Kinematic Visual Biofeedback Improves Accuracy of Swallowing Maneuver Training and Accuracy of Clinician Cues During Training in Stroke Patients with Dysphagia

Abstract

Background Dysphagia (swallowing impairment) is a common and often life‐threatening problem after stroke. Submental surface electromyography (ssEMG) visual biofeedback is a commonly used clinical tool to train novel swallowing maneuvers, even though its effectiveness has been questioned. Objective To compare the effect of ssEMG and videofluoroscopy (VF) visual biofeedback on swallowing airway protection accuracy when training the volitional laryngeal closure swallowing maneuver (vLVC) in poststroke patients with dysphagia. Researchers also examined whether clinicians accurately judged vLVC performance. The hypothesis was that patient vLVC accuracy and clinician verbal cue accuracy will be greatest with VF (kinematic) visual biofeedback. Patients Nineteen patients with dysphagia post stroke. Setting Outpatient swallowing research laboratory. Design Randomized clinical trial. Methods Patients underwent 2 study phases. Phase 1: first demonstrated ability to perform the vLVC accurately. Phase 2: vLVC training. Participants were randomized into three biofeedback groups including the ssEMG group (ssEMG biofeedback in both phases), the VF group (VF biofeedback in both phases), and the mixed group (VF phase 1, ssEMG phase 2). To promote the best vLVC performance, a clinician provided real‐time, verbal cueing using only the visual biofeedback type also seen by the patient, although both VF and ssEMG were recorded for all participants. Main Outcome Measure Patient performance accuracy and clinician feedback accuracy for performing the vLVC maneuver. Results Both accuracy of vLVC training performance and clinician feedback accuracy were worse in the ssEMG group compared with the VF and mixed groups (P < .001). Conclusions Swallowing airway protection requires precisely timed movements of small, hidden laryngeal and pharyngeal structures. Kinematic biofeedback (VF) may be required, at some point, to ensure that target swallowing movements are being trained during rehabilitation, rather than maladaptive movements. Level of Evidence I.

Implementation of a Home-Based mHealth App Intervention Program With Human Mediation for Swallowing Tongue Pressure Strengthening Exercises in Older Adults: Longitudinal Observational Study

“…The mHealth platform can enhance the delivery of exercise maneuvers through improvements in training accuracy, economic efficiency, safety continuity, and self-management compared with traditional clinician-to-client intervention [ 63 - 66 ]. In this study, we used a biofeedback system involving a mirror function (in effortful prolonged swallowing and effortful tongue rotation) and a real-time pitch graph (in effortful pitch glide), preventing improper or incorrect performance, which may counteract the purpose of the maneuvers and become entrenched [ 67 , 68 ]. In this way, the training accuracy is maintained.…”

Characterizing Effortful Swallows from Healthy Community Dwelling Adults Across the Lifespan Using High-Resolution Cervical Auscultation Signals and MBSImP Scores: A Preliminary Study

“…In addition to this, few accurate and non-invasive methods to provide biofeedback during dysphagia treatment are readily available within clinical settings and few clinicians are trained in deploying these methods [ 1 ]. FEES and VF have been implemented as biofeedback methods for dysphagia treatment and have been shown to be advantageous for patient/caregiver education and developing individualized treatment plans [ 2 – 4 ]. In fact, clinician feedback and participant/patient performance have been shown to be more accurate for certain swallowing maneuvers using VF compared to other biofeedback methods [e.g., surface electromyography (sEMG)] [ 3 , 4 ].…”

“…FEES and VF have been implemented as biofeedback methods for dysphagia treatment and have been shown to be advantageous for patient/caregiver education and developing individualized treatment plans [ 2 – 4 ]. In fact, clinician feedback and participant/patient performance have been shown to be more accurate for certain swallowing maneuvers using VF compared to other biofeedback methods [e.g., surface electromyography (sEMG)] [ 3 , 4 ]. However, dysphagia treatment using only VF for biofeedback is unrealistic within clinical settings due to the cost, radiation exposure, and time constraints/accessibility [ 3 , 4 ].…”

“…In fact, clinician feedback and participant/patient performance have been shown to be more accurate for certain swallowing maneuvers using VF compared to other biofeedback methods [e.g., surface electromyography (sEMG)] [ 3 , 4 ]. However, dysphagia treatment using only VF for biofeedback is unrealistic within clinical settings due to the cost, radiation exposure, and time constraints/accessibility [ 3 , 4 ]. Due to the limitations of FEES and VF as biofeedback methods for treatment, other non-invasive modalities such as sEMG have been explored.…”

“…While research studies have examined differences in temporal kinematic measurements between non-effortful and effortful swallows in healthy adults, no studies have examined differences between non-effortful and effortful swallows using a clinical rating tool (e.g., MBSImP), and few researchers have investigated non-invasive or non-imaging alternatives to VF that are capable of determining whether the effortful swallow maneuver is accurately performed once a patient has been properly trained. Such a system holds potential for enhancing clinician judgment of accurate performance (e.g., clinician feedback to patient) which is the source of accurate clinical cuing and patient performance for effortful swallows to mitigate maladaptive learning of the maneuver [ 3 , 4 ]. Therefore, this study investigated 1.…”