Table 1.
Intervention effect studies
| Level of evidence | Ref. | No. subjects (Etiology) (Gender) | Treatment(s) Group(s) | Biomechanical analysis; Reference points; Calibration, raters, reliability | Measurement hyoid bone motion (outcome); Bolus | Other measurements Tools | Author(s)’ conclusions/key findings |
|---|---|---|---|---|---|---|---|
| A | Shaker et al. [31] |
27 dysphagic patients (variety of causes) (25♂, 2♀) |
Randomized G1: Sham exercise program (N = 7) G2: Head-raising exercise program [N = 27 (including crossover G1–G2)] |
JAVA software Catheter with 3 tantalum markers 2 blinded raters; sufficient reliability |
Videofluoroscopy (maximum superior and anterior hyoid excursion (mm)) Saliva and 5-cc barium |
Videofluoroscopy (spatial and visuoperceptual variables) FOAMS |
The suprahyoid muscle-strengthening exercise program was shown to be effective in restoring oral feeding in a small group of patients with deglutitive failure caused by abnormal UES opening |
| B | Bülow et al. [32] |
8 dysphagic patients (6 CVA, 2 HNC) (4♂, 4♀) |
Chin tuck, supraglottic swallow, effortful swallow Single session |
Known intersensor distance manometric catheter 25 frames/s |
Videofluoroscopy (maximal hyoid excursion (mm)) 10-cc liquid barium (60% w/v) |
Videofluoroscopy (spatial, temporal, and visuoperceptual variables) Manometry |
The major finding was a significant reduction of the depth of contrast penetration when swallowing thin liquid and applying effortful swallow and chin tuck. None of the techniques reduced the number of misdirected swallows |
| B | Logemann et al. [33] | 9 dysphagic HNC patients post chemoradiation therapy | Super-supraglottic swallow | Anterior/superior aspect hyoid bone |
Videofluoroscopy (superior and anterior hyoid excursion at onset of the swallow and at maximal extent (mm)) 1-cc or 3-cc liquid |
Videofluoroscopy (spatial, temporal, and visuoperceptual variables) | The super-supraglottic maneuver in patients who received radiotherapy of the head and neck did improve airway closure at the entrance. Furthermore, the maneuver improved the speed of hyolaryngeal movement, especially early in the swallow as the cricopharyngeal region opens |
| B | Ludlow et al. [34] | 11 chronic dysphagic patients (diverse neurological pathologies) |
Different conditions, random order G1: Stimulation at sensory threshold level during swallow (N = 8) G2: Stimulation at motor threshold level during swallow (N = 10) G3: Stimulation at motor threshold level at rest (N = 10) G4: No therapy/no stimulation (N = 28 trials by N = 11?) Single session |
Anterior/inferior corner C2&C4 anterior/inferior point hyoid Radius of the ball-bearing (9.5 mm) 2 blinded raters, measurement reliability: ICC 0.58–0.99 |
Videofluoroscopy (hyoid position in superior and anterior direction (trajectory in mm)) 5-cc and 10-cc liquid barium |
Videofluoroscopy (spatial and visuoperceptual variables) | Only significant hyoid depression occurred during stimulation at rest. Aspiration and pooling were significantly reduced only with low sensory threshold levels of stimulation and not during maximum levels of surface electrical stimulation. Those patients who showed reduced aspiration and penetration during swallowing with stimulation showed greater hyoid depression during stimulation at rest. Stimulation may have acted to resist patients’ hyoid elevation during swallowing |
| B | Kendall and Leonard [35] |
65 dysphagic patients, 65 years or older (nonspecific causes) Healthy controls: (n = 83) 1. 18–62 years (n = 60) 2. 67–83 years (n = 23) |
Bolus volume modification Single session |
Image software Wire loop (1.7 cm) |
Videofluoroscopy (maximum superior-anterior hyoid excursion) 1-cc and 20-cc liquid barium (60% w/v) |
Videofluoroscopy (spatial and temporal variables) | The distance of hyoid bone elevation is usually greater for the larger bolus categories. Patients elevated the hyoid bone significantly farther than normal during a small-bolus swallow. It was also seen, but to a lesser extent, in the older control group. An increased extent of hyoid bone displacement in older dysphagic subjects may represent a necessary compensation designed to minimize the effect of the short duration of hyoid elevation on the upper esophageal sphincter opening |
| B | Kendall et al. [36] |
20 head and neck cancer patients after radiotherapy Normative value: 60 healthy controls |
Bolus consistency and volume modification Single session |
IMAGE software Wire circle (1.9 cm) 4 blinded raters, interrater reliability 75–90% |
Videofluoroscopy (superior hyoid excursion (cm)) 1-, 3-, and 20-cc liquid and 5-cc paste |
Videofluoroscopy (spatial and visuoperceptual variables) | A significant restriction of hyoid movement was demonstrated in the male radiotherapy patients for all bolus sizes. Following radiotherapy, it appeared that the extent of hyoid displacement may have been limited, especially in men, but was usually held at maximum elevation for a longer duration |
| B | Wintzen et al. [37] |
21 Parkinson (PD) patients (17♂, 5♀) Excluding N = 1 (faint hyoid shadow) Healthy controls: (n = 15) (4♂, 11♀) |
Bolus volume modification Single session |
Y-axis parallel to the cervical spine Height of C3 |
