Maximizing Rehabilitative Efforts for Dysphagia Recovery: SEMG Biofeedback Monitoring

Introduction

VB is a 72-year old farmer from Mississippi, status post supraglottic laryngectomy. When asked about his experiences with swallowing treatment, he provided a valuable insight to his clinician. "It’s like trying to make your way to the refrigerator at your in-laws house, at night, without turning on the lights. I just can’t see what I’m supposed to be doing. So I just feel around and hope for the best". We should listen to our patients, and let their wisdom guide our development of practice patterns.

Rehabilitation of disordered swallowing physiology is a rapidly expanding area of speech language pathology. As we strive to understand normal and disordered swallowing, we are able to identify mechanisms by which patients with dysphagia can, under optimal circumstances, improve the overall efficiency of the pharyngeal swallow. These techniques can take the form of compensations in which the patient adapts movement of residual anatomy to protect the airway and increase the effectiveness of the immediate pharyngeal swallow, or rehabilitation, in which the patient executes repetitive exercises thereby increasing the long term strength or efficiency of the pharyngeal swallow. Unfortunately, the maneuvers that we design may be compatible with swallowing recovery but are not always suitable to the abilities of the patients we treat, particularly those with associated cognitive deficits. Thus, the clinician is left with the dilemma of having an arsenal of techniques that should work, but a patient that just can’t make them work.

Our task then, is to not only develop appropriate rehabilitation techniques but to find ways in which we can maximize our teaching and reinforcement. Compensatory maneuvers may be facilitated through a variety of environmental controls such as strategic location of the meal to enhance posturing or cue cards to remind the patient of swallowing techniques. Rehabilitative maneuvers are perhaps more difficult to reinforce. We are asking patients, frequently those with associated cognitive deficits, to execute often-times complex and abstract tasks using muscle groups that have previously operated primarily under automatic response. Execution of these tasks is frequently not observable to the naked eye and as such, success, failure or change is extremely difficult to measure. We expect execution of these tasks as well in patients with neurologic deficits in whom proprioceptive and kinesthetic feedback systems may be compromised. In other realms of physical medicine and rehabilitation, such as physical or occupational therapy, muscle retraining is frequently a very visible process. As a patient contracts the biceps, the arm subsequently flexes; the greater the strength to the contraction and the greater movement is observed. In this process, the patient receives direct feedback of the adjustment in motor behavior. Unfortunately, this direct feedback is not available to the patient or clinician in swallowing rehabilitation. It behooves us then to identify some alternate source of feedback, in which we can maximize teaching and reinforcement of swallowing techniques and make treatment available to a larger population of dysphagic patients.

Biofeedback

Biofeedback is, by the definition of Basmajian, "The technique of using equipment (usually electronic) to reveal to human beings some of their internal physiologic events, normal and abnormal, in the form of visual and auditory signals in order to teach them to manipulate these otherwise involuntary or unfelt events by manipulating the displayed signals" (Basmajian and DeLuca 1985). Kasman more simply defines biofeedback as "extrinsic cues that signal the outcome or quality of a physiological response relative to an intended goal….an extension of the patients or clinicians senses" (Kasman, 1996). Surface electromyography (SEMG) biofeedback, through on-line monitoring of muscle activity, supplies an alternate feedback system of proprioception, thus attenuating the patients or clinicians awareness of one aspect of swallowing behavior. By yielding a visible representation of even the smallest motor response, rehabilitative efforts are maximized, allowing the patient and clinician a means of confronting automatic physiologic behaviors and enhancing access to volitional motor control.

