Braz. j. . vol.81 número1

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Brazilian

Journal

of

OTORHINOLARYNGOLOGY

www.bjorl.org

ORIGINAL

ARTICLE

Dysphagia

progression

and

swallowing

management

in

Parkinson’s

disease:

an

observational

study

夽

,

夽夽

Karen

Fontes

Luchesi

∗

_,

_Satoshi

_Kitamura,

_Lucia

_Figueiredo

_Mourão

UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil

Received1June2013;accepted3March2014 Availableonline8October2014

KEYWORDS Parkinsondisease; Deglutition;

Diseaseprogression; Deglutitiondisorders; Speechtherapy

Abstract

Introduction:Dysphagiaisrelativelycommoninindividualswithneurologicaldisorders.

Objective:To describethe swallowingmanagementand investigate associated factorswith swallowinginacaseseriesofpatientswithParkinson’sdisease.

Methods:Itisalong-termstudywith24patients.Thepatients wereobservedinafive-year period (2006---2011).Theyunderwent FiberopticEndoscopicEvaluation ofSwallowing, Func-tionalOralIntakeScaleandtherapeuticinterventioneverythreemonths.Inthetherapeutic interventiontheyreceivedorientationaboutexercisestoimproveswallowing.TheChi-square, Kruskal---WallisandFisher’stestswereused.Theperiodoftimeforimprovementorworsening ofswallowingwasdescribedbyKaplan---Meieranalysis.

Results:Duringthefollow-up,tenpatientsimproved,fivestayedthesameandnineworsened theirswallowingfunctionality.Themediantimeforimprovementwastenmonths.Priortothe worseningtherewasamediantimeof33monthsoffollow-up.Therewasnoassociatedfactor withimprovementorworseningofswallowing.The maneuversfrequently indicatedin ther-apeuticinterventionwere:chin-tuck,bolusconsistency,boluseffect, strengthening-tongue, multipleswallowsandvocalexercises.

Conclusion:Theswallowingmanagementwascharacterized byswallowingassessmentevery threemonthswithindicationofcompensatoryandrehabilitationmaneuvers,aimingtomaintain theoralfeedingwithoutrisks.Therewasnoassociatedfactorwithswallowingfunctionalityin thiscaseseries.

夽 _Please_cite_this_article_as:_Luchesi_KF,_Kitamura_S,_Mourão_LF._Dysphagia_progression_and_swallowing_management_in_{Parkinson’s}_disease: anobservationalstudy.BrazJOtorhinolaryngol.2015;81:24---30.

夽夽

Institution:UniversidadeEstadualdeCampinas,Campinas,SP,Brazil.

∗_{Corresponding}_author.

E-mail:karenluchesi@yahoo.com.br(K.F.Luchesi). http://dx.doi.org/10.1016/j.bjorl.2014.09.006

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DysphagiaprogressionandswallowingmanagementinParkinson’sdisease 25

PALAVRAS-CHAVE Doenc¸adeParkinson; Deglutic¸ão;

Progressãoda doenc¸a; Transtornosde deglutic¸ão; Fonoterapia

Progressãoetratamentodadisfagianadoenc¸adeParkinson:estudoobservacional

Resumo

Introduc¸ão: Adisfagiaéfrequenteemindivíduoscomdistúrbiosneurológicos.

Objetivo: Descreverotratamentodadisfagiaeinvestigarfatoresassociadosàdeglutic¸ãoem umasériedecasoscomdoenc¸adeParkinson.

Método: Trata-sedeumestudolongitudinalcom24pacientesacompanhadosporumperíodode cincoanos(2006---2011).Todosforamsubmetidosàvideoendoscopiadadeglutição,classificação deacordocomaFunctionalOralIntakeScale(FOIS)ereceberamorientaçõessobreotratamento dadeglutiçãoacadatrêsmeses.Asorientaçõesdotratamentodadeglutiçãocompreenderam exercíciosparaamelhoradadeglutição.OstestesQui-quadrado,Kruskal---WalliseFisherforam utilizadosparainvestigarassociaçãoentreoestadodadeglutiçãoevariáveisclínicas.

