Ross, D. (2013) Reliability of EMG/IOPI in OPD/OMD Diagnosis.
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Transcript of Ross, D. (2013) Reliability of EMG/IOPI in OPD/OMD Diagnosis.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 1
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RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 2
Inter-rater Reliability of Clinical Measures of Oromyofunctional
Disorders and Oropharyngeal Dysphagia
by
Dave Ross
B.Sc., Boston University, 2004
M. Sc., University of Alaska, 2009
M.Sc., Idaho State University, 2013
A thesis
submitted in partial fulfillment
of the requirements for the degree of
Master of Science in Speech-Language Pathology
Idaho State University
May 2013
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 3
Acknowledgements
Dr. Seikel, Dr. Sorenson; Dr. Mercaldo; Teri Peterson - for being a supportive committee.
Ruth Reardon, Chad Seibold, Blake Tanner and Savannah Leckington – it‟s over!
Marc Maron; Maria Bamford; Andy Dick – for keeping me sane lo these long nights.
Jude Jones and Sarah Knudsen – for all your kind help these years.
Donna Plant – for the final look-throughs!
My mother and father who have supported me unconditionally through the years.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 4
TABLE OF CONTENTS
List of Tables……………………………………………………………………………..ix
List of Figures…………………………………………………………………………......x
Abstract……………………………………………………………………………….......xi
Chapter 1: Introduction…………………………………………………………………....1
Chapter 2: Review of Literature…………………………………………………………..3
A:Reliability Studies of OPD/OMD………………………………………3
B:The Normal Swallow…………………………………………………...6
C:Etiologies and Pathologies of OPD……………………………………..7
D:Etiologies and Pathologies of OMD……………………………………8
E:Clinical Measures of OPD………………………………………………9
F:Clinical Measures of OMD…………………………………………….11
G: ICC versus Pearson r…………………………………………………11
Chapter 3: Methodology…………………………………………………………………13
A:Participants……………………………………………….………........13
B:Instrumentation………………………………………..………............14
C: Procedures…………………………………………………………….14
IOPI Measurements……………………………………………...15
EMG Measurements……………………………………………..16
Observational Measurements…………………………………….17
D:Variables………………………….…………………………...............18
E:Reliability………………………………………………………...........18
Chapter 4: Results and Discussion……………………………………….........................20
A:Data Analysis………………………………………….…………........20
B:Results and Discussion………………………………..…………….....21
Laryngeal Elevation……………………………………...22
IOPI………………………………………………………24
Masseter Baseline………………………………………..26
Masseter………………………………………………….27
Comparing ICC to Pearson r……………………………..29
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 5
C: Summary………………………………………………….…………..30
Limitations and Considerations………………………………….33
References………………………………………………………..………........................34
Appendix A: Graphs of ICC Values……………………………………………………..40
Appendix B: Human Subjects Consent Form…………………………………………....46
Appendix C: Demographic Survey…………………………………………………........49
Appendix D: ISU Tongue Thrust Protocol…………………………………………........58
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 6
List of Tables
Table 1.1 Problems of data collection inter-rater reliability may uncover……………….4
Table 1.2 Tongue thrust impact on swallowing…………………………………………...9
Table 2.1 Instrumental tasks recorded during the study……………………….………...14
Table 2.2 Three orders of protocols used for assessment during the study……………...15
Table 3.1 Coding procedures used during data analysis………………………………..22
Table 3.2 ICC Values for Judging Group 1 (Laryngeal elevation)……………………...23
Table 3.3 ICC Values for Judging Group 1 (IOPI)…………………………….………..25
Table 3.4 ICC Values for Judging Group 1 (Masseter baseline)……………………......26
Table 3.5 ICC Values for Judging Group 1 (Masseter)……………………………….....28
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 7
List of Figures
Figure 1 Coefficient Frequency for Judging Group 1 (Laryngeal elevation)……………24
Figure 2 Coefficient Frequency for Judging Group 1 (IOPI)……………………………26
Figure 3 Coefficient Frequency for Judging Group 1 (Masseter baseline)………….......27
Figure 4 Coefficient Frequency for Judging Group 1 (Masseter)……………………….29
Figure 5 Difference between ICC and Pearson r values for Masseter Baseline………...30
Figure 6 Coefficient Frequency for Judging Group 1 (Overall)…………………………31
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 8
ABSTRACT
Inter-rater reliability shows the degree of concordance among a group of raters observing
or performing the same action; a high level of inter-rater reliability indicates that any
results are not due to chance. In Speech-Language-Pathology, two instruments are used in
the diagnosis of oropharyngeal dysphagia and oromyofunctional disorders: The Iowa oral
performance instrument and Electromyography. This study examined the reliability of
these instruments as used in conjunction with the ISU Tongue Thrust Protocol. Two
judges examined inter-rater reliability by assessing a group of 24 healthy adults twice, on
two separate occasions, by two separate judges. The data were subjected to an intra-class
correlation. Data analysis revealed an overall moderate-almost perfect level of reliability
across all parameters analyzed; 60% of data points were strong-almost perfect
(ICC >0.700); no data point fell below 0.300. Overall data analysis supports the use of
IOPI and EMG in conjunction with the ISU Tongue Thrust Protocol.
.
Key Words: Inter-rater Reliability, Dysphagia, Oromyofunctional Disorders
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 9
Chapter 1 Introduction
Swallowing has been defined clinically as “the entire act of swallowing
(deglutition) from placement of food in the mouth through the oral, pharyngeal and
esophageal phases of the swallow until the prepared material (bolus) enters the stomach
through the gastro-esophageal junction” (Logemann 1998, p.4). Swallowing consists of
highly intricate movements that are coordinated by the cortical brain, brainstem reflexes
and the muscles and cartilages of the swallowing system. While swallowing is a
necessary daily function, many variables can impact its integrity; the impacts from these
variables all fall under the umbrella term swallowing disorders.
Broadly, swallowing disorders are defined as being either oropharyngeal or
oromyofunctional in nature, with oropharyngeal dysphagia (OPD) the most common. A
person with OPD may be at risk for penetration (food/liquid above the level of the vocal
folds) or aspiration (food/liquid below the level of the vocal folds), and in some cases,
complications from OPD can lead to death (Riquelme et al., 2008). Distinct from OPD is
the group of oromyofunctional disorders (OMD), which are disorders of the muscles
involving the face, mouth, lips, or jaw. Tongue thrust is the most well-known OMD, and
a large amount of research has been conducted on this disorder (Benkert, 1997;
Hemmings et al., 2000).Tongue thrust is thought of as the relic of an immature swallow
pattern, categorized by the tongue‟s far anterior rest or protrusion through the teeth
during speech, swallowing (Hanson & Mason, 2003).
Both OPD and OMD have some overlapping signs and symptoms, such as poor
lingual control and inadequate bolus retropulsion (Logemann, 1998; Hanson et al., 2003),
yet they are generally assessed and treated separately in the field. The Idaho State
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 10
University Tongue Thrust Protocol clinically assesses the presence of OMD and OPD in
a patient. During the clinical evaluation, both oral muscle contraction and oral
performance are gauged via electromyography (EMG) and the Iowa Oral Performance
Instrument (IOPI), respectively. The interpretation of the results of these instruments
depends on some subjective judgments, and the inter-rater reliability of these judgments
has been poorly researched. This study seeks to examine the inter-rater reliability of these
instruments combined with the protocol; this study is part of a larger study which seeks to
provide evidence of the relationship between diagnostic indicators of OMD and OPD
across the lifespan.
Inter-rater reliability is important as reliability speaks directly to the consistency
of the results collected during research. In order for research to be considered evidence-
based, the study should be able to produce similar results when repeated; a study is not
reliable if it cannot be reproduced with similar results. In the medical field, it is assumed
that different clinicians will be using a given protocol to assess either a new patient, or
the same patient (e.g., for therapy progress or baseline probing); this way, a degree of
concordance can be calculated between the different clinicians working with the patient.
In statistics, this is termed inter-rater reliability, and its calculation provides a researcher
with the degree of concordance among different observations taken at different times.
The following review of literature discusses the use of inter-rater reliability during
clinical evaluations of swallowing, the normal swallow, etiologies and pathologies of
OPD/OMD, and the methods of clinical assessments of OPD/OMD.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 11
Chapter 2 Review of Literature
A. Reliability studies in OPD/OMD
Inter-rater reliability is simply the degree of concordance among a group of raters
observing or performing the same action, and is quite useful in establishing whether a
certain tool is appropriate for measuring a certain variable (e.g., using a given instrument
to assess the severity of OPD in a patient); it also allows researchers to show the
consistency of how data were collected. With a high degree of inter-rater reliability, a
researcher is able to show a high level of confidence in both the way the data were
collected as well as feel confident that the same results may be obtained in the future
(Keyton et al., 2004).In an evidence-based paradigm (as is the case in the field of
medicine), reliability stands as a strong way of supporting hypotheses. High-quality
evidence can only come from statistically strong data, such as data that comes from inter-
rater reliability. Krippendorf (2004a) argued that the statistical tools used to measure
inter-rater reliability “provide a logistical proof that the answers collected are more than
simple chance” (p.2). Inter-rater reliability also exits to combat some experimenter bias.