Supportive Research

Clinical SEMG biofeedback has been extensively evaluated in other realms of physical medicine and rehabilitation with numerous studies demonstrating clinical efficacy for a variety of neuromuscular disorders. Wolf documents over 300 clinical studies addressing the efficacy of biofeedback in physical rehabilitation of neuromuscular disorders, not including associated disorders of pain (1994). Most of these studies have evaluated the use of SEMG in patients with intact cognition. A key study by Balliet, et al., describes the uses of SEMG at an adjunct to upper extremity retraining in cognitively impaired patients. In this study five patients with described "global aphasia, moderate to severe Brocas aphasia and/or Wernickes aphasia", all with chronic upper extremity paresis regained functional upper extremity function after 50 sessions using EMG biofeedback of the weakened limb. This study documents the benefits of this technology in assisting patients who may otherwise not be treatment candidates based on the severity of cognitive/communication deficits. Although not an assessment of the application of biofeedback to dysphagia rehabilitation, the study carries significant implications as many dysphagic patients present with concomitant cognitive communication deficits (Balliet, 1986). These data, paired with research on motor learning theory, provide a foundation for its application in the realm of physical rehabilitation. (Wolf, 1994, Rubrow, 1984). The discipline of speech language pathology, which encompasses rehabilitation of motor deficits associated with speech, voice and swallowing, has yet to extensively evaluate this modality. The application of SEMG biofeedback in dysarthria rehabilitation, despite the neuromuscular nature of this type of disorder, has been grossly underevaluated. A string of case studies documents consistently both the short term and long term benefits of this treatment modality in facilitating primarily facial muscle control in patients with both acute and chronic deficits. As documented in some, but not all, of the studies, this increased control subsequently resulted in improved appearance and speech production skills through greater volitional use of primarily the labial articulators (Netsell & Cleland, 1993; Janke, 1978; Brown, Nahai, Wolf & Basmajian, 1991; Rubrow, Rosenbek, Collins & Celesia, 1984; Daniel-Whiteney, 1989; Drazier, 1984; Brudny, Hammerschlag, Cohen & Ransoholff, 1988). However, there are no experimentally controlled studies which compare this modality to more traditional treatment.

A similar string of case studies has begun to emerge regarding the use of SEMG biofeedback in swallowing treatment. The first such paper was presented by Draizar (1984). In this paper, she outlines the use of biofeedback in the treatment of dysarthria and dysphagia, however little detail is provided regarded specific treatment methods or evaluation of progress. A more detailed account was provided by Bryant, which presented a description of the use of SEMG biofeedback in the treatment of a patient with oral pharyngeal carcinoma. This patient, a 40 year old female with severe dysphagia secondary to resection and radiation was able to discontinue tube feedings and return to a near normal diet after ten weeks of treatment (1991). Subsequent to this report, Crary described the treatment course of 6 patients with chronic dysphagia secondary to brain stem infarct treated with SEMG biofeedback. Of these 6 patients, with a mean time since onset of 18.8 months (5-54), all were able to return to oral feedings with discontinuation of tube feedings Crary further investigated patterns of swallowing dysfunction as measured by SEMG (1995).

Several other unpublished projects have addressed the clinical application of SEMG in swallowing treatment. At the American Speech Language and Hearing Association Annual Convention in 1991, Bednarek, et al.,. offered data which suggested that normals were able to utilize the SEMG tracing to increase muscular contraction during some swallowing maneuvers (1991). In 1995, at the Dysphagia Research Association Meeting, Huckabee, et al.,., presented SEMG norms at rest and at maximal amplitude during the swallow as measured from six different sites around the head and neck. Not surprisingly, the standard deviation from the mean was significant. However, for electrode placement sites most commonly used to measure amplitude of the muscles directly involved in the pharyngeal swallow, the standard deviation from the mean was relatively smaller (1995). Berman, et al, at the 1995 American Speech Language and Hearing Association Annual convention, reported on their experiences in using SEMG biofeedback with mostly geriatric dysphagic individuals in a chronic care facility, noting both successes and failures in treatment with this population (1995). Finally, Huckabee, et al., at the 1996 American Speech Language and Hearing Association Convention reported on 10 additional patients with dysphagia secondary to brain stem injury who participated in a one week accelerated swallowing treatment program with SEMG monitoring. Of these 10 patients, with a mean time post onset of 26 months, 8 eventually returned to full oral feeding with removal of feeding tube. All maintained oral feeding with the exception of 2, both of whom suffered further neurologic injury unrelated to their swallowing disorder.