Resultados: Duranteoacompanhamento,dezpacientesmelhoraram,cincomantiveramenove pioraramafuncionalidadedadeglutição.Umamedianadedezmesesfoiobservadaatéa mel-horanadeglutiçãoserobtida.Foiobservadaumamedianade33mesesdeacompanhamentoaté apioranadeglutição.Asmanobrasmaisfrequentementeindicadasnaterapiaforam:queixo parabaixo,mudançanaconsistênciaenoefeitodobolo,exercíciosparaforçaemobilidadede língua,deglutiçõesmúltiplaseexercíciosvocais.

Conclusão:Otratamentodadisfagiafoicaracterizadoporavaliaçõestrimestraisdadeglutição comindicaçãodemanobrascompensatóriasereabilitadoras.Nestacasuísticanãoforam iden-tificadosfatoresassociadosàsmudançasnafuncionalidadedadeglutição.

Introduction

Dysphagia is common in individuals with neurological disorders. It affects food intake, which may lead to complicationssuchaschoking,malnutrition,andpulmonary aspiration.1

Parkinson’s disease (PD) is one of the most com-monneurodegenerative disease inthe elderlypopulation, with a worldwide incidence between 1 and 20 per 1000people/year.2,3 _It _is _{characterized} _by _impairment _of

basal ganglia in voluntary movements, causing resting tremor, rigidity, akinesia (or bradykinesia), and postural instability.2,4

Dysphagiais verycommonin PD,affectingover 80%of individuals, reflecting the underlying motor impairments andtheextentofthedisease’sprogression.5_The_swallowing

difficultiesmostfrequentlyassociatedwithPDarerelated to the oral and pharyngeal phase, resulting in abnormal bolus formation,delayed swallowingreflex,and prolonga-tionofthepharyngealtransittime,withrepetitiveswallows toclearthethroat.6

Thesedysphagia-relatedimpairmentshaveadirect influ-enceonthenutritionalandhealthstatusofthepatients,and are associated with increased morbidity and mortality.7,8

However,fewstudieshavedescribedtheprogressionof dys-phagiaanditsseverityinPD.9_There_is_very_little_information

regardingthetemporalaspect ofdysphagia progressionin PD.

KnowledgeondysphagiaprogressioninPDcoulddecrease theriskof aspirationpneumonia,consequentlydecreasing theriskofdeath,sinceitisoneofthemostfrequentcauses of deathin thispatients.10,11 _It _can_also _orient _physicians

andtherapistsonwhattoexpectoftheirpatientsandwhich treatmentmaybenecessaryovertime.

Swallowing management, through the utilization of methodsthat compensate for the alterationsin the swal-lowingprocess,aimstopreserveasafeoralfeedingaslong aspossible. Swallowing management is based on maneu-vers that, according to Crary,12 _can _be _categorized _as

compensatoryandrehabilitationmaneuvers.Compensatory maneuvers refer to behavioral intervention in dysphagia, characterizedbydietarymodifications,changesinthe man-ner of administrationof the diet, changes in the patient position,andalterationsin themechanism of swallowing. These maneuvers,such aschin-tuck, head rotation,head tilt, head back, among others, are commonly known as postural maneuvers. Their purpose is to direct the bolus andmodifytheflow velocityofthebolus. Themaneuvers characterizedbydietmodificationspromotechangesin sen-sorystimuli, as modifying volume and consistency of the foodmayaltersensoryinput.Themodificationofthe swal-lowingmechanismrequireschangesinswallowingpattern, regardingmusclestrength,rangeofmotion,and coordina-tionofeventsinswallowing,forexampleeffortswallowing, supraglotticmaneuver,multipleswallows,betweenothers. Among rehabilitation maneuvers are the sensor-motor oralexercises,whichenablemodificationsofforce,length, andrangeof motionofthestructuresinvolvedin theoral cavity,pharynx,andlarynx.Amongthemostusedmaneuvers arethe shakermaneuver, lingual control,vocal exercises, andpharyngealexercises.

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Methods

Selectionofpatients

This was a prospective long-term study of 24 dysphagic patients with idiopathic PD, followed-up for a five-year period(2006---2011)inalargeBrazilianuniversityhospital. Thiswasanopen caseseriesand,duringthefiveyearsof study,somepatientsdroppedout.Thepatientswereinuse ofmedicineswithLevodopa.

Only the patients who had at least three evaluations, complaintsofswallowing,exclusiveoralfeeding,and regu-larcheck-upswithanoutpatientneurologistwereincluded inthe study.Patientswithnon-oral feeding and concomi-tantdiseasesordisordersthatcouldcausedysphagiawere excluded.