While inter-rater reliability is important to show the amount of confidence and
agreement between raters, it can also help highlight some problems that may occur during
data collection. Neuendorf (2002) highlighted some of these problems in Table 1.1:
Table 1.1
Problems of data collection inter-rater reliability may uncover
1. Poorly executed coding procedures (in surveys/interviews)
2. Poor survey/interview administration
3. Poor research design
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 12
Computing inter-rater reliability is not difficult; programs exist both for free on
the internet, as well as for purchase (Keyton et al., 2004).Computing inter-rater reliability
is a fairly straightforward procedure and some of the main statistical tools used include
Cohen‟s kappa, the Intra-class correlation coefficient, and the Pearson Product Moment
Correlation.
The impedance of the EMG signal has been shown to be somewhat problematic
with EMG (Duff, Nolan, Rybansky & O‟Malley, 2002). EMG electrode placement for
the masseter trials was somewhat imprecise. This is because, no matter how perfect a
judge may follow procedure, when it comes to EMG placement on the face, there is no
accounting for impedance due to skin issues, hair, cuts/scars/bruises (scar tissue is more
fibrous than regular tissue), sweating and makeup. The true levels of impedance for each
material (e.g., cotton, blush, scar tissue) have not been calculated in relation to EMG (and
is beyond the scope of this project), but it is important to note that the variation in data
seen with the masseter trials during chewing and swallowing may be due to this fact.
While reliability studies have been conducted on various aspects of the non-
invasive instrumental assessment of swallowing disorders (Butler et al., 2009; Stierwalt
et al., 2009), very few studies have looked at the reliability of the invasive instrumental
assessment tools. Stoeckli, Huisman, Seifert and Martin–Harris (2003) examined the
inter-rater reliability for VFSS in relation to the timing of oral and pharyngeal phase, the
presence of penetration/aspiration (including amount of aspiration/penetration), and the
location of bolus residue. Stoeckli et al. found that only the aspiration presence was
evaluated with high reliability and all other parameters had poor inter-rater reliability. A
study done by Leslie, Drinnan, Finn, Ford and Wilson (2004) examined inter-rater
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 13
reliability in cervical auscultation (CA) and found that clinicians‟ rating of twenty audio
files of swallows (both normal and abnormal) was poor. Colodny (2002) looked at inter-
rater reliability in relation to aspiration and penetration seen during a FEES evaluation.
Colodny filmed seventy-nine swallows that four raters would judge the resultant levels of
aspiration and penetration; data analysis showed good inter-rater reliability for both
aspiration and penetration (inter-rater reliability of penetration was the highest).
As IOPI has been used recently as a part of many OMD and OPD assessments, a
fair amount of research has been done on the reliability of IOPI, however, most of these
studies have looked at the reliability of IOPI as it relates strictly to lingual strength and
endurance for a variety of speech and non-speech tasks (Robin, Goel, Somodi & Luschei,
1992; Youmans, Stierwalt, & Clark, 2002; Clark et al., 2003). EMG has recently become
popular to use in therapy, especially as a biofeedback device (Fritz, Chiu, Patterson and
Light, 2005), and some research has been done in the inter-rater reliability of EMG in
therapy. Vaiman, Eviatar and Segal (2004) were the first to look solely at the reliability
of EMG data as it relates to the oral preparatory and oral phase of the swallow. EMG
studies were performed on 440 normal adults in order to establish a normative database
for duration of oral muscle activity during swallowing (both solid and liquid boluses),
which is clinically useful for both SLPs and ENT outpatients. Vaiman and his colleagues
examined the timing of activity of the orbicularis oris, masseter, submental, and
infrahyoid muscle groups, and organized the data into discrete age groups for each
muscle. The normative data collected by this group allows future clinicians to compare
their patient‟s data with a peer group (similar to the scope of this study).While there have
been a fair number of studies conducted on the inter-rater reliability for some various
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 14
aspects of the instrumental assessment of swallowing as a whole, it should be noted that
very little research has focused on the inter-rater reliability of the instruments used during
a clinical evaluation of OMD and OPD, which is the focus of this study.
B. The Normal Swallow
The normal swallow consists of highly intricate muscle movements (with both
voluntary and reflexive components), as well as perceptual feedback from the muscles
and nerves that innervate the swallowing anatomy. The typical swallow has four phases,
each with their own anatomical and physiological function (Logemann, 1998). The four
phases are: (1) the oral preparatory phase, (2) the oral phase, (3) the pharyngeal phase,
and (4) the esophageal phase; each of the phases of the swallow requires coordinated
movements to achieve proper bolus preparation for transport to the next phase. This paper
will only cover the first three phases.
During the oral preparatory phase, food or liquid is introduced to the oral cavity,
and the lips form a seal so neither food nor liquid can escape. This labial seal is
important, as it allows for pressure to build up in the oral cavity which is integral in the
proper movement of the bolus throughout the entire swallow. The food or liquid is
prepared (masticated if food) and mixed with saliva to form a bolus. If the bolus is liquid,
mastication is not required though the liquid bolus will be held on the tongue until the
next phase of the swallow (the oral phase) is initiated (Logemann, 1998).
During the oral phase, the prepared bolus is transported to the posterior
tongue/fauces, in order to trigger the next phase (the pharyngeal phase). In this phase, the
tongue moves in a systematic way in order to propel the bolus posteriorly; when the
posterior tongue base hits the posterior pharyngeal wall, the next phase is triggered.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 15
During the pharyngeal phase, a few major physiological events occur in a very
short amount of time. The first major event is the closing of the velopharyngeal port,
which helps prevent bolus material from leaking into the nasopharynx (nasal
regurgitation). The second major event is hyo-laryngeal excursion (the anterior and
superior movement of the hyoid and larynx), which aids in the opening of the upper
esophageal sphincter (UES). The third major event is the protection of our airway via
inversion of the epiglottis and adduction of the true and false vocal folds (to protect
against aspiration or penetration through the larynx). The fourth major event is the
opening of the UES, which the bolus passes through to the next phase.
C. Etiologies and Pathologies of OPD
The etiologies of OPD fall into three categories: structural, neurogenic, and
functional; OPD can occur as a result of any dysfunction to any structure in the oral or
pharyngeal region of the swallowing mechanism (Logemann, 1998). The structural
etiologies of OPD can all be attributed to something affecting the structure of the
swallowing anatomy either externally (tissue/muscle removed or added), or internally
(tissue/muscle altered so it does not move as easily). Patients who have had surgery for
pharyngeal or laryngeal cancer may have difficulty moving the bolus into the esophagus,
and may be at risk for aspiration or penetration (Riquelme et al., 2008). The neurogenic
etiologies are the largest group of etiologies of OPD; Domench (1999) and Terre-Boliart
(2004) have both proposed that the majority of people develop OPD due to a neurogenic
etiology. These etiologies cause a disruption in the neural-muscular signals from the
brain to the swallowing anatomy (ASHA, 2008). The functional etiologies of OPD are
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 16
the smallest category of etiologies. Functional OPD has been defined by Clause (2003) as
“OPD with no organic cause that can be identified.”
D. Etiologies and Pathologies of OMD
The etiologies of tongue thrust are widespread and varied; Hemmings et al. have
put forth a fairly substantial list of possible etiologies (p.15, 2000). Barrett and Hanson
argue that tongue thrust is a normal behavior in infants, and by about the age of five,
most children appear to be swallowing without the tongue thrust. Barrett and Hanson
further suggest that, “when tongue thrust occurs in children beyond the age of 7 years, it
represents either a fixation of, or a regression to, early childhood behavior” (p.130, 1998).
This preservation of childhood tongue thrust into the adult years can cause some
problems with both speech and swallowing. Both Barrett and Hanson (1988) and Benkert
(1997) provide a fairly extensive list of impacts on swallowing by tongue thrust, as seen
in Table 1.2. Many children with tongue thrust may present clinically with frontal or
lateral lisps, and may have difficulty producing the grammatical morphemes for plural
marking (/s/, /z/) and for the contractible copula (-„s as in „he‟s happy‟). Phonemes /t/,
/d/, /n/, and /l/ may also be at risk due to poor tongue tip muscles (ASHA, 2008).