Videofluoroscopy (superior hyoid excursion, hesitations hyoid bone (% of vertebral height C3)) Saliva, 3-, 6-, 9-cc and 12-cc barium-opaque fluid |
The adaptive descent of the hyoid bone at starting position was not seen in PD patients. This lack of adaptation was interpreted as a consequence of hypokinesia. Furthermore, PD patients showed an increased frequency of hesitancy during the onset of swallowing. Increasing bolus volumes showed no evident variation in amplitude of hyoid bone movement, neither in PD patients nor in controls | |
| A | Logemann et al. [38] |
14 chronic dysphagic patients (HNC, stroke) Excluding N = 5 (no follow-up assessments) |
G1: Shaker exercise (N = 5) G2: Traditional swallowing exercises (super-supraglottic maneuvers, Mendelsohn maneuvers, tongue exercises) (N = 6) and bolus modification |
ImageJ software Anterior/superior corner hyoid bone Penny (1.78 cm) 2 blinded raters, reliability >95% |
Videofluoroscopy (anterior and superior hyoid excursion (cm)) 5- and 10-cc liquid barium and 3-cc barium pudding |
Videofluoroscopy (spatial and visuoperceptual variables) | Shaker exercise and traditional therapy result in different effects. The Shaker patients exhibited a greater reduction in postswallow aspiration. Traditional therapy resulted in significant improvements in biomechanical measures. However, because of the small number of patients, caution is necessary in interpreting the data |
| B | Carnaby-Mann and Crary [39] |
5 chronic dysphagic patients (3 stroke, 2 HNC, 1 traumatic brain injury) Excluding N = 1 (unrelated adverse effects) (4♂, 2♀) |
15 sessions NMES and swallowing maneuvers and bolus modification |
ImageJ software Anterior/inferior corners C2&C4j Anterior/inferior point hyoid bone Vertical dimension anterior border C3 (15 mm) 2 blinded raters; interjudge reliability: ICC 0.89 (0.72–0.96); intrajudge reliability: ICC 0.94 (0.85–0.97) |
Videofluoroscopy (superior hyoid excursion (mm)) 5- and 10-cc thin liquid and nectar thick liquid |
Videofluoroscopy (spatial and visuoperceptual variables) MASA/FOIS | Significant change was demonstrated for clinical swallowing ability, functional oral intake, weight gain, and patient perception of swallowing ability. Hyoid and laryngeal elevation during swallowing demonstrated bolus-specific patterns of change. A systematic therapy for chronic pharyngeal dysphagia using adjunctive NMES produced improvement in clinical swallowing ability and functional oral intake without significant weight loss or complications |
| B | Ciucci et al. [40] |
14 Parkinson patients (12♂, 2♀) |
Deep brain stimulation (DBS) and bolus volume and consistency modification Single session |
Aligning the calibration, orbital cavity and posterior nasal spine Anterior/inferior edge hyoid bone Disk (1.8 cm) 2 blinded raters, intrarater reliability: 94–98%; interrater reliability 91–98% |
Videofluoroscopy (maximum hyoid bone excursion (cm)) 5- and 10-cc liquid barium (60% w/v), 7 g of graham cracker coated with barium sulfate esophageal cream (60%w/v) |
Videofluoroscopy (temporal and visuoperceptual variables) | Subthalamic DBS appeared to improve timing and muscle excursion for some aspects of the pharyngeal stage, as shown by improved pharyngeal total composite score and pharyngeal transit time in the stimulated condition. Hyoid bone excursion was not significantly influenced by DBS condition |
| B | Suiter et al. [41] |
18 dysphagic tracheostomy patients (14 with cuff) (variety of causes) (13♂, 5♀) |
Randomization One-way tracheostomy speaking valve, cuff inflation and deflation and bolus consistency modification Single session |
One-cent coin on left mandible 2 blinded raters |
Videofluoroscopy (maximum superior and anterior hyoid excursion (mm)) 2 liquid barium boluses (60% w/v), 2 puree boluses (apple sauce with barium powder 4:1) |
Videofluoroscopy (spatial, temporal, and visuoperceptual variables) | Cuff status had no effect on penetration or aspiration. One-way speaking valve placement significantly reduced scores on the penetration-aspiration scale for the liquid bolus |
| B | Logemann et al. [42] |
8 dysphagic HNC patients with tracheostomy tube (5 oral cancer, 3 laryngeal cancer) (7♂, 1♀) |
Digital occlusion tracheostomy Single session |
Anterior/inferior corner C2&C4 Anterior/superior aspect hyoid bone Diameter of a coin |
Videofluoroscopy (maximum anterior and superior hyoid hyoid excursion (mm)) 3-cc liquid barium |
Videofluoroscopy (spatial, temporal, and visuoperceptual parameters) | Light digital occlusion of the tracheostomy tube may improve the swallow biomechanically and may also eliminate aspiration. However, the results vary from individual to individual, and the effects must be assessed for each patient videofluoroscopically |
G1 first group, G2 second group, JAVA Jandel Scientific, San Mateo, CA, Visuoperceptual data including only qualitative measurements of the swallowing act like the penetration-aspiration scale, FOAMS functional outcome assessment of swallowing, UES upper esophageal sphincter, CVA cerebrovascular accident, HNC head and neck cancer, w/v weight per volume, C cervical vertebrae, ICC intraclass correlation coefficient, NIH Bethesda, MD, NMES neuromuscular electrical stimulation, MASA Mann Assessment of Swallowing Ability, FOIS functional oral intake scale