The Technique of Biofeedback

Electromyography is a method of measuring myoelectric impulses initiated in the cell body during firing of a motor unit. For diagnostic purposes, specificity requires hooked wire or other needle electrodes inserted directly into target muscles. For purposes of clinical biofeedback, surface electrodes adhere to the skin surface overlying the target muscle or muscle group. In it’s very simplest form, SEMG biofeedback may consist of a raw electromyographic signal. However, most commercially available SEMG biofeedback devices, including Kay’s Swallowing Signals Lab, provide signal averaging and rectification which produces a more responsive, comprehensible signal for patient use. The ultimate signal produced by the device provides the patient with a continuous line tracing that represents both timing and amplitude, or strength. Most devices are dual or multichanneled (the Swallowing Signals Lab provides two SEMG channels), allowing for measurement of multiple muscle sites to observe and retrain agonist/antagonist muscle groups. Rubrow (1984) provides a detailed summary of many of the parameters available on commercially biofeedback equipment.

Complications are inherent in the application of this technology for both evaluation and treatment. Electromyography is an inexact procedure utilizing sensitive equipment. A multitude of external factors have the potential of interfering with adequate measurement even in a carefully controlled clinical setting. Surface electrode placement is a highly inferential process. At best, one can only assume the targeted muscle to be measured, particularly in regions of the head and neck where the muscle tissue itself is frequently small in both depth and width and a complex mantle of overlying muscle is required to produce the intricacies of swallowing. Because of this it is important to recognize the limitations of SEMG. Although these complications do not preclude the knowledgeable use of this modality, they caution careful interpretation of findings. Although the biofeedback tracing may provide the patient and clinician with valuable insights for enhanced motor learning, SEMG should not be considered at diagnostic tool.

Electrode placement for SEMG biofeedback will vary dependent upon the goals of treatment. Unfortunately, because of the density of tissue in and around the neck region and the overlying muscle, there is no feasible way to measure myoelectric activity from the pharyngeal constrictor muscles. Thus SEMG biofeedback will not provide the clinician or patient with direct feedback about the strength of pharyngeal contraction. However, swallowing is a synergistic response with coordinated contraction of multiple muscle groups. Given this, measurement of those muscle that contribute to laryngeal excursion provides direct feedback about the function of only those muscle groups, but the clinician may be able to infer information about the function of the pharynx. The most commonly utilized placement by this clinician for most patients is a submental method, with the two recording electrodes placed in line between the spine of the mandible and the superior edge of the palpable thyroid cartilage. The ground electrodes is then placed over the mandible or lateral to the two recording electrodes if triode patch electrodes are used. Using this placement, one collectively receives myoelectric feedback from the collective suprahyoid muscles that are associated with laryngeal excursion, as well as some feedback from the floor of mouth and lingual musculature. Although movement of the tongue can produce artifact that needs to be clinically discriminated from swallowing behavior, for many patients intervention may be targeted toward minimizing or facilitating this tongue movement, thus observation of this behavior is important. If rehabilitation is not addressing lingual components and the patient is distracted by the artifact, placement of the electrodes approximately over the lateral lamina of the thyroid cartilage likely provides information about the function of the strap muscles, which also contribute to laryngeal excursion. Alternative electrode placements may include monitoring of the masters or sternocleidomastoids to target relaxation and eliminate overall tension.

Electrode Placement

 

In general, the basic principles of electrode placement are:

1. Electrodes should be placed over the "belly" of the target muscle, not the insertion points.

2. The electrodes will measure as deep as the recording electrodes are spaced apart. Thus, if monitoring of lingual movement is targeted, optimal electrodes placement may be farther apart in order to pick up lingual activity. Conversely, if lingual movement is distracting, closer electrodes placement may minimize artifact.