Table 1.2
Tongue Thrust Impact on Swallowing (adapted from Benkert, 1997)
1. Poor lingual control
2. Poor bolus control/propulsion
3. Poor labial seal
4. Poor lingual tone
5. Poor oral musculature tone
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 17
E. Clinical Measures of OPD
The clinical measures used in the assessment and diagnosing of OPD fall broadly
into two categories: instrumental and behavioral. Instrumental assessments of OPD tend
to focus on the anatomy and physiology of the patient‟s disordered swallow (e.g., amount
of residue left in the pyramidal sinus), while behavior assessments of OPD tend to focus
on the patient‟s presentation of signs/symptoms of the disordered swallow (e.g., vocal
quality post-swallow). While both types of assessment are used to create a full picture of
the patient‟s swallowing mechanism, an instrumental view provides a clinician with an
intimate first-hand look at the patient‟s unique swallowing structures, which may be used
to make a final diagnosis.
During an instrumental assessment of OPD, a clinician may use either a non-
invasive instrument or an invasive instrument. A non-invasive instrumental assessment
may include instruments like electromyography (EMG) and the Iowa Oral Performance
Instrument (IOPI), which are easily placed on the patient, and require very little training.
The information gained from this type of instrumental assessment can help a clinician
evaluate the levels of bolus timing, oral pressures, and muscular contractions during the
swallow (mainly in the oral preparatory and oral phase). However, this type of
instrumental assessment does not give very in-depth information relating to the
physiology of the patient‟s swallow. An invasive instrumental assessment may include
instruments like fluoroscopy (e.g., videofluoroscopic swallow study, VFSS), endoscopy
(e.g., flexible endoscopic swallow study, FEES), ultrasound, and manometry, which
evaluates pressure throughout the swallowing mechanism (ASHA, 2008).
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 18
Behavioral assessment of OPD does not require any additional instruments, with
the exception of possibly a stethoscope and/or a tongue depressor. Primarily, clinicians
are most interested in vocal quality, bolus texture/shape, eye/nose watering, and
coughing/choking (Logemann et al., 2002). Cervical auscultation (CA) is used to detect
presence of swallow and aspiration by listening to the sounds produced by the patient's
body before, during and after the swallow with a stethoscope (Zenner, Losinki& Mills,
1995, p.3). Zenner et al. (1995) examined the use of CA in the clinical dysphagia
examination in long-term care; their results support the use of cervical auscultation as a
"highly sensitive and specific method of dysphagia assessment" (Zenner et al., 1995, p.5).
Information gained from CA is behavioral-based, but can help provide the clinician with
further information on how the swallowing disorder is affecting the patient. As with
anyinstrumental assessment in the medical field, the reading of any findings found during
an OPD assessment relies heavily on the clinician‟s expertise and experience in the field.
F. Clinical Measures of OMD
While clinicians have a variety of instrumental and behavioral assessments to help
them diagnosis the presence (or absence) of OPD, very few assessments exist to help
diagnose OMD. A clinician diagnosing an OMD usually uses a behavioral assessment
(e.g., checklist of signs and symptoms). These types of assessments allow the clinician to
gauge the amount of support the patient may need during swallowing; in the case of
tongue thrust. When diagnosing OMD, it is important to note that there is not a large
amount of normative data on variables like tongue strength, or amount of deviation.
However, instruments like EMG and IOPI allow the clinician to objectively gauge (with
an allowable error of measurement) some variables, like swallow timing, as well as oral
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 19
musculature strength. Stierwalt and Youmans (2007) found a positive correlation
between reduced tongue strength and OPD. Further, Stierwalt, Youmans and Youmans
(2009) stated that “the addition of an objective, quantifiable method for evaluating tongue
strength that is reliable and valid, such as the IOPI, makes it possible to establish ranges
of normal tongue strength and tongue strength during swallowing” (p. 64).
G. ICC versus Pearson r
The intra-class correlation coefficient was chosen as a superior value to the
Pearson product moment correlation (Pearson r) as ICC values measure correlations in
conjunction with more than two observers, while a Pearson r measures a similar
correlation for two observers; with three total judges, the ICC is the standard and most
appropriate metric to analyze the data (Romberg, 2009). Used in this study, the ICC will
highlight how strong or weak participants in each judging group resemble each other.
Evans (2003) noted that the ICC can be used for a number of different reasons. He argued
that the ICC algorithm is the most appropriate when a group of more than two judges
wish to “analyze the homogeneity within groups relative to the homogeneity overall”
(Evans, 2003). Evans (2003) further noted that "the Pearson product-moment correlation
coefficient does not measure agreement, only trend"; as the purpose of this study is to
measure the agreement between two different observers and not the trends, the ICC was
ultimately chosen as the most appropriate for this study. Evans (2003) also noted that the
ICC is a more appropriate algorithm to use than a Cohen‟s kappa for measuring
agreement along an ordinal/interval scale. It is of prime importance to choose the most
appropriate statistical algorithm to analyze the data, as this study‟s results ultimately
speaks to the validity of the ISU Tongue Thrust Protocol.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 20
The purpose of this research project was to determine the level of inter-rater
reliability of the instruments used during the clinical assessment of OPD and OMD (e.g.,
EMG and IOPI). This was determined by using the EMG and IOPI to measure intra-oral
pressure, lingual strength, masseter contraction and transit timing in a group of healthy
adults. Three raters assessed both OMD and OPD in this group of healthy adults using the
Logemann (1998) clinical evaluation for OPD, and using the ISU Tongue Thrust protocol
for OMD. The question posed by this study was “to what degree are measures of EMG
and IOPI stable when used to measure oral function by two different raters on the same
subject?” The three judges were split into three judging groups (with two judges per
group); this study tracked judging group one.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 21
Chapter 3 Methodology
The purpose of this research project was to determine the level of inter-rater
reliability of the instruments used during the clinical assessment of OPD and OMD (e.g.,
EMG and IOPI). This was determined by using the EMG and IOPI to measure intra-oral
pressure, lingual strength, masseter contraction and transit timing in a group of healthy
adults. Three raters assessed both OMD and OPD in this group of healthy adults using the
Logemann (1998) clinical evaluation as well as the ISU Tongue Thrust protocol. The
question posed by this study is “to what degree are measures of EMG and IOPI stable
when used to measure oral function by two different raters on the same subject?”
A. Participants
Participants chosen for this study were healthy adults (no diagnosis of OMD or
OPD) between 18 and 60 years of age (participants were split evenly between male and
female; 4 were between age 20-30, 3 were between 31-40; 1 was 41-60). Participants
were chosen from around the Pocatello area of southeastern Idaho. Participants were
selected after responding to an email (or other personal contact) generated from the
researchers, and a total of 24 participants were selected. A demographic survey was
conducted that questioned various aspects of their health histories, eating habits, age,
smoking habits, and other health- and diet-related questions (Appendix B). The
Logemann (1998) clinical evaluation served as the basis for OPD assessment, and the
ISU Tongue Thrust Protocol served as the tool for OMD assessment.
B. Instrumentation
This study utilized surface electromyography (EMG) as well as the Iowa Oral
Performance Instrument (IOPI) as the main tools of instrumental assessment. The IOPI
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 22
measured superior tongue tip, tongue dorsum, masseter and lip strength. The EMG (a 2-
channel Infiniti) measured masseter contraction and oral transit time. During the clinical
evaluation of OPD, a Hunt‟s Snack Pack Sugar Free chocolate pudding was used, as well
as water, and Triscuit brand crackers. A 10-cc syringe was used to measure pudding
amounts and water. Other materials used included gloves and tongue depressors.
C. Procedures
Both OMD and OPD were assessed both objectively (via instrumentation) and
subjectively (via clinician observation). Tasks for both assessments are seen in Table 2.1.
Table 2.1
Instrumental tasks recorded during the study
1. Tongue dorsum elevation (via IOPI)
2. Tongue tip strength (via IOPI)
3. Lip strength (via IOPI)
4. Masseter contraction (via EMG and IOPI)
5. Oral transit time (via EMG)
Three different protocols were utilized during assessment (seen in Table 2.2), and
the order of the tasks within each assessment was counter balanced in order to
compensate for any possible presentation effect. Participants were allowed a drink of
water after each trial was presented.
Table 2.2
Three orders of protocols used for assessment during the study
Group A:IOPI EMG Masseter EMG oropharyngeal transit time
Group B:EMG Masseter EMG oropharyngeal transit time IOPI
Group C: EMG oropharyngeal transit time IOPI EMG Masseter
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 23
Participants were assessed at the Idaho State University Speech-Language-
Hearing clinic. Participants were seated in an upright position, and both signed a consent
form as well as filled out the demographic survey. After the survey and consent form
were completed, the assessment began, and the stimuli were presented to the participants
(following the protocol found in Appendix D). The participants were informed about the
IOPI and EMG, including where the IOPI bulb is placed (and how it works), as well as
where the EMG electrodes are placed (and how it works). All participants were made
aware that they were able to end the procedure at any time during the study.
