This study uses 3D images acquired by 320-row area detector computed tomography ('320-ADCT'), to measure the pharynx and larynx and to investigate the effects of age, gender and height. Fifty-four healthy volunteers (30 male, 24 female, 23-77 years) underwent one single-phase volume scan (0.35 s) with 320-ADCT during resting tidal breathing. Six measurements of the pharynx and two of larynx were performed. Bivariate statistical methods were used to analyse the effects of gender, age and height on these measurements. Length and volume were significantly larger for men than for women for every measurement (P < 0.05) and increased with height (P < 0.05). Multiple regression analysis was performed to understand the interactions of gender, height and age. Gender, height and age each had significant effects on certain values. The volume of the larynx and hypopharynx was significantly affected by height and age. The length of pharynx was associated with gender and age. Length of the vocal folds and distance from the valleculae to the vocal folds were significantly affected by gender (P < 0.05). These results suggest that age, gender and height have independent and interacting effects on the morphology of the pharynx and larynx. Three-dimensional imaging and morphometrics using 320-ADCT are powerful tools for efficiently and reliably observing and measuring the pharynx and larynx.

Anatomy of the larynx and pharynx: effects of age, gender and height revealed by multidetector computed tomography

Nishimura K, Kagaya H, Shibata S, Onogi K, Inamoto Y, Ota K, Miki T, Tamura S, Saitoh E. Accuracy of Dysphagia Severity Scale rating without using videoendoscopic evaluation of swallowing. Jpn J Compr Rehabil Sci 2015; 6: 124-128. Objective: This study compared the Dysphagia Severity Scale (DSS) scores obtained from clinical findings and screening tests by a skilled nurse with the DSS scores obtained by videoendoscopic evaluation of swallowing (VE). Methods: Forty-five dysphagic patients (average age: 75 years) were enrolled in this study between July 2011 and March 2012. DSS scores were obtained from clinical findings and screening tests done by a certified nurse of dysphagia nursing (CNDN). DSS scores were re-evaluated by a dysphagia care team in swallowing rounds using VE. DSS scores obtained using our protocol, CNDN, and swallowing rounds were compared. Results: DSS scores revealed 64% consistency between the protocol and the swallowing rounds, 91% consistency between the CNDN and the swallowing rounds, and 69% consistency between the protocol and the CNDN. Conclusion: Our results indicate that the DSS scores based on clinical findings and screening tests obtained by a skilled CNDN are accurate and consistent with the DSS rating obtained by the swallowing rounds and the protocol.

/pdf/accuracy-of-dysphagia-severity-scale-rating-without-using-22p4wum03h.pdf

Accuracy of Dysphagia Severity Scale rating without using videoendoscopic evaluation of swallowing

Retrospective study of the degree of gait independence achieved by persons with spinal cord injury (SCI) using knee–ankle–foot orthosis with a medial single hip joint (MSH-KAFO). To examine the effects of the neurological level, degree of paresis, age, and inhibitory physical/other factors on the gait with a MSH-KAFO in patients with SCIs. Three university hospitals and two rehabilitation hospitals in Japan. The 45 patients (36 men, nine women) examined included 10 with injuries in the cervical cord between C6 and C8 (group C), 20 with injuries in the upper-middle thoracic cord between T4 and T10 (group UT), and 15 with injuries in the lower thoracic-lumbar cord between T12 and L1 (group TL). Mean age was 34.0 years (range 16–68 years). Of these patients, 13 used the Walkabout, four used the gear joint, and 28 used the Primewalk as the medial hip joint. Recursive partitioning, which predicted the final status of gait from the level, degree of paresis, age, and inhibitory factors, was performed, and a decision tree for gait was constructed. Inhibitory factors were spasticity, involuntary spasms or muscle contractions, pain, contracture, weakness of the upper extremities, and decreased motivation to perform gait exercise. The degree of gait independence was rated on the following five-point scale: outdoor independent gait (5 points), indoor independent gait (4 points), indoor supervised gait (3 points), indoor assisted gait (2 points), and gait within parallel bars (1 point). New branches were added to the decision tree for gait based on the clinical experience, thereby constructing a new decision tree. The coincident ratio between the value predicted on the basis of the decision tree of gait and the value actually observed was 53.3%. The coincident ratio between the value predicted on the basis of the modified decision tree of gait and the actually observed value was 68.9%. The results provide valuable information to medical teams that may assist prescription of gait orthoses.

/pdf/prediction-of-gait-outcome-with-the-knee-ankle-foot-orthosis-18biyianka.pdf

Prediction of gait outcome with the knee-ankle-foot orthosis with medial hip joint in patients with spinal cord injuries: a study using recursive partitioning analysis.

Onogi K, Kondo I, Saitoh E, Kato M, Oyobe T. Comparison of the effects of sliding-type and hingetype joints of knee-ankle-foot orthoses on temporal gait parameters in patients with paraplegia. Jpn J Compr Rehabil Sci 2010; 1: 1-6. Objective: To determine the effi cacy of sliding-type medial hip joint (Primewalk system) and a hinge-type medial hip joint (Walkabout system) of knee-anklefoot orthoses in improving the temporal gait parameters in patients with paraplegia. Methods: The subjects were 7 consecutively recruited patients with paraplegia (6 men and 1 woman; age, 20-45 years). All subjects had got used to the Walkabout system and were trained using the Primewalk system for at least 1 month before the measurements of the temporal gait parameters. The average gait velocity, cadence, and stride length were measured. The pelvic rotation angle was additionally measured in 1 patient. Results: The average gait velocity was higher, cadence was faster, and stride was longer with the Primewalk system than with the Walkabout system. The value for the step length divided by the pelvic rotation angle was larger with the Primewalk system than with the Walkabout system. Conclusion: The Primewalk system improved the gait effi ciency by the sliding mechanism that set the virtual axis of the orthoses hip joint higher than that of the

/pdf/comparison-of-the-effects-of-sliding-type-and-hinge-type-15w1xxbypk.pdf

Keiko Onogi

Papers

The Repetitive Saliva Swallowing Test(RSST)as a Screening Test of Functional Dysphagia(2)Validity of RSST

Anatomy of the larynx and pharynx: effects of age, gender and height revealed by multidetector computed tomography

Accuracy of Dysphagia Severity Scale rating without using videoendoscopic evaluation of swallowing

Prediction of gait outcome with the knee-ankle-foot orthosis with medial hip joint in patients with spinal cord injuries: a study using recursive partitioning analysis.

Comparison of the effects of sliding-type and hinge-type joints of knee-ankle-foot orthoses on temporal gait parameters in patients with paraplegia