3. The smaller the electrode, the more specific the measurement. Conversely, the larger the electrode recording surface the more activity will be measured, thus loosing specificity. Unfortunately, the options commercially available for electrode size are limited.

Treatment Approach

Traditional physical rehabilitation of neuromuscular deficits tends to be addressed within three areas of focus: muscle relaxation / inhibition in cases of hyperfunction or spasticity, coordination / patterning of the muscle response to address poor coordination of agonist/antagonist muscle groups and muscle recruitment to address weakness or paresis. Although swallowing is a finely orchestrated process requiring viability and integration of multiple physiologic motor and sensory systems, at it's most fundamental level, it is a motor task. Thus, through biofeedback monitoring, one clear component of swallowing can be directly, and measurably addressed. It should be clear the SEMG treatment goals are a means to an end; that is, safe swallowing behavior. Traditional swallowing treatments and compensations are integral components of a well rounded treatment protocol for efficacious service delivery. Standing alone, an achieved SEMG objective holds little information; however, when paired appropriately with a functional swallowing goal, this information is quite valuable as a relative measure of progress.

A rather peculiar oversight in areas of research in speech pathology is the absence of data evaluating the duration or intensity of treatment needed to produce a desired effect. In utilizing SEMG biofeedback as an adjunct to treatment, clinical experience suggests that an optimal program to enhance swallowing function consists of an initial intensive treatment regime followed by home programming and a more traditional therapy schedule. An accelerated swallowing treatment program would consist of 10 hours of direct SEMG biofeedback assisted treatment in one week (two sessions daily of one hour duration for five consecutive days). Treatment is focused on intensive sensory stimulation of the oral pharyngeal cavity paired with execution of swallowing exercises with adjunctive biofeedback monitoring. Every effort is made, during this first week of therapy, to return the patient to at least limited oral intake, as can be safely tolerated with airway protection maneuvers. After this initial week, the patient begins a very structured home programming with 5-6 brief therapy session daily, paired with direct outpatient therapy at the clinic twice weekly. This regime is continued until clinical goals are achieved and the patient returns to an oral diet, or the patient demonstrates a plateau in function.

Initial Teaching

Substantial initial teaching is critical to the success of treatment using this modality, particularly for patients with cognitive deficits. Prior to electrodes being placed, it is important to discuss with the patient and the caretaker, if appropriate, the nature of the swallowing disorder and the treatment plan outlined. When introducing SEMG biofeedback, a full explanation of motor potentials and myoelectric activity will likely exceed the interest or cognition of most patients. It is important to identify to the patient that the device that will be used to facilitate treatment is a way of measuring the electrical activity of muscles used in swallowing and displaying that information on a computer screen so the patient can learn with those muscles are doing as he execute swallowing maneuvers. As a means of ensuring that the patient understands this very basic concept, it is usually helpful to place electrodes first on the arm, and then ask the patient to clinch his/her fist and observe the change in the feedback tracing. Using this method initially, allows the patient to learn the technique of biofeedback using muscles that are easily observable and thus more concrete. Next, the electrodes are placed submentally and the patient is not asked to swallow, but to open and close the mouth. With a small movement, there should be a relatively small amplitude excursion of the feedback tracing; with a larger movement, the tracing should demonstrate a greater amplitude excursion. If needed for patients with cognitive deficits, a mirror can be used to provide visual feedback and enhance learning. This exercise allows the patient to begin relating to degrees of movement and the relative effects on the feedback tracing. Finally, the patient is asked to swallow and observe the effect of the swallow on the SEMG tracing. It is important during initial teaching as well as throughout the course of therapy, that the patient be encouraged to actively interpret the SEMG tracing and associate that tracing with what he/she feels proprioceptively. For this purpose, the availability of a "freeze frame" option is essential. It is important, after each screen sweep, to hold that image and asked the patient to describe his motor events as related to the biofeedback tracing.