IOPI Measurements
The IOPI measurements measured lip strength, tongue dorsum/tongue tip strength
and masseter strength. The IOPI bulb was placed on the tongue tip, and the participants
were told to bite down with their teeth and lips in order to compress the IOPI bulb against
the alveolar ridge. Participants were instructed to hold this positioning for about 2
seconds. Next, the IOPI bulb was placed on the tongue dorsum, just beneath where the
hard and soft palates meet. Participants were told to bite down with their teeth and lips
while pushing the bulb against the hard palate as hard as they can; participants were
instructed to hold this positioning for about 2 seconds over the course of three trials.
Next, the IOPI bulb was placed between the lips of the participants, who were told to
press their lips together as hard as they can (without biting down with their teeth);
participants were instructed to hold this positioning for about 2 seconds. Finally, the IOPI
bulb was placed between the participants‟ back right molars (both parallel and
perpendicular to the dental arch), who were instructed to bite down on their back molars
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 24
as hard as possible; participants were instructed to hold this positioning for about 2
seconds. This was repeated for the participants‟ back left molars.
EMG Measurement (Masseter Baseline and Masseter)
The EMG electrodes were placed on the masseter muscle (e.g., the lateral surface
of the face, medial to the ears). The EMG records the amount of muscular activity the
masseter produced. Electrodes were placed first in order to obtain a baseline
measurement for the given participant. Participants were instructed to clench their back
molars while the researcher palpated the belly of the masseter muscle. The electrodes
were placed bilaterally on the belly of the masseter (channel A of the EMG was assigned
to the right master, and channel B was assigned to the left masseter). The ground
electrode was placed on the participants‟ clavicle bone and the electrode cables were
attached to the participant‟s shirt. After the baseline was established, participants were
presented with 4 bolus trials: ½ teaspoon of pudding, 1½ teaspoons of pudding, 10cc of
water, and a Triscuit cracker. The participants were instructed to hold the bolus in their
mouth until instructed to swallow. The researcher palpated the laryngeal region using the
four-finger method of Logemann (1998), while concurrently depressing the spacebar of
the computer at initiation of the swallow (which placed a marker on the EMG recording).
During each swallow, the researcher marked the absence or presence of masseter
contraction on the EMG printout.
EMG Measurement (Laryngeal Elevation)
Oral transit timing was measured both instrumentally and behaviorally; this
helped to identify both the initiation and termination of the participant‟s swallow.
Initiation of swallowing was defined as movement of the tongue posteriorly (towards the
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 25
posterior pharyngeal wall) and was instrumentally measured by utilizing EMG electrodes
placed on the sub-mental region of the face (e.g., between the chin and the thyroid notch).
Termination of the swallow was defined as the depression of the larynx following the
participant‟s swallow. The termination of the swallow cannot be similarly gauged by
EMG, as the depression of the larynx is a passive movement (e.g., it produces no
myogenic response). This was thus measured behaviorally by using the four-finger
method of palpation by Logemann (1998), as well as by depressing the spacebar on the
computer at the initiation of the swallow and the depression of the larynx.
Observational Measurements
During separate trials utilizing a Triscuit cracker, bolus cohesion and amount of
oral residue was examined. Subjects were instructed to masticate the cracker until they
were ready to swallow, and then opened their mouths so the researcher could examine the
bolus cohesion. The participants were then instructed to swallow, and to then open their
mouths.
D. Variables
Independent variables included age, gender, and bolus characteristic, as well as
open mouth rest posture, tongue protrusion, bolus cohesion and amount of oral residue,
post-swallow. IOPI measurements included tongue tip, dorsum, and lip strength. EMG
measurements included masseter contraction during swallow as well as total
oropharyngeal transit time. Oropharyngeal transit time was marked behaviorally by
depressing the spacebar of the computer through which the EMG was recorded at onset
and offset of swallow. In addition to these measures, researchers examined the oral space
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 26
for post-swallow residue, as well as bolus quality. Tongue protrusion during swallow was
tested by pulling down on the lower lip during the swallow.
E. Reliability
A total of three raters were a part of this study; each of the 24 participants were
assessed on two different occasions (no more than one month apart) by two different
raters. In order to examine the relationship between two individual raters completing the
same protocol on the same participants, the participants were recorded by the first judge,
and then re-recorded by the second judge within a maximal month interval between
measurement sessions. Each judge measured his or her own data set, and the sets of
measures were subjected to an intra-class correlation to determine degree of agreement
between sessions; the inter-rater reliability was calculated as an intra-class correlation
(ICC) coefficient across the different parameters.
Though it will not be reported in this study, two additional raters were utilized as
well: a fourth judge examined the intra-judge reliability by assessing 16 separate
participants at two different times (maximal month interval between assessment sessions)
using the same protocol and by examining the set of procedures followed by each of the
raters during assessment; this helped to shed light on any variations seen during a given
judge‟s assessment, as well as making sure all raters followed the same procedures during
data collection. Data analysis includes correlational examination of relationships of
timing, force, and EMG/IOPI data, between examiners (inter-rater) and between
examinations of the same participants (intra-judge). This component of the study will
shed light on the reliability of clinical evaluations for both OPD and OMD.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 27
Chapter 4 Results and Discussion
A. Data Analysis
This study sought to examine the level of inter-rater reliability of the instruments
used in the ISU Tongue Thrust Protocol (e.g., IOPI and EMG). To this end, the level of
inter-rater agreement of each trial (at each level) was measured by calculating the intra-
class correlation coefficient (ICC) via the SPSS Statistics software package (IBM;
Armonk, N.Y). Calculating the ICC involves choosing a type of model; a variety of
models are available (the most common are one-way random, two-way mixed, and two-
way random). These models simply describe how the judges and participants were
chosen as well as whether variances were considered important or not (differing studies
may interpret variances in the different as important or not important). Romberg (2009)
provides the following: Choosing a model should first entail choosing either a one-way or
two-way model; these terms are simply used to define what groups are being discussed
(one-way refers to the participants and two-way refers to both the participants and the
judges). The terms random and mixed refer to how the groups were chosen (mixed refers
to the group not being chosen from a larger pool, and random means the group was
chosen from a larger pool). As this study seeks to examine a random set of participants
by a random set of judges, a two-way random model was chosen.
After choosing the ICC model, the agreement type is chosen. There are two types
of agreements: consistency or absolute. These terms refer to whether variances in the data
are important or not; if the variances are important, or if a study is looking for an absolute
value, an absolute type is chosen. If the variances in the data are not important, or if a
study is looking to examine the consistency of values across judges, a consistency model
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 28
is chosen. As this study sought to examine the consistency of observations among the
three judges, a consistency model was ultimately chosen.
The ICC value may be understood as a measure of consistency of computable
measurements made by different judges of the same quantity; this speaks directly to the
validity of the quantity being observed (in this case, an assessment tool for speech-
language pathologists). Inter-rater agreement for each level of food/liquid presentation
was obtained; confidence intervals across all levels and trials were 95%.
B. Results and Discussion
Each judge made a total of 2,048 ratings (16 participants x 128 items). In order to
examine the relationship between two individual raters completing the same protocol on
the same participants, data were subjected to an Intra-class Correlation Coefficient
analysis (ICC value) using the IBM SPSS Statistics Software Package1. For each food or
liquid presentation, each judge ran three trials to compensate for any random variances in
data collection, and these values were aggregated during data analysis. Interpretation of
the ICC values is as follows (adapted from Salkind, 2010): 0.0-0.2 indicates weak
agreement, 0.2-0.4 indicates fair agreement, 0.4-0.6 indicates moderate agreement, 0.6-
0.8 indicates strong agreement, and >0.8 indicates almost perfect agreement.
Three judges were utilized to examine this question, and these judges were
separated into three groups: judging group 1 (judge 1 compared to judge 2), judging
group 2 (judge 1 compared to judge 3) and judging group 3 (judging 2 compared to judge
3). This study will be tracking judging group 1, and the results are found below in section
B; two other studies (Reardon, 2013; Seibold 2013) report the other two judging groups.
There will be a total of four tables presented: laryngeal elevation, IOPI, masseter
1 Version 21.0.0
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 29
baseline, and masseter; discussions will follow each table presented. Post-hoc analyses
included examining trends in the data (across trials), as well as analysis of the judge‟s
journal that was kept, detailing any issues/extraneous concerns or questions the judge
noted during that particular participant‟s study. Graphs for each of the Tables will be
found in Appendix A. For the following tables, data were coded as in Table 3.1.
