Motor Learning in Dysphagia Rehabilitation

The overall goal is to exploit motor learning principles in a novel way to enhance dysphagia
rehabilitation in patients with dysphagia due to stroke. Dysphagia is swallowing impairment
that can lead to serious illness or death due to ingested material entering the trachea
(aspiration). Specifically, this study will determine whether lasting behavioral
modifications after swallowing training occur with motor learning principles versus standard
care. Motor learning principles emphasize continual kinematic assessment through biofeedback
during training. However, continual kinematic assessment is rare in standard dysphagia care
because swallowing kinematics require instrumentation such as videofluoroscopy (VF) to be
seen. Since VF involves radiation exposure and higher costs, submental electromyography
(sEMG) is widely used as biofeedback, although it does not image swallowing kinematics or
confirm that a therapeutic movement is being trained. This research study will compare three
forms of biofeedback on training swallowing maneuvers or compensatory techniques (referred to
as targeted dysphagia training throughout this document) that might reduce their swallowing
pathophysiology. VF biofeedback training will provide kinematic information about targeted
dysphagia training performance, incorporating motor learning principles. sEMG biofeedback
training will provide non-kinematic information about targeted dysphagia training performance
and, thus, does not incorporate motor learning principles. A mixed biofeedback training,
which involves VF biofeedback early on to establish the target kinematics of the targeted
dysphagia training maneuver, then reinforces what was learned with sEMG. Mixed biofeedback
training is being examined because it is more clinically feasible than VF biofeedback
training, while still incorporating motor learning principles during part of the targeted
dysphagia training.

The investigators hypothesize that VF training will reduce swallowing impairment more than
mixed training, but mixed training will reduce swallowing impairment more than sEMG training.
Additionally, this study will investigate whether adjuvant techniques known to augment motor
training (non-invasive neural stimulation and explicit reward tested independently), will
augment outcomes of each of the proposed training's. This innovative experimental design is
significant because it investigates motor learning principles within an ideal training (VF
biofeedback) as well as within a clinically feasible option (mixed biofeedback) to
differentiate them from standard dysphagia training (sEMG), which has reported little to no
improvements after intense motor training.

Inclusion Criteria:

- swallowing problem

Exclusion Criteria:

- pregnant

- allergy to barium

- moderate to severe dementia

- serious respiratory illness