This study examines the effects of bolus characteristics, voluntary maneuvers and oropharyngeal stimulation in three groups of neurologically impaired subjects, i.e., 40 patients who have suffered a first CVA in the left frontoparietal area, 40 patients who have suffered a first CVA in the right frontoparietal area, and 40 patients who have suffered a brainstem (medullary) CVA and 60 age matched normal subjects. Lesion site will be corroborated by MRI studies done at three weeks post ictus. All patients will be tested some time between the 3rd and 5th week post ictus. For each lesion site, age will be controlled so that 20 patients between the ages of 40-55 and 20 patients between the ages of 70-85 will be studied. In these three groups of neurogenically impaired subjects, we have an opportunity to examine how bolus characteristics, voluntary maneuvers and oropharyngeal stimulating affect the temporal and biochemical aspects of the four critical portions of the disordered oropharyngeal swallow: 1) the onset off the oral swallow, 2) tongue movement, 3) the onset of the pharyngeal swallow, and 4) the neuromuscular components of the pharyngeal swallow. Patients will be randomized onto one of two protocols which will study the effects of bolus size (both protocols), bolus consistency, bolus temperature, bolus placement, bolus flavor, posture, preswallow stimulation (such, thermal stimulation), and voluntary maneuvers. A swallows will be studied with simultaneous videofluoroscopy and solid state manometry. These studies are designed to determine 1) the normalcy of the patient's oropharyngeal swallow (as compared to similar data collected on normal subjects); 2) the types of swallowing abnormalities seen in patients with specific neurologic lesions; 3) those bolus characteristics, voluntary maneuvers and/or preswallow stimulation techniques which improve the patient's oropharyngeal swallow and can, therefore, be applied clinically; and 4) variables which should be included in the diagnostic evaluation of particular types of neurogenically impaired dysphagic patients. We hypothesize that each type of neurologic patient will exhibit a different profile of response to the variables introduced in this study. We believe left cortical CVA patients will exhibit more normal swallows on cold stimuli, salty stimuli, rough textures and larger bolus volumes, while right CVA patients will exhibit improved swallowing on cold stimuli, thickened consistencies, thermal stimulation, such swallow, and the supraglottic swallow maneuver. We hypothesize that brainstem CVA patients will get most benefit from swallow maneuvers, i.e., supraglottic swallow, effortful swallow and the Mendelsohn maneuver, though we anticipate that all subjects (normal & CVA) will be able to perform these maneuvers consistently, thereby corroborating our underlying hypothesis that many of the specific neuromuscular components of the pharyngeal stage of swallow can be placed under voluntary neural control.
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