Table 3.1
Coding procedures used during data analysis
Pud1 = Food trial of .5 tsp of pudding,
Pud2 = Food trial of 1.5 tsp of pudding
Water = Liquid trial of 10ccs of water
Triscuit = Food trial of Triscuit cracker
Lips = IOPI bulb between lips
TT = IOPI bulb at tongue tip
TD = IOPI bulb at tongue dorsum
RMAS PAR= IOPI bulb for right masseter contraction parallel to dental arch
RMAS PAR = IOPI bulb for right masseter contraction perpendicular to dental arch
LMAS PAR= IOPI bulb for left masseter contraction parallel to dental arch
LMAS PAR = IOPI bulb for left masseter contraction perpendicular to dental arch
A AVG = Average reading for EMG electrode A
B AVG = Average reading for EMG electrode B
A MAX = Maximum reading for EMG electrode A
B MAX = Maximum reading for EMG electrode B
1. Laryngeal Elevation
In these trials, the timing of the laryngeal mechanism was examined. Timing was
judged by measuring the difference in time between the initiation of the swallow and the
ending of the swallow. These times were judged both instrumentally (via EMG) as well
as behaviorally (via researcher pressing the spacebar on the computer).
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 30
Table 3.2
ICC Values for judging group 1 (laryngeal elevation measures via EMG)
Trial ICC Value Interpretation of ICC values
Pud1 T1 .326 Fair
Pud1 T2 .651 Strong
Pud1 T3 .429 Moderate
Pud2 T1 .443 Moderate
Pud2 T2 .923 Almost Perfect
Pud2 T3 .680 Strong
Water T1 .636 Strong
Water T2 .843 Almost Perfect
Water T3 .709 Strong
Triscuit T1 .441 Moderate
Triscuit T2 .521 Moderate
Triscuit T3 .708 Strong
In Table 3.2, the laryngeal elevation data are presented, with ICC values ranging
from .326 to .923. In these data, most notably, the Pud1 trials showed the lowest
correlations. One reason for this may be that these levels provide the smallest amount of
material to the participant; because of this, it can be somewhat difficult to form a
traditional bolus with a small amount of material. As such, there tends to be a large
variety in bolus formation produced by participants at these levels (some choosing to just
abandon bolus formation for a quick swallow versus those who continue to try to form a
tradition bolus before initiating the swallow). Having more material with which to create
a bolus is preferred, and there is less variety in bolus formation and cohesion with larger
amounts of material (Logemann, 1988). This may potentially be seen in the higher
correlations found in the levels that provide more material (e.g., Pud2, Triscuit).The
variability relative to bolus size only serves to increase the inherently unstable nature of
EMG amplitude measurement (as compared to the timing measurements to be discussed).
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 31
The reduced cohesion of these data most likely reflects the sum of experimenter learning,
participant variability and instrumental instability.
While 92% of the data points were considered to have a moderate level of
agreement (or above), 8% fell below this level; post-hoc analysis revealed one participant
with major dental work which may be partly at fault for some variance (see Figure 1).
Figure 1 Coefficient Frequency for Judging Group 1 for Laryngeal Elevation (n=12)
2. IOPI
In these trials, the IOPI machine was used to gauge the force of the oral
articulators (e.g., lips, tongue and masseter). Participants enacted force on the IOPI bulb
(e.g., pushing, biting or compressing the bulb with the articulators).
0
1
1
2
2
3
3
4
0.3 0.4 0.5 0.6 0.7 0.8 0.9
Fre
qu
en
cy o
f O
ccu
ren
ce
Range of ICC Values of Laryngeal Elevation
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 32
Table 3.3
ICC Values for judging group 1 (for measurements using IOPI)
Trial ICC Value Interpretation of ICC value
LIPS T1 .334 Fair
LIPS T2 .467 Moderate
LIPS T3 .580 Moderate
TT T1 .875 Almost Perfect
TT T2 .911 Almost Perfect
TT T3 .746 Strong
TD T1 .716 Strong
TD T2 .544 Moderate
TD T3 .685 Strong
RMAS PAR T1 .884 Almost Perfect
RMAS PAR T2 .810 Almost Perfect
RMAS PAR T3 .872 Almost Perfect
RMAS PERP T1 .721 Strong
RMAS PERP T2 .662 Moderate
RMAS PERP T3 .567 Moderate
LMAS PAR T1 .561 Moderate
LMAS PAR T2 .541 Moderate
LMAS PAR T3 .657 Moderate
LMAS PERP T1 .561 Moderate
LMAS PERP T2 .792 Strong
LMAS PERP T3 .409 Moderate
In Table 3.3, the IOPI data are presented, with ICC values ranging from .334
to .911.For this judging group, IOPI was largely correlative. However, the lips trials
showed the lowest agreement. Post-hoc analysis revealed that some participants
compensated for lip closure by using their mandible, which was error on the part of the
researcher; this likely caused some larger readings found in this group. The other low
agreement value was with the LMAS PERP (which had the IOPI bulb placed on the
participant‟s left side with the bulb perpendicular to their dental arch).
About 96% of the data points were considered to have a moderate-almost perfect
level agreement, while about 4% fell below this level; post-hoc analysis revealed one
participant with major dental work on their left side, which most likely influenced the
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 33
moderate agreement seen throughout all the trials on that side of the mouth (see Figure
2). Overall, these higher results were likely due to the IOPI bulbs being largely easier to
place than the EMG electrodes.
Figure 2 Coefficient Frequency for Judging Group 1 of IOPI (n=21)
3. Masseter Baseline (EMG)
In these trials, the EMG was utilized to record baseline data for each participant‟s
masseter muscle. Electrodes were placed on both of the participant‟s masseter muscles
and participants were told to clench their back teeth in order to gauge their baseline data.
Table 3.4
ICC Values for judging group 1 (masseter baseline measures via EMG)
Trial ICC Value Interpretation of ICC value
A AVG T1 .696 Strong
B AVG T1 .845 Almost Perfect
A AVG T2 .716 Strong
B AVG T2 .642 Strong
A AVG T3 .903 Almost Perfect
B AVG T3 .736 Strong
In Table 3.4, the masseter baseline data are presented, with ICC values ranging
from .642 to .903. The average of the masseter contraction was used for calculations of
0
1
2
3
4
5
6
7
0.3 0.4 0.5 0.6 0.7 0.8 0.9
Fre
qu
en
cy o
f O
ccu
ren
ce
Range of ICC Values of IOPI
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 34
ICC as opposed to the peak measure since it is more stable. As can be seen, the general
trend was towards strong-almost perfect. In these trials, 100% of data points were
considered to have a strong-almost perfect level of agreement; as such, no post-hoc
analysis was conducted for these trials (see Figure 3).
Figure 3 Coefficient Frequency for Judging Group 1 of Masseter Baseline (n=6)
4. Masseter (EMG)
In these trials, the same configuration was kept from the masseter baseline trials;
however, in these trials, participants were instructed to masticate and swallow food and
liquid presentations. Masseter values were taken as a maximum recording of the masseter
contraction.
0
1
1
2
2
3
0.6 0.7 0.8 0.9
Fre
qu
en
cy o
f O
ccu
ren
ce
Range of ICC Values of Masseter Baseline
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 35
Table 3.5
ICC Values for judging group 1 (masseter measures via EMG)
Trial ICC Value Interpretation of ICC value
PUD1 AMAX T1 .955 Almost Perfect
PUD1 BMAX T1 .813 Almost Perfect
PUD1 AMAX T2 .437 Moderate
PUD1 BMAX T2 .698 Strong
PUD1 AMAX T3 .513 Moderate
PUD1 BMAX T3 .474 Moderate
PUD2 AMAX T1 .622 Strong
PUD2 BMAX T1 .624 Strong
PUD2 AMAX T2 .664 Strong
PUD2 BMAX T2 .459 Moderate
PUD2 AMAX T3 .681 Strong
PUD2 BMAX T3 .316 Fair
WAT AMAX T1 .557 Moderate
WAT BMAX T1 .698 Strong
WAT AMAX T2 .449 Moderate
WAT BMAX T2 .694 Strong
WAT AMAX T3 .552 Moderate
WAT BMAX T3 .307 Fair
CRAC AMAX T1 .352 Fair
CRAC BMAX T1 .907 Almost Perfect
CRAC AMAX T2 .552 Moderate
CRAC BMAX T2 .939 Almost Perfect
CRAC AMAX T3 .346 Fair
CRAC BMAX T3 .927 Almost Perfect
In Table 3.5, the masseter data are presented, with ICC values ranging from .307
to .955. These data represent a generally moderate level of agreement and reflect the
lowest level of agreement in this judging group. However, even as the lowest level of
agreement, relationships remain at the fair or better level of agreement. In this study, 84%
of data points were considered to have a moderate level of agreement (or above), while
16% of data points fell below; post-hoc analysis revealed some issues related to skin
impedance (e.g., electrodes not sticking well on three participants, and skin scarring
noted on one participant). While these issues were most likely the cause of the variances
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 36
seen in these data, the inherent learning curve may also have affected these data (see
Figure 4).