Muscle Relaxation and Inhibition

C.K. is a 58 year old male, 1 year status post brain stem infarct with a severe to profound swallowing disorder. He had previously attempted and failed traditional swallowing treatment attempts. Interestingly, when monitoring his submental musculature response at rest, the patient was unable to demonstrate relaxation of the suprahyoid musculature for greater than three consecutive seconds. He was observed at rest to demonstrate an SEMG reading spread erratically within a 35 mv range. With focused attention, after nine sessions, he was able to maintain a baseline rest average within a range of +/- 5 µv for a maximum of 10 seconds prior to again, experiencing atypical, non-volitional contractions. This apparent hyperfunction was not correlated with the presence of the speech deficit of spastic dysarthria, although a mild spastic hemiplegia was evident in the right upper extremity. At the conclusion of one week of treatment attempts, C.K. elected to terminate treatment efforts. In follow-up, C.K. was referred for manometry to evaluate the upper esophageal sphincter. This examination confirmed UES hypertonicity, as well as increased diffuse pharyngeal pressure.

The case of C.K. above raises interesting issues regarding swallowing function that would not be apparent without the benefit of SEMG monitoring. Is there a subgroup of dysphagic individuals that can be characterized as demonstrating spastic features, thus treatment attempts will be futile without first addressing this abnormal muscle function? Physical and occupational therapists know very well that a spastic muscle is not likely to effectively perform a functional motor activity. A goal of their rehabilitative efforts, then, may initially be to inhibit this spastic response, thus freeing the muscle group to function under volitional control. Although this issue has not been addressed in the dysphagia literature, clinical practice utilizing SEMG biofeedback suggests that this may be a contributing feature in the dysphagic symptoms of some patients. Again, SEMG is not a diagnostic tool and could not confirm this as a clinical feature; however, it may serve as a clinical screening tool to aid the clinician in making appropriate referrals. Other populations that may demonstrate atypically increased SEMG amplitude at rest include patients with spastic cerebral palsy or those with psychogenic, or functional, dysphagia. Therapeutic instruction for this type of focuses on differential contraction and relaxation of the targeted muscle group with visual feedback of the relative degree of muscle tension provided via the biofeedback tracing. Although the focus of this goal is not on swallowing, the patient should be instructed to swallow as necessary to manage secretions. An adult patient with cerebral palsy benefited well with this modality as an adjunct to treatment, with a functional outcome of improved secretion management and swallowing. As well, this technology may hold promise in addressing oral facial spasm of children with cerebral palsy. Clinically, in some patients who have achieved a degree of success with this treatment activity, transiently increased amplitude may reflect inadequate secretion clearance. It would appear that increased pharyngeal secretions result in "posturing" of the pharynx to inhibit aspiration, thus resulting in increased muscle contraction.

Coordination and Patterning of Muscle Response

S.J. is a 66 year old male with a 4-year history of Parkinson’s Disease. Although he was on an oral diet, he was progressively requiring increased time to eat due to abnormal, non-functional oral pharyngeal movements and was subsequently experiencing significant weight loss. When his swallowing was monitored with a SEMG biofeedback tracing, S.J. demonstrated an ability to relax submental musculature at rest, but during attempts to elicit a pharyngeal swallow, either with or without food, he demonstrated multiple peaks of amplitude prior to onset of the swallow that were well correlated with tongue pumping and swallowing gesture behaviors. This pattern was pointed out to the patient, with the treatment goal of extinguishing this non-purposeful movement. With practice, S.J. was able to limit extraneous movement to one pre-swallow gesture for exaggerated bolus transfer, with associated decreased time required for ingestion of adequate oral nutrition and eventual weight gain.