Procedures

Patients underwent swallowing evaluation, assessment throughtheFunctionalOralIntakeScale(FOIS),13_and

ther-apeuticinterventioneverythreemonths.

The swallowing evaluation was obtained through a fiberopticendoscopic evaluationof swallowing(FEES)and clinically. In both evaluations, three types of food were offered:(1)lemonjuicecoloredwithgreenfoodcoloring; (2) Nectar, honey, and pudding consistencies, all colored withgreenfoodcoloring (thesefluids wereobtained with theadditionof two,three, andfourteaspoonsofa thick-ener[Thicken-easy®_]_to₁₀₀_mL_of_water,_{respectively,}_and

wereofferedintwodifferentquantities,3mLand7mL);(3) solidconsistency,representedbyacornstarchbiscuit.

Thefoodwasgiventopatientsinthefollowingsequence: liquidandnectar(3mLand3mL,respectively,followedby 7mLand7mL,respectively);honey(3mLand3mL, respec-tively, followed by 7mL and 7mL, respectively); pudding (twotablespoons); solid(½ _cornstarch_biscuit)._The_liquid

foodwas administered in 20mL syringes, and the sample wasintroducedintothepatient’soralcavity.Asdifficulties inswallowingwereobserved,airwayprotectivemaneuvers and/orchangesinheadposturewereperformedinorderto assistoralfeedinginasafeway.

FEES was conducted by an otolaryngologist, while the foodwasofferedbyaspeech-languagetherapist.

Intheclinicalevaluation,asthepatientsswallowed, cer-vicalauscultationwasperformedtoidentifyabnormalsigns atthepharyngealswallowingphase.Oralbolustransittime, anteriororposteriorescape,positivecervicalauscultation (with signs that indicate a presence of stasis or penetra-tionwithaspirationrisk),coughing(before,during,orafter swallowing),andwetvoicewerealsoobservedbya speech-languagetherapist.

Based on the clinical evaluation and FEES, the FOIS13

wasapplied.The FOIS rankspatients intolevels,adapted tothe present study asfollows: level 1,No oral feeding; Level2,tube-dependentwithminimalattemptsoffoodor liquid;Level3,Tube-dependentwithconsistentoralintake offoodorliquid;Level4,Completeoraldietofoneortwo consistencies(nectarandhoney,honeyandpudding);Level 5a,Completeoraldietwithmultipleconsistenciesbutwith restrictions in two consistencies (for example, solid and

liquid),withorwithoutcompensation;Level5b,Complete oral diet with multiple consistencies but with restriction of one consistency (for example, solid or liquid), withor without compensation; Level 5c,Complete oral diet with multiple consistencies, but requiring compensation; Level 6, Completeoral diet withmultiple consistencieswithout special preparation but with specific food limitations (for example: fibers, grains, and some vegetables) and speed andvolume modificationif necessary; andLevel 7, Completeoraldietwithnorestriction.

Atthe initial evaluation,every patientreceiveda cor-responding FOIS classification. Every time the patients returnedtothehospitaltheywerereevaluatedand reclas-sified underFOIS. To analyzethe swallowingfunctionality byKaplan---Meiersurvivalanalyses,patientswereobserved until occurrence of the event improvement or the event worsening, i.e.,theywereobserveduntilthepoint ofthe timeatwhichafallorriseinFOISwasnoted.Patientswhose swallowing functionality stayed the same were observed duringthefollow-upperiodandnoeventwasregistered.

Following these swallowing evaluations, patients received therapeutic intervention every three months regarding adequate food consistency and volume, in additiontomaneuversor exercisestoimproveswallowing functionality.Theywereorientedtoperformthemaneuvers dailyandreceivedwritteninstructionsforeachone.

Thecompensatorymaneuversusedwere(1)chin-tuck,to improveairwayprotectionduringswallowing;(2)bolus con-sistency,tofacilitatethefeedingofpatientswithdecreased coordinationoftongue,reducedcontractionofpharynges, delayintriggeringswallowingreflex,reducedairway protec-tionandchewingdifficulty;(3)effortfulswallow,toincrease strengthtoejectthebolusandtoapproximatethelarynx structures, improving airway protection; (4) frequency of swallowing(multipleswallows),toclearstasis;and(5)bolus effects,i.e.changesinvolume,viscosity,temperature,or taste,wereintroducedinordertoimproveoraland pharyn-gealsensibilityandcontrolbolusmanagement.