Figure 4 Coefficient Frequency for Judging Group 1 of Masseter (n=24)
Comparing ICC values to Pearson r
Though this study used an ICC to calculate the level of inter-rater reliability, and
it has been argued that the ICC is the most appropriate statistical algorithm to use for
calculating inter-rater reliability in a research paradigm such as this project, Figure 5
highlights a sample data analysis of the Masseter Baseline data, calculated both as an ICC
as well as a Pearson r. This is simply to capture the differences between the two different
algorithms as well as to highlight the more robust and reliable coefficients that were
analyzed via ICC.
0
1
2
3
4
5
6
7
8
0.3 0.4 0.5 0.6 0.7 0.8 0.9
Fre
qu
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Range of ICC Values of Masseter
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 37
Figure 5 Difference between ICC and possible Pearson r for Masseter Baseline
As seen in Figure 5, this sample set of data was run both through the ICC
algorithm (the results of which were reported on page 25), as well as through the Pearson
r algorithm. Correlation values for ICC ranged from .642 to .903, while correlation
values for Pearson r ranged from .486 to .741. Across all parameters, the Pearson r values
were below the ICC values. Both Evans (2003) and Romberg (2009) argue that this is one
of the main reasons why, in a research paradigm such as this study, an ICC provides a
more reliable and robust analysis of the data.
C. Summary
This research project examined the level of inter-rater reliability of the
instruments used during the clinical assessment of OPD and OMD (EMG and IOPI) in
conjunction with the ISU Tongue Thrust Protocol. This was determined by using the
EMG and IOPI (as well as a through some behavioral methods) to measure intra-oral
pressure, lingual strength, masseter contraction and transit timing in a group of healthy
0.000
0.100
0.200
0.300
0.400
0.500
0.600
0.700
0.800
0.900
1.000
MB A AVGT1
MB B AVGT1
MB A AVGT2
MB B AVGT2
MB A AVGT3
MB B AVGT3
Co
rre
lati
on
Val
ue
s
Masseter Baseline Trials
ICC
Pearson r
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 38
adults. The question posed by this study is “to what degree are measures of EMG and
IOPI stable when used to measure oral function by two different raters on the same
subject?” Three judges were utilized to examine this question, and intra-rater reliability
was calculated as an intra-class correlation coefficient. The three judges were separated
into three groups: judging group 1 (judge 1/judge 2), judging group 2 (judge 1/judge 3),
and judging group 3 (judge 2/judge 3); this study tracked judging group 1. Figure 5 below
presents the total ICC value frequency across judging group 1.
Figure 6 Coefficient Frequency for Judging Group 1 (n=63)
Figure 6 highlights the overall ranges of coefficients (ICC values) found for
judging group one (across all participants and trials). Following Salkind‟s (2010) ICC
interpretation table, reliability for this judging group generally tended towards a
moderate-strong correlation (>.4). 90% of all the data points fell in this range (57 out of
63 total data points) with 60% of the data in the strong- almost perfect range (37 out of 63
total data points), and in this judging group, no data points fell below .34 (no data points
in the poor/no agreement range); in total, only 10% of all data points were considered to
have a fair level of agreement or less (6 out of 63 total data points).
0
2
4
6
8
10
12
14
16
0.3 0.4 0.5 0.6 0.7 0.8 0.9
Fre
qu
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Range of ICC Values of Total
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 39
The present study showed lower overall agreement than the other two groups
(Reardon, 2013; Seibold, 2013), which is in part due to an amount of learning bias on
behalf of the judges (this group was the first group to run participants). However, the
overall reliability of this group showed strong reliability, and it is also worth noting that
the Leckington (2013) post-hoc analysis of all three judges revealed a similar overall
upward trend in reliability as time progressed. That is to say the more each researcher ran
subjects, the more reliable their results were. As this judging group was the first to run
participants, it is theorized that the majority of the variance seen in this group is due to
the novelty of the task. Notably, the masseter baseline values were steady due to the fact
that participants only had to clench their masseter muscle versus performing swallows
with food or liquid. IOPI values were steady as the IOPI does not have the same
impedance issues noted with the EMG, and is largely easier to place than EMG.
Masseter values showed the most variance, though by and large this is due to the
facial placement of electrodes for these trials, which are more susceptible to
movement/electrode displacement issues. Because the electrodes for these trials are
placed on the face (directly over the masseter), movements during feeding, chewing,
swallowing, drinking and talking affect the data that is collected. It is impossible to
recreate every movement of the participants for both times they were observed.
Limitations and Considerations
The issues noted with EMG electrode placement on certain parts of the body (e.g.,
the face) should not be overlooked when using the EMG in these types of studies. EMG
data largely showed moderate-strong-almost perfect agreement, but there were some
large variances in the data perhaps attributable to the impedance issues noted by Duff
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 40
(2002) Future studies should examine the somewhat large skin impedance issues noted
with EMG, or if possible, have researchers spend time becoming familiar with the ISU
Tongue Thrust Protocol and the IOPI and EMG instruments (e.g., practicing on real
people); it was noted in a comparison study (Leckington, 2013) that the more the
researchers ran participants and became more familiar with the instruments and protocol,
the overall reliability increased. It is worth noting that, though EMG is inherently
variable due to issues of placement, impedance and performance, it does allow for a high
level of agreement, as seen in the majority of the data, thus the imprecision of the EMG
measure itself may be partly at fault for causing some of this variance. Ultimately, the
results of the data analysis support both IOPI and EMG as instruments in the assessment
of oropharyngeal dysphagia and oromyofunctional disorders, as used in conjunction with
the ISU Tongue Thrust Protocol.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 41
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RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 44
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RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 45
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RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 46
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RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 47
Appendix A: Graphs of ICC Values
1. Laryngeal Elevation
0.000
0.200
0.400
0.600
0.800
pud1 T1 pud1 T2 pud1 T3
Series1
0.000
0.200
0.400
0.600
0.800
1.000
pud2 T1 pud2 T2 pud2 T3
Series1
0.000
0.200
0.400
0.600
0.800
1.000
wat T1 wat T2 wat T3
Series1
0.000
0.200
0.400
0.600
0.800
crac T1 crac T2 crac T3
Series1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 48
2. IOPI
0.000
0.200
0.400
0.600
0.800
LIPS T1 LIPS T2 LIPS T3
Series1
0.000
0.200
0.400
0.600
0.800
1.000
TT T1 TT T2 TT T3
Series1
0.000
0.200
0.400
0.600
0.800
TD T1 TD T2 TD T3
Series1
0.750
0.800
0.850
0.900
RMASPAR T1
RMASPAR T2
RMASPAR T3
Series1
0.000
0.200
0.400
0.600
0.800
RMASPERP T1
RMASPERP T2
RMASPERP T3
Series1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 49
3. Masseter Baseline
0.000
0.200
0.400
0.600
0.800
LMAS PART1
LMAS PART2
LMAS PART3
Series1
0.000
0.200
0.400
0.600
0.800
1.000
LMASPERP T1
LMASPERP T2
LMASPERP T3
Series1
0.000
0.200
0.400
0.600
0.800
1.000
MB A AVG T1 MB B AVG T1
Series1
0.600
0.650
0.700
0.750
MB A AVG T2 MB B AVG T2
Series1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 50
4. Masseter
0.000
0.200
0.400
0.600
0.800
1.000
MB A AVG T3 MB B AVG T3
Series1
0.700
0.750
0.800
0.850
0.900
0.950
1.000
pud1 A MAX T1 pud1 B MAX T1
Series1
0.000
0.200
0.400
0.600
0.800
pud1 A MAX T2 pud1 B MAX T2
Series1
0.440
0.460
0.480
0.500
0.520
pud1 A MAX T3 pud1 B MAX T3
Series1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 51
0.621
0.622
0.623
0.624
0.625
pud2 A MAX T1 pud2 B MAX T1
Series1
0.000
0.200
0.400
0.600
0.800
pud2 A MAX T2 pud2 B MAX T2
Series1
0.000
0.100
0.200
0.300
0.400
0.500
0.600
0.700
0.800
pud2 A MAX T3 pud2 B MAX T3
Series1
0.000
0.200
0.400
0.600
0.800
wat A MAX T1 wat B MAX T1
Series1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 52
0.000
0.200
0.400
0.600
0.800
wat A MAX T2 wat B MAX T2
Series1
0.000
0.100
0.200
0.300
0.400
0.500
0.600
wat A MAX T3 wat B MAX T3
Series1
0.000
0.200
0.400
0.600
0.800
1.000
crac A MAX T1 crac B MAX T1
Series1
0.000
0.200
0.400
0.600
0.800
1.000
crac A MAX T2 crac B MAX T2
Series1
0.000
0.200
0.400
0.600
0.800
1.000
crac A MAX T3 crac B MAX T3
Series1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 53
Appendix B: Human Subjects Consent Form
Idaho State University
Human Subjects Committee
Informed Consent Form for Non-Medical Research
CONSENT TO PARTICIPATE IN RESEARCH
RELIABILITY OF CLINICAL MEASURES OF
OROMYOFUNCTIONAL DISORDERS AND OROPHARYNGEAL
DYSPHAGIA
You are asked to participate in a research study conducted by Tony Seikel, Ph.D., of
Communication Sciences & Disorders, and Education of the Deaf, Idaho State University
(208.282.3992). The co-investigator for this study is Dave Ross, Idaho State University
Graduate Student (907.347.7860). Data from this study will be reported in this student‟s
Master‟s thesis. You have been asked to participate in this research because you have not
been identified as being a healthy adult between the ages of 18 and 60 years. This study is
part of a larger study, and for this study a total of 24 subjects will be used (with a total of
444 subjects for the larger study). Your participation in this research project is voluntary.