During normal swallowing behavior, we all demonstrate some variation in patterns of muscular contraction. Rarely, do we demonstrate a clean pattern of complete relaxation followed by sharp contraction representing execution of the swallow and followed immediately by complete relaxation. These variations are not, however of great enough magnitude to impact the efficiency of deglutition. Crary identifies in his study of 6 patients with brain stem infarct 4 distinct swallowing patterns, which he correlates with degree of swallowing coordination (1994). Clearly in patients with diseases such as Parkinson’s Disease, brain stem infarct and psychogenic dysphagia, these patterns of muscular contraction may be so pronounced as to be intrusive to the effectiveness of swallowing. In this case, rehabilitative efforts may focus on reinforcement and mastery of a more efficient swallowing pattern as described above in the case of S.J.

Muscle Recruitment

S.R. is a 51 year old female, 28 months status post excision of a right foramen magnum meningioma. Intra-operatively, she hemorrhaged into her tumor site. She received traditional swallowing treatment for 18 months without significant change in swallowing behavior. A videofluoroscopy completed 3 weeks prior to a SEMG assisted treatment program revealed profound pharyngeal phase dysphagia characterized by absent swallow on approximately 70% of attempts. Despite the guarded prognosis, S.R. elected to attempt treatment. By the end of nine treatment sessions, she demonstrated persisting severe dysphagia but with remarkable gains in the coordination of swallowing components. She was started on a puree diet and continued progress in swallowing through traditional treatment. Her feeding tube was removed 5 months following her SEMG assisted swallowing treatment. At that time, the patient was tolerating a near normal diet with no pulmonary symptoms and a needed weight gain of approximately 20 pounds.

SEMG Tracing: Valsalva Swallows

SEMG Tracing: Masako Maneuver

SEMG Tracing: Mendelsohn maneuver on two swallows.

A patient with weakened or dyscoordinated pharyngeal swallowing from neurological injury or resection/radiation secondary to carcinoma may experience a variety of dysphagic complications. The traditional exercises of Modified Valsalva (or effortful) swallow and Mendelsohn Maneuver, and as well, perhaps the newly described Masako Maneuver, can be highly effective if they are executed correctly. For execution of the Modified Valsalva the patient is instructed to "swallow hard", with the presupposition that repetitive execution with increasing effort will produce overall stronger pharyngeal contraction. However, subjective estimates of strength of the swallow or relative degree of laryngeal excursion are difficult to assess by observation or palpation. The Mendelsohn Maneuver requires an abstract alteration in the way we swallow. The patient is instructed to initiate a normal swallow, but when the larynx is at it's highest point of excursion, the patient is to volitionally sustain this maximal contraction. This maneuver is clinically thought not only to strengthen the pharyngeal swallow but enhance opening of the sphincter muscle that separates the pharynx from the esophagus. Because of the complexity of the maneuver and the required alteration of an automatic process, many patients are not able to master the technique and thus do not reap the benefits. The Masako Maneuver is a newly described maneuver that may hold potential for swallowing rehabilitation (21). Research demonstrates that there is greater posterior pharyngeal wall movement during swallowing if the tongue is anchored anteriorly during the incisors. Thus this is suggested as a rehabilitative exercise to improve pharyngeal swallowing. All of these traditional swallowing treatment exercises can be greatly enhanced via SEMG monitoring.

The patient described above would, by many accounts, be considered a chronic, perhaps hopeless, dysphagic. Certainly, the extent of her injury and time since onset would tend toward a poorer prognosis. She illustrates, however, our lack of knowledge regarding accurate prognostication and perhaps our underestimation of the effects of rehabilitation. In this case, once she was able to accurately master several swallowing exercises, S.R. demonstrated not only increased strength of the pharyngeal swallow, but remarkably increased synergy of the individual components that collectively constitute a swallowing response. This raises another interesting, but as yet, unanswered question. What exactly are we effecting through our rehabilitative efforts? If execution of these exercises were only to strengthen the swallowing musculature, why then, do we not see as a result, only a stronger, poorly coordinated swallow? Can we in some ways, re-program a swallowing response, thus not only effecting strength but, as well, coordination and elicitation of a pharyngeal swallow? These questions are yet unanswered in the swallowing literature, but as improved swallowing rehabilitation modalities yield better results, we are gaining more insights into the issues related to swallowing treatment.

