Robert T. Wertz

Sensitivity and specificity of clinical/bedside examination signs for detecting aspiration in adults subsequent to stroke

UNLABELLEDnWhile detecting the presence of aspiration is only one aspect of a noninstrumented examination of swallowing function, it is an important component due to its potential health status consequences. The purpose of this investigation was to investigate the sensitivity and specificity of clinical/bedside examination signs for predicting aspiration on videofluoroscopic examination of swallowing. Sixty consecutive, acute stroke patients were investigated with clinical/bedside and videofluoroscopic exams. Clinical signs consisted of history, oral motor/speech praxis, voice, and trial swallow ratings. Results confirm that more work needs to be done if data collected from noninstrumented examinations are to be strongly predictive of aspiration on VFSE. However, comparisons of the current results with previous investigations provides a promising framework for future research.nnnEDUCATIONAL OBJECTIVESn(1) To understand the use of sensitivity and specificity in detecting disease; (2) To understand the current evidence regarding clinical signs of aspiration.

Inter- and Intrajudge Reliability for Videofluoroscopic Swallowing Evaluation Measures

Abstract Interjudge reliability for videofluoroscopic (VFS) swallowing evaluations has been investigated, and results have, for the most part, indicated that reliability is poor. While previous studies are well-designed investigations of interjudge reliability, few reports of intrajudge reliability are available for VFS measures derived from frame-by-frame analysis that clinicians typically employ. The purpose of this study was to examine the inter- and intrajudge reliability of VFS examination measures commonly used to assess swallowing functions. No training to criteria occurred. VFS examinations were conducted on 20 patients who had suffered a stroke within six weeks and had no structural abnormalities or tracheostomies. Three clinical judges served as subjects and rated the VFS examinations from videotape using frame-by-frame analysis. A clinicians repeated review of measures employed in the 20 examinations indicated high intrajudge reliability for a number of measures, suggesting that an experienced clinician may employ consistent standards for rating certain VFS measures across patients and time. These standards appear to vary among clinicians and yield unacceptable interjudge reliability. The need to train clinicians to criteria to improve interjudge reliability is discussed.

Utility Of Clinical Swallowing Examination Measures For Detecting Aspiration Post-Stroke

The purpose of this investigation was to determine the utility of clinical swallowing examination (CSE) measures for detecting aspiration as defined by videofluoroscopic swallowing examination (VFSE). This study, involving 165 participants, is a follow-up to a previously published investigation of 60 participants. Findings are compared with that investigation as well as with other research on CSEs. The results suggest that clinicians can make an accurate judgment of the occurrence of aspiration in most post-stroke patients. However, ruling out aspiration when it is absent appears more problematic. More work needs to be done if data collected from non-instrumented examinations are to be strongly predictive of the presence and absence of aspiration on VFSE. At present, there are no data to suggest that CSEs can be used to quantify aspiration or make adequate recommendations regarding patient care.

Quality of life with and without aphasia

Background: Although the social approach to managing aphasia is designed to improve the quality of life (QOL) of the aphasic person, the influence of being aphasic on different facets of QOL is unknown. Aims: To delineate socially valid therapy targets, we examined 24 facets of QOL proposed by the World Health Organisation (WHO) to determine which facets differentiate QOL between aphasic and nonaphasic people. Methods & Procedures: A prospective, observational, non-randomised group design was employed. Two measures--the WHO QOL Instrument, Short Form (WHOQOL-BREF) and the Psychosocial Well-Being Index (PWI)--were administered to 18 adults with chronic aphasia and 18 nonaphasic adults. Indices of determination (ID) and degrees of overlap (DO) were calculated to determine which of the 24 facets were best in differentiating between the aphasic and nonaphasic groups. Outcomes & Results: Facets within three domains--level of independence, social relationships, and environment--were best in distinguishing QOL between the aphasic and nonaphasic groups. Conclusion: Therapy that focuses on situation-specific communication and societal participation appears to be most appropriate for enhancing the QOL of people with chronic aphasia.

Stuttering following brain damage

Abstract This paper describes the neurological, language, and speech status of seven brain-damaged patients with symptoms of cortical stuttering. We compare data from our seven patients to data presented on other brain-damaged stutterers, review theories of cortical stutterings etiology, advance alternative hypotheses about mechanisms underlying such dy sfluencies, and compare cortical stuttering to stuttering in childhood.

Inter-And Intrajudge Reliability Of A Clinical Examination Of Swallowing In Adults

This study investigates inter- and intrajudge reliability of a clinical examination of swallowing in adults. Several investigations have sought correlations between clinical indicators of dysphagia and the actual presence of dysphagia as determined by videofluoroscopy. Whereas some investigations have reported interjudge reliability for the videofluoroscopic measures employed, none have reported reliability for clinical measures. Without established reliability for rating clinical measures, conclusions drawn regarding the utility of a measure for detecting aspiration can be called into question. Results of the present study indicate that fewer than 50% of the measures clinicians typically employ are rated with sufficient inter- and intrajudge reliability. Measures of vocal quality and oral motor function were rated more reliably than were history measures or measures taken during trial swallows. There is a need to define more clearly the measures employed in clinical examinations and to be consistent in reporting reliability for clinical measures of swallowing function in future research.

