1. Kristen K Maul, Elizabeth E Galletta, Peii Chen, Mooyeon Oh-Park, Yekyung Kong, Kelsea Sandefur, AM Barrett AAPMR Annual Meeting 2014 1

2. Disclosure Kristen K Maul Elizabeth E Galletta Peii Chen Mooyeon Oh-Park Yekyung Kong Kelsea Sandefur And AM Barrett have no relevant financial disclosures. 2

3. Eating is a complex behavior Volitional - Oral stage. Mastication, manipulation and transit of the bolus. Reflexive - Pharyngeal stage. Initiation of patterned response. Epiglottic inversion. Laryngeal elevation. Upper esophageal sphincter opening. Bolus transit through pharynx into esophagus. Cognitive Body spatial cognition 3 Logemann, 1995; Leopold and Daniels, 2010

4. Spatial neglect and eating activity Spatial neglect & swallowing deficits common post stroke (Flowers, 2013) Neglect - inattention to left-side affects eating behaviors and patterns may affect volitional stage of swallowing (Andre, 2000) Failure to initiate chewing/swallowing on left side of mouth. Dribbling on the left side of the face. Food retention in the oral cavity. Neglect may not affect reflexive stage of swallowing and aspiration ( Steinhagen et al., 2009) 4

5. Objective of the study is to Evaluate whether the presence of spatial neglect has an impact on oral phase of swallowing function and eating independence. 5

6. Methods Design: Retrospective analysis of Medical Record Setting: Inpatient Rehabilitation Facility 06/12- 06/13 Inclusion: First time unilateral hemispheric stroke (L or R) being evaluated for spatial neglect Exclusion: Bilateral lesions Previous CVA 6

7. Methods Predictor variable: Severity of neglect Catherine Bergego Scale (CBS score via Kessler Foundation-NAP) Outcome measures Presence and Type of dysphagia on clinical examination (oral, pharyngeal, oral-pharyngeal) FIM - eating score 7

8. RESULTS 8

9. Demographics & Functional Status (n=82) CharacteristicsNo Neglect, n = 24Neglect, n = 58P value Age - yrs (sd)70.5 (16.2)70.3 (13.3).958 Female (%)13 (54.2)34 (58.6).711 Rt Stroke (%)11 (45.8)48 (82.8) <.001 Days post-onset (sd)8.8 (5.0)8.7 (4.7).971 CBS (sd)010.5 (8.5)N/A 9

10. Results Dysphagia Dx (type) No Neglect, n=24 Neglect, n=58 P value Dysphagia, any phase (%)14 (58.3)41 (70.1).279 Oral phase (%)1 (0.1)13 (22.4).015 Pharyngeal phase (%)4 (28.6)1(.02) Oro-pharyngeal phase (%)9 (64.3)27 (46.6) NDD = National Diet Level (solids) 10

11. Impairment in Oral Stage Swallowing impairment (%)No Neglect n=14Neglect n=41 Tongue retraction2 (14)8 (20) Tongue pumping01 (2) Extended mastication2 (14)14 (34) Premature spillage2 (14)10 (24) Anterior leakage1 (7)9 (22) Bolus formation07 (17) Bolus propulsion time010 (24) Oral residue1 (7)8 (20) Rotary chew05 (12) Piecemeal degluttition1 (7)3 (7) Apraxic component1 (7)3 (7) Awareness of bolus01 (2) 11

12. Multivariate Logistic Regression OR (95% Confidence Interval)P value CBS Score1.15 (1.05 - 1.26)<.001 Age 0.99 (0.96 - 1.03).648 Sex (F) 2.99 (1.00 - 8.93).050 Right Stroke 0.30 (0.09 - 1.03).065 Neglect predicts diagnosis of dysphagia, controlling for age, sex, & stroke side 12

13. Eating FIM score by Neglect Severity 13

14. Summary In a sample of 82 first-time stroke survivors, individuals with spatial neglect were more-likely to have oral dysphagia Spatial neglect is associated with greater dependence in eating. Interdisciplinary communication is required in treatment of patients with dysphagia and spatial neglect. 14

15. Future Directions Relationship between the type of neglect (personal neglect vs extrapersonal neglect) and the oral phase dysphagia Prospective study of oral phase swallowing difficulties to distinguish stroke severity and neglect to assess the morbidity in neglect associated dysphagia 15

16. Demographics & Functional Status (n=82) CharacteristicsNo Neglect, n = 24Neglect, n = 58P value Days post-onset (sd)8.8 (5.0)8.7 (4.7).971 Total FIM-admit (sd)82.8 (17.1)57.8 (16.6)<.001 Cog FIM-admit (sd)26.1 (5.8)22.1 (2.9)<.001 Motor FIM-admit (sd)56.7 (13.6)35.8 (13.5)<.002 CBS (sd)010.5 (8.5)N/A 16

17. Results Dysphagia Dx (type) No Neglect, n=24 Neglect, n=58 P value Dysphagia, any phase (%)14 (58.3)41 (70.1).279 Oral phase (%)1 (0.1)13 (22.4).015 Pharyngeal phase (%)4 (28.6)1(.02) Oro-pharyngeal phase (%)9 (64.3)27 (46.6) NDD 1211 NDD 247 NDD 3311 NDD 41115 NDD = National Diet Level (solids) 17

18. Impairment in Pharyngeal Stage Swallowing impairment No Neglect n=14Neglect n=41 Delayed swallow Initiation1 (7%)12 (29%) Pharyngeal constriction1 (7%)7 (17%) Vallecular pooling2 (14%)10 (24%) Pyriform pooling prior to the swallow1 (7%)11 (26%) Penetration2 (14%)13 (32%) Silent aspiration1 (7%)5 (12%) Pharyngeal transit time03 (7%) Pharyngeal residue1 (7%)2 (5%) Sensory integrity03 (7%) Hyolaryngeal elevation1 (7%)8 (20%) Epiglottic retroflexion03 (7%) 18 No difference in Pyriform /Valllecular residue, aspiration, reduced tongue base retraction

19. References 19 André, J. M., Beis, J. M., Morin, N., & Paysant, J. (2000). Buccal hemineglect.Archives of neurology, 57(12), 1734-1741. Flowers, H. L., Silver, F. L., Fang, J., Rochon, E., & Martino, R. (2013). The incidence, co-occurrence, and predictors of dysphagia, dysarthria, and aphasia after first-ever acute ischemic stroke. Journal of communication disorders,46(3), 238-248. Logemann, J. A., & Logemann, J. A. (1997). Evaluation and treatment of swallowing disorders. 2 nd Edition, Pro Ed: Austin, TZ. Leopold, N. A., & Daniels, S. K. (2010). Supranuclear control of swallowing.Dysphagia, 25(3), 250-257. Steinhagen, V., Grossmann, A., Benecke, R., & Walter, U. (2009). Swallowing disturbance pattern relates to brain lesion location in acute stroke patients.Stroke, 40(5), 1903-1906.