The following rehabilitation maneuvers were used (1) tongue strengthening, to increase strength to eject the bolus; (2)tongue control,toimprovetonguemobility and facilitate the bolus management in the oral cavity; (3) Shakermaneuver,toincreasestrengthinsuprahyoid mus-cles reducing the penetration and aspiration risk due to stasis in pyriform sinus; (4) vocal exercises, to improve airway protection though the improvement in the glot-tis adduction; (5) tongue holding (Masako maneuver), to increasemovementsofpharyngealmusclesagainstthebasis ofthetongueduringtheactofswallowing.

Dataanalysis

The patients were classified according to changes in swallowing functionality measured by FOIS, grouped as: improved,nochange,andworsened.

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Theswallowingfunctionalityovertimewasdescribedby Kaplan---MeierSurvivalAnalysis.It isimportanttomention thattheresultsofasurvivalanalysisexpresstheprobability ofthepatientnotsufferingfromagiveneventovertime.

The statistical analysiswas performed usingStatistical Package for the Social Sciences (SPSS), version 13.0 for Windows, and p-values lower than 0.05 were considered significant.

This studywasapprovedbytheEthicBoardCommittee oftheUniversityofCampinas(Protocolnumber796/2005).

Results

Thegroupof24patientscomprised16menand8women. TheaverageageofonsetofPDsymptomswas53.8(±6.5) years. The average age for the first evaluation was 65.4 (±8.6)years.Theaveragediseasedurationwas139.2(±65) months,i.e.,anaverageof11yearsbetweenthefirst symp-tomsandthefirstevaluationforswallowingmanagement.

Ten patients improved, five presented no change, and nineworsenedtheirswallowingfunctionalityduring follow-up. The characteristics of these groups are described in

Table 1. There was no statistically significant difference betweenthegroups.

Noneoftheinvestigatedvariableswasstatistically asso-ciatedwithswallowingfunctionalityinthiscaseseries.

Fig.1showsthesurvivalcurveoftheworsened swallow-inggroup.Thiscurveillustratesthechanceofnotsuffering fromworseningofswallowinginthiscaseseries.

The patients gradually lost swallowing functionality. AccordingtoKaplan---Meieranalysis,theyhad17% probabil-ityofworsenedswallowingfunctionalityatthetenthmonth offollow-up.

+

1.0

0.8

0.6

0.4

0.2

0.0

Survival function

C

um survival (probability of non-worsening)

Survival function Censored*

0 20 40 60 80

Time up to worsened swallowing functionality (months)

Figure 1 Survival plot considering worsened swallowing according to Functional Oral Intake Scale (FOIS) levels in Parkinson’sdiseasepatientsfollowedatadysphagiaoutpatient between2006and2011(n=24).*Censoredobservationshows patients lostinfollow-uporpatients withoutworsened swal-lowingfunctionalityduringtheobservationperiod.

0.6

0.5

0.4

0.3

0.2

0.1

0.0

Hazard function

C

um hazard (probability of improvement)

0 10 20 30 40 50 60 70

Time up to improved swallowing functionality (months)

Censored* Survival function

+

Figure 2 Hazard plot considering the improved swallow-ingaccordingto FunctionalOralIntake Scale(FOIS) levelsin Parkinson’sdiseasepatientsfollowedatadysphagiaoutpatient between2006and2011(n=24).*Censoredobservationshows patientslosttofollow-uporpatientswithoutimproved swal-lowingfunctionalityduringtheobservationperiod.

Fig.2showsthehazardfunctionoftheimprovementof swallowinggroup.Thiscurveillustratesthechanceof swal-lowingimprovement in thiscase series.The majority had improvedswallowingfunctionalityuptothetenthmonth. Accordingto theKaplan---Meier analysis, in tenmonths of follow-up, the probability of improvement in swallowing functionalitywas44%.

The frequencies of maneuvers indicated in the thera-peuticintervention are shown in Table 2. The maneuvers chin-tuck, bolus consistency, tongue strengthening, vocal exercises, swallow frequency,and bolus effect were sug-gestedto50%ormoreofthepatients.