Clinicians’ Preferences and Practices in Conducting Clinical/Bedside and Videofluoroscopic Swallowing Examinations in an Adult, Neurogenic Population

The purposes of this investigation were: (a) to determine which clinical/bedside and videofluoroscopic (VFS) examination methods and measures clinicians believe should be employed to assess swallow...

MRI asymmetries and language dominance.

Objective: To examine the relationship between language dominance, as measured by Wada testing, and hemispheric asymmetries on MR brain images. Background: A previous report that did not include verification of language dominance compared the length of the planum temporale with hemispheric asymmetries seen on CT and inferred that occipital lobe asymmetry is related to language dominance. Methods: Language dominance was identified by the Wada test in 57 patients evaluated for surgical treatment of epilepsy. Fifty-five had an MRI scan that allowed accurate measurement. In a blinded fashion, two examiners independently measured bilateral frontal, parietal, and occipital lobe lengths on MR scan for each patient. Measurements of asymmetries were compared with language dominance established by the Wada test. Results: Reliability of measurement between the examiners was 97%. Asymmetry of the occipital lobe length on MR scan 10 mm above the tentorium was the only measurement significantly related to language dominance (p < 0.01). Occipital lobe length was longer on the left in 19 (40%) and on the right in 10 (21%) patients with left dominance. The right lobe was longer in six of seven (86%) patients with bilateral dominance. One patient with right hemisphere dominance had a longer left lobe. None of the measurements significantly related to handedness. Conclusion: Asymmetries of occipital lobe length relate to language dominance, but such dominance cannot be reliably identified by MR in an individual patient.

Outcomes of computer‐provided treatment for aphasia

Background: Computers have become a familiar component of aphasia treatment over the past 20 years. Published research continues to indicate the influence computerised treatment may have on improving language performance of aphasic adults. As a result of the move to develop evidenced‐based clinical guidelines, there is a need to evaluate the research methodology and the level of evidence provided by computerised interventions for aphasia. Aims: The purposes of this paper are to evaluate examples of reports in the computerised treatment for aphasia outcomes research literature by applying precise definitions of the treatment outcome research terminology, placing the examples within the context of the five‐phase treatment outcomes research model, applying a level of evidence scale to rate the evidence provided by the selected examples, and speculating where we are and where we may need to go in demonstrating the influence of computer‐provided treatment on improvement in aphasia. Methods & Procedures: We applied Robey and Schultzs (1998) model for conducting clinical‐outcome research in aphasia and the level of evidence scale developed by the American Academy of Neurology (1994) to the results of computer‐provided aphasia treatment studies. Eight Phase 1 studies, three series of Phase 2 studies, and one Phase 3 study are described as examples. Outcomes & Results: While several Phase 1 and 2 studies imply that computer‐provided treatment is active in the treatment of people with aphasia, evidence to support the efficacy of computerised treatment for adults with aphasia is based on a single Phase 3 study. Additional Phase 3 studies are needed to demonstrate the efficacy of additional treatment software, and Phase 4 and Phase 5 studies are necessary to demonstrate the effectiveness and efficiency of computerised treatment for people with aphasia.

Affective prosodic disturbance subsequent to right hemisphere stroke: A clinical application

Abstract We examined Ross (1981) hypothesis regarding the disruption of affective prosody subsequent to right hemisphere brain damage (RHD). Twenty patients who had suffered a right hemisphere stroke were compared with 18 normal, non-brain-damaged subjects for affective prosody in spontaneous speech, gesturing accompanying spontaneous speech, repetition of affective prosody, comprehension of affective prosody, and comprehension of affective gestures. In addition, we attempted to classify our RHD subjects with Ross prosodic taxonomy, determine the relationship between classification and site of lesion, and explore the contribution of coexisting dysarthria to prosodic disturbance. All RHD subjects displayed affective prosodic disturbance in spontaneous speech. Only one normal subject was judged mildly dysprosodic. The RHD group had significantly more difficulty in repeating affective prosody and comprehending affective gestures. There were no significant group differences in gestures accompanying spontaneous speech or comprehending affective prosody. Eighty percent of the RHD subjects were classified with the Ross taxonomy, however there was no systematic relationship between classification and site of lesion. And, while dysprosody without a coexisting dysarthria was present in three RHD subjects, 17 displayed a coexisting dysarthria. We conclude that affective dysprosody is common subsequent to RHD, however the relationship between classification of dysprosody and site of lesion or the contribution of coexisting dysarthria to dysprosody is not clear.