Home Programming

The ultimate goal of SEMG biofeedback monitoring in any rehabilitative program is for the patient to ultimately internalize the biofeedback signal, thus maximizing carryover to alternate environments and eventually eliminating the need for direct rehabilitation. The initial steps toward this goal are introduction to rehabilitative exercises and direct intervention in the clinic setting. The logical next step is the establishment of a program to facilitate carryover of the learned behavior to alternate environments. An optimal home program for many patients will consist of five to six brief (5-10 minutes) sessions daily, addressing the goals from direct treatment in the home environment. For patients who can tolerate at least a limited oral diet, these sessions may be structured to precede snacks and meals. It has been the experience of this clinician that if the patient completes an initial intensive training program with SEMG biofeedback, use of a biofeedback device for home programming is rarely required. As described by a patient who utilized this equipment, "The images you worked at my building are permanently etched on my mind".

Precautions and Contraindications

SEMG biofeedback monitoring is a non-invasive treatment technique. There are only a few situations which warrant precautions. The nature of the treatment tends to be a very intensive form of traditional swallowing treatment and requires considerable effort on behalf of the patient. As such, patients with unstable cardiac conditions may be unable to tolerate the intensive, Valsalva type maneuvers required for treatment. Additionally, recent surgical patients or patients undergoing radiation therapy, may be contraindicated secondary to the delicacy of fresh surgical incisions or the friability of irradiated tissue. In these patient populations, SEMG biofeedback assisted treatment is not absolutely contraindicated, but should be approved by the referring physician with specific written orders.

Summary

Eating is a favorite among past-times in this country with almost all holidays and family celebrations centered around the dinner table. Thus, in addition to the medical complications, the social implications of dysphagia are tremendous. It is not uncommon in the clinical practice of dysphagia to encounter patients who would rather eat than talk, and elect for a surgical procedure which separates the trachea from the alimentary system, thus permanently sacrificing the potential for speech. The patient SR, described above, has very articulately shared her experiences of being dysphagic and recovering from dysphagia. When writing about her experiences immediately after surgery, she expresses "...since I equated living with the ability to swallow, I thought I was just marking time until I died." She further describes the social isolation of her disorder after her hospital discharge. "It was embarrassing. At theaters, restaurants and other public places, people with forbidding glares would move away from us after hearing me 'clear' (my secretions). Strangers did not know that I couldn't swallow." Upon removal of her feeding tube and return to a near normal diet, she celebrated her recovery with a trip to Europe. She states, "....mostly swallowing is, oh so wonderful a gift I will never take it for granted again!"

As clinicians involved in the provision of services to patients with a variety of handicapping conditions, it behooves us to listen carefully to our patients and let their words motivate us to discover innovative therapies or alternative applications of well-known treatment modalities. SEMG biofeedback provides great potential for the enhancement of clinical rehabilitation of the dysphagic patient. Bryant (1991), Crary (1994) and Huckabee, et al, (1996) have documented case studies of dysphagic patients successfully treated with SEMG biofeedback. These studies are compelling in that they recount recovery of swallowing function well after the expected period of spontaneous recovery, implying that the rehabilitation exercises provided resulted in the functional change. However, the key to recovery is patient involvement and understanding. The concept is simple. As described by K.T., as 68 year old male who recovered from brain stem dysphagia:

"It gives you a target to shoot at, and most people need that in life. You can't have a general theory and expect someone to react to it. You have to have something that you can see, feel and hear that gives you direction. This way you can relate to it. In other words, when you see that you had a good swallow, you know what it feels like. Without this equipment, this feeling of your Adams apple, that doesn't do me any good at all. If I have a target, I'll work for it and I think most people are the same way. You can see progress and determine what was good and what was bad."

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