Discussion

Inthiscaseseries,anaverageof11yearsbetweenPDonset andthepatient’sfirstevaluationatthedysphagiaoutpatient clinicwasobserved.Thiscouldbeexplainedbyseveral fac-tors,includinglack ofinformationor latencybetweenthe PDonsetandthebeginningofswallowingcomplaints. The literatureindicates that the delay in seeking professional assistance may be damaging, especially since dysphagia is prevalent in long-standing PD, but may be subclinical specially in the early course of the disease.5,14

Objec-tiveswallowingevaluationshaverepeatedlyfoundimpaired swallowingin over 50% of patients with PDwho reported noswallowingabnormalities.14 _During _the_disease _course,

75---97% of the patients will suffer from dysphagia.15---17

Becauseoftheseevidences,itisimportanttopayattention toswallowing, always monitoring for weight loss, malnu-trition,andpulmonaryaspectsinordertoavoiddysphagia complications.

Mülleretal.,18 _in _a_postmortem_study,_found _a_median

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Luchesi

KF

et

al.

Table1 DescriptiveanalysisofclinicalaspectsofacaseseriesofpatientswithParkinson’sdiseasefollowedinadysphagiaoutpatientbetween2006and2011,stratifiedby swallowingfunctionality(n=24).

Variables Worsened(n=9) Stayedthesame(n=5) Improved(n=10)

Min---max Mean±SDa _Median _Min---max _Mean_±_SDa _Median _Min---max _Mean_±_SDa _Median

Gender(male/female) 2/7 3/2 4/6

Ageatfirstevaluation (years)

51---78 63.3±9.7 64 52---75 65.4±8.5 66 53---81 65±10.7 61

Ageatsymptoms’onset (years)

39---74 53.5±11.3 57 49---65 53.8±6.4 52 49---75 59±11 53

Diseaseduration (months)

24---204 68.6±65.7 48 36---204 139.2±65 168 24---144 80±36.5 78

Timeuptoworsened swallowing(months)b

7---78 50.2±23.9 33 --- --- --- --- ---

---Timeoffollow-up (months)

--- --- --- 15---37 27.6±9.7 30 --- ---

---Timeuptoimproved swallowing(months)c

--- --- --- --- --- --- 1---67 3.7±2 10

a _{Standard-deviation}_(SD).

b _Time_estimated_from_the_onset_of_{Parkinson’s}_disease_symptoms.

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Table 2 Frequency of maneuvers recommended in the swallowing management in a case series of patient with Parkinson’s disease followed in a dysphagia outpatient between2006and2011(n=24).

Categories Maneuvers n(%)

Compensatory maneuvers

Chin-tuck 16(66.7) Bolus

consistency

19(79.2)

Effortful 10(41.7) Swallow

frequency (multiple swallows)

19(79.2)

Boluseffects 20(83.3)

Rehabilitation maneuvers

Strengthening-tongue

16(66.7)

Tonguecontrol 10(41.7)

Shaker 3(12.5)

Vocalexercises 12(50.0) Tongueholding 4(16.7)

approximately 14 years, and a dysphagia latency of 10 years. The authors demonstrated that disease durationis important,becausethelatencyofdysphagiacomplaintswas positivelycorrelatedwiththetotalsurvivaltime.

Thepresentstudyfoundnoassociationbetweengender andswallowingfunctionalityinPD.Intheliterature,a rela-tionshipbetweenbronchoaspirationandgenderwasalsonot observed.19,20_These_facts_reveal_that_aspects_related_to

gen-der,suchashormones,anatomicdifferences,amongother gender differences,appeartonotinfluence swallowingof PDpatients.

Althoughtheprogressiveimpairmentofswallowingisan expectedfact,inthisstudy,maintenanceor improvement ofswallowingfunctionalitywasobservedinthemajorityof thepatientsduringthefollow-upperiod.

There was no statistic difference found between the groups that presented no change, improved, or worsened swallowing functionality. Although this study did not find aspectsstatisticallyassociatedwithswallowingchangesin PDpatients,Lorefaltetal.21_reported_a_significant_reduction

of solid food intake in older patients with PD. The non-ingestion of solidfoods per seindicates a loss in FOIS. In PD,highermortalityisassociatedwithsomeaspects,such asolderage,dysphagia,andlatediagnosis.22 _According_to

Auyeungetal.23_the_older_onset_is_associated_with_a_negative

impactonsurvivalofPDpatient.

