Exercise for velopharyngeal incompetence in subacute stroke
focus on strength and endurance for the efficacy and safety of
the swallowing process (11). Twenty sessions of conventional
swallowing rehabilitation therapy were conducted for both the
study and the control groups, twice a day, 5 days a week, for 2
weeks, with each session lasing 30 min. Ten sessions of MIE
exercise were conducted for the study group once a day, 5 days
a week, for 2 weeks, with each session lasting 30 min.
Evaluations
Swallowing function was evaluated using the American
Speech-Language-Hearing Association’s National Outcome
Measurement System (ASHA-NOMS), Functional Dysphagia
Score (FDS) and, Penetration Aspiration Scale (PAS) based on
the results of VFSS.
VFSS was performed with the patients in a sitting position
to allow a lateral view. A modified version of the protocol
from a study performed by Logemann was used (18). First, 3
ml of barium-containing thick liquid was administered to the
subject. Then, pureed, semisolid, solid, and thin liquid were
administered in this sequence. All of the food samples contained
barium and were administered 2 or 3 times. All patients received
individualized feeding therapy and dysphagia treatment based
on the results of VFSS.
The ASHA-NOMS criteria were published by the American
Speech-Language-Hearing Association. These criteria comprise
1–8 stages, depending on the patient’s dietary pattern and the
range of possible meals. “Stage 1” indicates the most severe
condition of dysphagia and “Stage 8” indicates the mildest
condition. It correlates with the severity of dysphagia (19).
The FDS is a scale that was developed to quantify dysphagia
severity and it consists of 11 items with weighted values represen-
ting 4 kinds of oral (lip closure, bolus formation, residues in oral
cavity, oral transit time) and 7 kinds of pharyngeal (triggering of
pharyngeal swallow, laryngeal elevation and epiglottic closure,
nasal penetration, residue in valleculae, residue in pyriformis
sinus, coating of pharyngeal wall after swallow, pharyngeal transit
time) functions that can be observed by VFSS (Table I). The FDS
can be used to identify various physiological measures, such as
the aspiration status and nasal penetration of food. The maximum
possible score is 100, achieved by applying different weight va-
lues to each item; thus, it is useful for quantifying the degree of
swallowing difficulty in dysphagia patients and to quantitatively
determine the effectiveness of dysphagia treatment. Among the
11 items, “nasal penetration” is a specific item according to the
VPI severity, the absence of residual food to the nasal cavity was
scored as 0, < 10% of residual food to the nasal cavity as 4 points,
10–50% of residual food as 8 points, and > 50% of residual food
as 12 points for evaluation (20).
The PAS evaluates airway invasions and has a maximum score
of 8 points. Scores are determined primarily based on the depth
to which material passes into the airway and based on whether
material passes below the vocal fold and any effort to make
eject the material. The penetration category corresponds to level
2–5 on the scale, and levels 6–8 correspond to aspiration (21).
In addition, for indirect measurement of the muscle strength
of the pharyngeal muscle involved in the expiration process, the
PCF was measured using a Digital Peak Flow Meter® (Micro
Medical, NY, USA). Before testing, patients were allowed to
use the peak flow meter several times to become accustomed to
the test; after this the patients were asked to make their maximal
effort at least 3 times. PCF was defined as the highest point of
the flow volume of 3 attempts was used for analysis. The PCF
is useful to monitor expiratory muscle weakness and bulbar
involvement in patients with neuromuscular disease (22).
99
Table I. Functional dysphagia scale using videofluoroscopic swallowing
study
Factor Coded value
Lip closure Intact
Bolus formation
Residue in oral cavity, %
Oral transit time, s
Triggering of pharyngeal swallow
Laryngeal elevation and epiglottic closure
Nasal penetration, %
Residue in valleculae, %
Residue in pyriform sinuses, %
Coating of pharyngeal wall after swallow
Pharyngeal transit time
Inadequate
None
Intact
Inadequate
None
None
≤ 10
10–50
≥ 50
≤ 1.5
> 1.5
Normal
Delayed
Normal
Reduced
None
≤ 10
10–50
≥ 50
None
≤ 10
10–50
≥ 50
None
≤ 10
10–50
≥ 50
No
Yes
≤ 1.0s
> 1.0s
Total
Score
0
5
10
0
3
6
0
2
4
6
0
6
0
10
0
12
0
4
8
12
0
4
8
12
0
4
8
12
0
10
0
10
6
6
6
10
12
12
12
12
10
4
4
100
All tests were performed before and after 2 weeks of re-
habilitation therapy under the same conditions by 2 blinded
physiatrists. Basic information of the stroke patients, including
their age, sex, type of stroke, and the time from diagnosis to
VFSS evaluation were also investigated. The study protocol was
approved by the Institutional Review Board, and all participants
provided written informed consent.
Statistical analysis
All statistical analyses were performed with the SPSS ver. 21.0
(SPSS Inc., Chicago, IL USA). Statistical significance was
evaluated with the Wilcoxon signed-rank test for comparing the
results before and after treatment in each group. To investigate
the differences in swallowing function between the 2 groups,
the Mann–Whitney U test was performed. A p-value < 0.05 was
considered statistically significant.
RESULTS
A total of 62 subacute stroke patients with VPI were
initially enrolled. Among them, 21 patients with a past
history of pulmonary disease or neurological damage,
with medical complications that could affect VPI, or
who were unable to cooperate were excluded. The
remaining 41 patients were randomized and divided
into the study group and the control group for treat-
ment. Three patients in the study group and 2 in the
control group were lost to follow-up because of early
J Rehabil Med 51, 2019