You should read the information below, and ask questions about anything you do not
understand, before deciding whether or not to participate.
1. PURPOSE OF THE STUDY
This study is designed to examine several aspects of how a person swallows, including
muscle strength, timing of swallowing, and swallow pattern.
2. PROCEDURES
If you volunteer to participate in this study, I would ask you to do the following things:
a. You will be asked to fill out a questionnaire concerning eating and health habits. The
form will only have a number on it (not your name) so that your responses won‟t be
identified with your name.
b. I will apply electrodes to the side of your face to measure muscle contraction, and then
I will ask you to bite down while I make recordings. I will then ask you to chew and
swallow pudding and a cracker, as well as to take drinks of water while I make these
same recordings. I will hold your lips open at one point so I can observe what your
tongue is doing during the swallow process. I will also ask to look inside your mouth.
c. I will then apply electrodes under your chin and to the area of your larynx (voice-box)
and ask you to chew and swallow liquid, crackers, and pudding.
d. There are no specific subgroups in this study, besides male versus female.
e. The total time should be approximately 40-50 minutes for your participation.
f. The study will be performed at the ISU Speech and Hearing Center in Pocatello, or in
your home if you wish.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 54
3. POTENTIAL RISKS AND DISCOMFORTS
The procedures are standard procedures used to examine a person‟s swallow function.
Preparation of your skin will involve cleaning an area using an electrode preparation gel,
much like that used in EMG recordings. This may make your skin temporarily red, but
that effect will not last long after the period of the study. If you are diabetic we will
provide foods with artificial sweetener. If you are allergic to the foods being presented
we ask that you not participate in the study. You might feel embarrassment by the
attention to your eating habits. You could take food or liquid into your lungs (aspiration),
which would be a sign of significant swallowing problems. In that case we would end
the study and refer you to a Speech-Language-Pathologist for attention to this problem.
The research procedures may involve risks that are currently unforeseeable.
4. ANTICIPATED BENEFITS TO SUBJECTS
This study may identify either an oromyofacial or a swallowing problem that you may so
that you could receive treatment to alleviate the problem.
5. ANTICIPATED BENEFITS TO SOCIETY
This study will examine the reliability of measures used to assess both swallowing
disorders and oromyofunctional disorders, which will assist during assessment and
diagnosis.
6. ALTERNATIVES TO PARTICIPATION
Participation is voluntary, and you may end participation at any time. There are no other
alternatives to participation.
7. PAYMENT FOR PARTICIPATION
There is no payment offered or available for participation.
8. FINANCIAL OBLIGATIONS
You will not be asked to pay for any of these procedures.
9. PRIVACY AND CONFIDENTIALITY
The only people who will know that you are a research subject are members of the
research team. No information about you, or provided by you during the research, will be
disclosed to others without your written permission, except (a) if necessary to protect our
rights or welfare (for example, if you are injured), or (b) if required by law.
When the results of the research are published or discussed in conferences, no
information will be included that would reveal your identity. If photographs, videos, or
audiotape recordings of you will be used for educational purposes, your identity will be
protected or disguised. If a video of your participation were to be used you would be
informed and have the right to decline its use. Data will be stored in a file cabinet in a
locked office, and will be separated from your name so that no one could identify your
data individually. Contact data will be destroyed seven years after publication of the
research findings.
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 55
10. PARTICIPATION AND WITHDRAWAL
Your participation in this research is VOLUNTARY. If you choose not to participate,
that will not affect your relationship with Idaho State University, or your right to receive
services at Idaho State University to which you are otherwise entitled. If you decide to
participate, you are free to withdraw your consent and discontinue participation at any
time without prejudice to your future at Idaho State University.
11. WITHDRAWAL OF PARTICIPATION BY THE INVESTIGATOR
The investigator may withdraw you from participating in the research if circumstances
arise which warrant doing so. If you experience any of the following (coughing or hoarse
voice after swallowing) you may have to drop out of the research, even if you would like
to continue. The principal researcher will make the decision and let you know if it is not
possible for you to continue. The decision may be made either to protect your health and
welfare, or because it is part of the research plan that people who develop certain
conditions may not continue to participate.
12. IDENTIFICATION OF INVESTIGATORS
In the event of a research related injury or if you experience an adverse reaction, please
immediately contact one of the investigators listed above. If you have any questions
about the research, please feel free to contact Tony Seikel at 208.282.3992 or
[email protected], or Dave Ross at 907.347.7860 or [email protected] any time.
13. RIGHTS OF RESEARCH SUBJECTS
You may withdraw your consent at any time and discontinue participation without
penalty. You are not waiving any legal claims, rights or remedies because of your
participation in this research study. If you have any questions regarding your rights as a
research subject, you may contact the Human Subjects Committee office at 282-2179 or
by writing to the Human Subjects Committee at Idaho State University, Mail Stop 8130,
Pocatello, ID83209.
Appendix C: Demographic Survey
Subject ID#________________
Demographic Survey
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 56
1. Birth Date: _________________________
2. Circle One: MALE FEMALE
3. Ethnicity (check one):
□ (1) European American (not Hispanic)
□ (2) White Hispanic
□ (3) Latino
□ (4) Asian
□ (5) African American
□ (6) Native American
□ (7) Other / Multi-racial
Health Status
4. Do you have or have you experienced any of the following? (check yes or no)
Heart & Blood
a. Heart & Blood Problems (including chest pain due to heart problems, irregular
heartbeat, high blood pressure, blood clots, anemia, hypertension, blood
transfusion, high cholesterol, heart failure, or heart bypass surgery)
□ Yes □ No
b. COPD (Chronic Obstructive Pulmonary Disorder)
□ Yes □ No
c. Bleeding GI (stomach, throat, intestines)
□ Yes □ No
Psychiatric
d. Psychiatric Treatment for depression or anxiety
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 57
□ Yes □ No
Illness
e. Cancer (what kind _________________________?)
□ Yes □ No
f. Rheumatologic Disease (Sjogren‟s, Lupus, Arthritis)
□ Yes □ No
Neuromedical Risks/Condition
g. Head injury (describe and include point of impact)
__________________________________________________________________
_____________________________________________________________________
□ Yes □ No
h. Loss of consciousness (how long?) _________________________________
□ Yes □ No
i. Seizures
□Yes □ No
j. Stroke/TIA
□Yes □ No
k. Sleep Apnea
□Yes □ No
l. Toxin/Chemical Exposure (what kind?)
_______________________________________
□Yes □ No
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 58
m. Parkinson‟s Disease (when
diagnosed?)________________________________________
□ Yes □ No
n. Huntington‟s Disease (when diagnosed?)
______________________________________
□ Yes □ No
o. Brain Masses (location)
____________________________________________________
□ Yes □ No
p. Multiple Sclerosis (when diagnosed?)
_________________________________________
□ Yes □ No
q. Cerebral Palsy
□ Yes □ No
r. Dementia/Alzheimer's (when diagnosed?)
_____________________________________
□ Yes □ No
s. Oral Apraxia (when diagnosed?)
_____________________________________________
□ Yes □ No
t. Spinal Injury (describe)
____________________________________________________
□ Yes □ No
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 59
u. Brain Surgery (describe)
___________________________________________________
□ Yes □ No
v. Poliomyelitis (when diagnosed?)
_____________________________________________
□ Yes □ No
w. Guillain-Barre (when diagnosed?)
____________________________________________
□ Yes □ No
aa. Riley-Day Syndrome or Dysautonomia (when diagnosed?)
________________________
□ Yes □ No
bb. ALS (when diagnosed?)
____________________________________________________
□ Yes □ No
cc. Werdig- Hoffmann Disease (when diagnosed?)
_________________________________
□ Yes □ No
dd. Myasthenia Gravis (when diagnosed?)
________________________________________
□ Yes □ No
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 60
ee. Muscular Dystrophy (when diagnosed?)