An earlierfirstevaluationandstartof swallowing man-agement in PD patient is very important. Manor et al.8

observed that, in PD, swallowing management in earlier stages of dysphagia wasable to preventaspiration pneu-monia and help in the maintenance of the quality of life. Therefore, early swallowing management may pos-itively affect swallowing functionality. According to the literature, compensatory maneuvers used in swallowing managementcanimproveairwayprotectionandreduce dys-phagiacomplications.24

DespitealackofblindcontrolledstudiesandalthoughPD is aprogressive andneurodegenerative disease,thereare

otherstudies indicatingthat improvementcanbebrought byrelativelysimpleinterventions.25,26_Although_the_present

study did not aim to verify the efficacy of the methods of therapeutic intervention, the patients in this swallow-ing management group showed improvement in the first tenmonths.AccordingtoRobbins,12_when_some_maneuvers

areperformedrepeatedly,theypromoteneuroplasticityand improvetheswallowingfunctionality.

SwallowingmanagementinPD

Theswallowingmanagementofpatientswith neurodegen-erativediseasesisrelativelyrecent;formanyyears,itwas believedthatdegenerativediseasewouldhaveaconsequent progressive dysphagia; swallowing could not be rehabili-tated, and thus any attempt to therapeutic intervention wouldbedoomedtofailure.

Theswallowingmanagementaimstoimprovethe swal-lowingactasmuchaspossibleandtocompensateforwhat cannotbesolved,inordertosavedeglutition.

As a result of this study, it was observed that one of themostrecommended interventionswere compensatory. Thegreater useof compensatorymaneuversin PDcanbe explainedbytheinstantaneousresultoftheseinswallowing, whatcanbeverifiedempiricallyinclinicalandinstrumental evaluation.

Compensatorymaneuvers are designed to redirect the bolusawayfromtheairway,withoutchangingairway phys-iology.The literatureelucidatesthat thickeningliquids to a nectar or honey consistency should be used because it exhibitsanimmediateeffect.27 _Chin-tuck_maneuver_is

fre-quentlyrecommendedforswallowingthinliquids.28 _In_PD,

there are evidences that the chin-tuck maneuver com-bined with thick liquid can be important in preventing pneumonia.20

In this swallowing management program, bolus consis-tencywasindicatedwhenothermaneuverswereinefficient tomaintainoralfeedinganditwasnecessarytoavoidthe consistenciesthatwerehazardous.

Forthepatientofthisstudy,theboluseffectmaneuver wasindicatedwhenthelackoforalcontrolmadeitdifficult toswallowquicklyandingreatervolumes.Theboluseffect, andchangesintheconsistency,taste,ortemperatureofthe bolus,improveoralintakeandpreventaspiration.

Other frequently indicated maneuversin this swallow-ing management were frequency or multiple swallowing. Theywereindicatedtobeperformedduringthedaily feed-ing,aimingtoclearstasisandreducethechanceoflarynx penetrationoraspiration.

In rehabilitation maneuvers, the exercises of tongue strengtheningandtonguecontrolwerefrequentlyindicated becausetonguemovementsofPDpatients,especiallythose responsible for propulsion and chewing, are considered hypokineticin theoral phase.In thesepatients the swal-lowingoralphaseisusuallylongerandevenslowerthanthe pharyngealphase.29

Forhalfofthepatients,vocalexerciseswereindicated, asthereareevidencesthatthistypeofexercisesworksto improve the cough function and tongue’s mobility during swallowing,27 _which_leads_to_a_better_swallowing

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Futurestudiesabouttheefficacyofinterventionmethods in swallowingof PD patients arenecessary. The improve-mentandmaintenance,notexpectedinneurodegenerative diseases,foundinthepresentstudy,suggestthatswallowing managementmightpositivelyaffectswallowing functional-ityofPDpatients,butitcannotbeaffirmedduetothedesign ofthisstudy.

Inconclusion,the swallowingfunctionality was charac-terizedbymaintenanceorimprovement,especiallyinthe firsttenmonthsoffollow-up,comprisingcompensatoryand rehabilitation maneuvers, reoriented each three months. Therewasnoassociatedfactorwithchangesinswallowing functionalityinthesecases.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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