_______________________________________
□ Yes □ No
ff. Dystonia (when diagnosed?)
________________________________________________
□ Yes □ No
Oromyofunctional Risks/Conditions
gg. Recurrent Pneumonia
□ Yes □ No
hh. Frequent Temperature Spikes
□ Yes □ No
ii. History of Artificial Airway
□ Yes □ No
jj. Mouth Breather
□ Yes □ No
kk. History of Finger Sucking
□ Yes □ No
ll. History of Cheek Biting
□ Yes □ No
mm. Deviated Septum
□ Yes □ No
nn. Enlarged Tonsils/Adenoids
□ Yes □ No
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 61
oo. Tonsils/Adenoids Removed
□ Yes □ No
pp. Open Spaced During Mixed Dentition
□ Yes □ No
qq. Current Open Spaces in Dentition
□ Yes □ No
rr. Allergies (explain)
_______________________________________________________
□ Yes □ No
ss. TMJ Syndrome
□ Yes □ No
tt. Eating Disorders
□ Yes □ No
uu. Oral Surgery (explain)
_____________________________________________________
□ Yes □ No
vv. Neck Surgery (explain)
____________________________________________________
□ Yes □ No
ww. Oral Sores
□ Yes □ No
Other
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 62
xx. Other Surgery (explain)
____________________________________________________
□ Yes □ No
5. List and describe any serious accidents that required hospitalization.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________
Medications
6. Have you taken any medication today? □ Yes □ No
If yes, list medication, dose, time taken, and reason for taking it. (Use back of
page for more room)
Name of medication Time Taken Dose Reason for Taking
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
________________ _________ ______mg _______________
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 63
Alcohol and Tobacco
7. Do you consume alcohol? □ Yes □ No
8. If you answered yes to question 7, how much alcohol do you typically consume in 1
month?
_______ glasses/month
9. Do you chew tobacco? □ Yes □ No
10. If you answered yes to question 9, how much do typically use in a month?
________
cans/month
11. Do you smoke? □ Yes □ No
12. If you answered yet to question 11, how much do you smoke in a month?
________
packs/month
Food Information
13. What are your three favorite foods?
_____________________________________________
14. What are your three least favorite foods?
_________________________________________
15. Are there any foods that you avoid?
________________________________________________________________________
16. How often do you chew gum?
_________________________________________________
17. Have you ever participated in tongue thrust therapy? □ Yes □ No
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 64
Appendix D: Idaho State University Tongue Thrust Protocol
ISU Tongue Thrust Protocol
Note: To derive a total score for prediction purposes circle numbers in “score” box for
items representing problems.
Name:_____________________________ Examiner:_________________________
Date:______________________________
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 65
DOB:_____________________________
Case History Information
Characteristic Presence/
absence
Score Notation
Feeding History
Nursed or bottle fed
Age for solid food (4-6 for
cereal)
Age hard food (carrot,
celery)
Food preferences (hard,
soft)
History swallow problem
(choke, gag)
History regurgitation
Tx regurgitation
Persistent
regurgitation
Food allergy
Family Issues (genetics)
Fam. Hx. Tongue thrust
Fam. Hx feeding problems
Famhx low tone
Famhx allergy
Fam. Hx upper respiratory
FamHxMacroglossia
FamHx Small nares
FamHx Deviated septum
FamHx Dental problems
(small mouth requiring
extractions)
FamHx Mouth breathing or
nasal
Habits
Digit sucking (lips, tongue,
finger, thumb, hand)
Late bottle use
Late pacifier use
Mouth breathing
Cheek biting
Medical/Anatomical
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 66
history
Open spaces during mixed
dentition
Diastema?
Micrognathia?
Missing dentition?
Hypertrophied
adenoids/tonsils
Allergies
New?
Old?
When develop?
Treated?
Hypertrophied turbinates?
Cleft palate?
Tonsillitis
ENT visits for tx?
Removed?
When
Neurophysiological issues
Low sensory awareness
/sensation seeking
Drooling, saliva pooling
Oral discrimination ability
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 67
Tongue Thrust Assessment Protocol
Characteristic Action Score Notation
1. Observation Observe client at
rest
2. Facial tone
Observe client at
rest
3. Facial symmetry
Observe client at
rest
4. Mouth or nose
breathing
Observe client at
rest
5. When mouth
open, how much of
upper dentition is
covered by lip?
Criterion: Upper
lip covers ½ of
upper teeth
Less=1
6. Rest posture of
tongue
observe: contact
upper dental arch
at rest
If not=1
7. Lip movement
during dry swallow
Observe for open
or clamped
(watch for
wrinkle of chin as
sign of clamping)
Present=
1
8. Tongue out,
mouth open
Perception of
macroglossia?
1
Oral Examination:
1. Dentition
Bite down on
molars;
Tongue depressor
in buccal cavity;
Ask to spread lips
Class I
malocclusion
Mandibular 1st
molar ½ tooth
ahead of
maxillary 1st
molar; anterior
teeth maligned
1
Class II Retracted
mandible
1
Class III Prognathic
mandible
1
Open bite Front teeth don‟t 1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 68
occlude
Closed bite
Back teeth don‟t
occlude
Teeth meet at
rest
Observe rest
posture re:
muscles of
mastication
1
2. Nares:
Deviated
septum
Ask in Hx;
observe
Apparent
blockage
Ask in Hx;
observe breathing
3. Lips
Contact
Criterion: Rest
along entire
length without
effort
If not=1
Chapping?
Chapping
indicates mouth
breathing, tongue
thrust
“fat” lower
lip: low
tone?
Indicates low tone
Overjet:
If excessive
dental overjet,
crease in lower
lip where teeth
rest
1
4. Hard palate
High Vault
View with open
mouth, flashlight
1
5. Soft palate
Elevates with
/a/?
Transilluminate
Watch in /a/
Observe and
palpate
Length
adequate?
Transilluminate
Watch in /a/
Observe and
palpate
Blue
coloration?
(submucous)
Transilluminate
Watch in /a/
Observe and
palpate
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 69
6. Tongue
microglossia
Observe, mouth
open
Lingual
frenulum
Protrude tongue;
heart shape
anterior?
1
Macroglossia Observe, mouth
open
1
resting
posture?
Ask; criterion =
contact upper
dentition at rest
1
7. Respiration
mouth versus
nose
breathing
Observe
Sustain vowel
Manometer use
Listen
adequate
support?
Manometer;
count to 30 at 1
word per second
(number of
words/breath)
easily
fatigues?
Observe, ask
Respiratory
noise
(adenoids?)
Observe
Water Swallow
1. Water retention Water on tongue,
open mouth,
retains water?
2. Water swallow x3
lips closed
Masseter
contract?
Swallow water:
Palpate
Fail=1
Symmetrical
contract?
Swallow water:
Palpate
Thyroid
elevate?
Swallow water:
Palpate
Fail=1
3. Water swallow,
lips open x 3
lip tension?
Swallow water:
Lips open, pull
lips open
Observe for
protrusion,
interdental
Tense=1
Water loss?
Swallow water:
Lips open, pull
Loss=1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 70
lips open;
Observe
protrusion;
interdental; water
loss
Tongue
thrust?
Swallow water:
Lips open; pull
lips open;
Observe
protrusion;
interdental
1
Food mastication
1. Cracker/cookie
mastication x 3
bolus:
scatter, tube,
ball?
Observe before
swallow, after
swallow
Scatter=
1
Saliva:
mixed?
Observe Dry=1
too large
bite?
Observe
Too small
bite?
Observe
Lips open
when chew?
Observe 1
2. Cracker/cookie
swallow X 3
number of
swallows?
Observe >2
swallow
=1
Cleaned
using
tongue?
Observe
Followed
with water?
Observe 1
Lips clamp in
swallow?
Observe; watch
for wrinkling of
mentalis
Clamp
or
wrinkle
=1
Masseter
contract?
palpate no
contracti
on = 2
Food remains
in sulcus
after swallow
Observe after
swallow using
tongue depressor
1
Excessive Look for position 1
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 71
food on
tongue after
swallow
of tongue and lips
on glass
Tongue
protrudes in
swallow
Pull down lower
lip
1
Hold water
on tongue
Can client cup
tongue and hold
water?
3. Type of tongue
thrust
Unilateral
Left
Unilateral
right
Spread
Bilateral
Upper thrust
Lower thrust
Pull lip down
Resting posture
Swallowing
movement
Look at dentition
4. severity
0=normal
1= dental
contact, but
not pass
through teeth
or over teeth
2.=dental
contact, and
between
teeth, onto
occlusal
surface, or
contact lips
Observation: be
specific!
Total Score (add
circled numbers)
RELIABILITY OF EMG/IOPI IN OPD/OMD DIAGNOSIS 72