Jeri Logemann’s Legacy

You have accessThe ASHA LeaderFrom My Perspective1 Oct 2015Jeri Logemann’s LegacyShe forever changed the way we study, diagnose and treat swallowing disorders. And the questions she asked shaped the ones we continue investigating today. Cathy Lazarus, andPhD, CCC-SLP Barb PauloskiPhD, CCC-SLP Cathy Lazarus Google Scholar More articles by this author , PhD, CCC-SLP and Barb Pauloski Google Scholar More articles by this author , PhD, CCC-SLP https://doi.org/10.1044/leader.FMP.20102015.np SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In All of us in communication sciences and disorders well know the name Jeri Logemann. She was a pioneer in dysphagia and a leader to a generation of clinicians and researchers. In the wake of her death just over a year ago, let’s take a look at her storied career path and legacy—and where we’re going next in the burgeoning field of swallowing disorder research and intervention. Logemann was a clinician by nature and diverse in her talents: Early in her career she developed the well-known Fisher-Logemann Test of Articulation and did the original line drawings for that test. Ultimately, her clinical insights helped her tailor her research to improve patients’ swallowing function. She first became interested in swallowing in the late 1970s when she treated people with Parkinson’s disease and head and neck cancer who had difficulty swallowing. Although she was involved in many aspects of our field, she made significant and lasting contributions in three major areas: Developing methods for evaluation of swallowing function. Pioneering procedures for swallowing treatment. Establishing efficacy of those interventions through clinical trials. Through such innovation, she became a prominent leader in the field: She was one of the original founding members of The Dysphagia Research Society; associate editor of the journal Dysphagia since its inception in 1985; ASHA president in 1994 and 2000; and chair of Northwestern University’s Department of Communication Sciences and Disorders for 14 years. But she began her career examining swallowing in people with neurological impairments, specifically those with Parkinson’s. She cajoled Northwestern University neurologist Benjamin Boshes to support her in examining his patients with videofluoroscopy. She developed the modified barium swallow (MBS) test, which everyone at Northwestern Memorial Hospital knew as “the cookie swallow test,” not to be confused with the barium swallow test. The MBS test was designed to examine oropharyngeal swallow physiology by giving small volumes of liquids to an upright patient. In contrast, typical barium swallow tests performed for gastrointestinal problems examine esophageal anatomy and function in a supine patient, requiring large and sequential boluses (obliterating oropharyngeal structures and possibly contributing to aspiration in people with dysphagia due to the large amounts of barium consumed). The MBS test became the gold standard tool to evaluate swallowing. Other methods of examining swallow function have been compared or validated against it, and are often used in conjunction with MBS or to supplement the information gleaned from it. Among these methods are bedside swallow evaluation protocols (brief assessment of oral motor and sensory function related to potential for safe oral intake), fiberoptic endoscopic evaluation of swallowing (FEES, an evaluation performed with a flexible endoscope inserted through the nasal passage and passed transnasally into the hypoharynx), and the Penetration-Aspiration (Pen-Asp) Scale, a unidimensional ordinal scale used with an imaging procedure such as MBS or FEES that describes the depth of material into the airway and the person’s ability to clear it (see sources). The Pen-Asp Scale (as described by John C. Rosenbek and colleagues in 1996 in Dysphagia) has enhanced the MBS evaluation, as has the MBSImP (modified barium swallow impairment profile), which provides a systematic and consistent way to rate the overall swallow by providing a score/severity rating for the 17 functional components that can be examined during the MBS study (as described by Bonnie Martin-Harris in the book “Standardized Training in Swallowing Physiology: Evidence-Based Assessment Using the Modified Barium Swallowing Impairment Profile Approach”). Over the years, others, including Logemann, have identified new ways to examine and quantify swallowing with the MBS test. Meanwhile, technology has advanced with development of improved, high-resolution manometric catheters to measure pharyngeal pressures, new imaging tools to examine swallowing, and new devices to improve swallowing (see sources). In addition to treating people with neurological impairments, Logemann worked with people with head and neck cancer and conducted research on the types of swallowing disorders they experienced. She developed rehabilitation strategies to improve swallow function in people affected by the gamut of diseases and disorders, including stroke, head injury, Parkinson’s disease, multiple sclerosis and ALS. She developed widely used swallow maneuvers—such as the supraglottic swallow, Mendelsohn maneuver and effortful swallow—to improve bolus clearance through the pharynx. Logemann always worked in multidisciplinary settings, collaborating with surgeons, neurologists, gastroenterologists, statisticians, neuroscientists, engineers and speech-language pathologists in many single and multi-institutional studies. Her research laid the groundwork for others to further examine swallowing function, including effects of various bolus textures and volumes, postures, and maneuvers on swallowing, respiration, airway protection and nutrition. Perhaps Logemann’s most significant contribution to the field of speech-language pathology was the attention she brought to the need for randomized clinical trials on treatment efficacy outcomes. During her 1994 term as ASHA president, the National Institute of Deafness and other Communication Disorders (NIDCD) announced that it would solicit applications for cooperative groups to conduct clinical trials for treatment of communication disorders. Logemann helped to establish such a group as a 501c3 within ASHA. ASHA submitted a successful application for this funding mechanism, and, in April 1997, the NIDCD funded a clinical trials grant through the Communication Sciences and Disorders Clinical Trials Research Group, with Logemann as principal investigator. Under Logemann’s leadership, the Communication Sciences and Disorders Clinical Trials Research Group supported the research of such prominent scientists as JoAnne Robbins, Reza Shaker and LEAP Learning Systems. The group funded Robbins’ Protocol 201, a randomized clinical trial designed to identify which of three treatments for aspiration on thin liquids—chin-down posture, nectar-thickened liquids or honey-thickened liquids—resulted in the most successful immediate elimination of aspiration on thin liquids during the videofluorographic swallow study in people with dementia and/or Parkinson’s disease. Study results prompted the development of the first standardized formulas for thickened liquids for research purposes and for improved clinical standardization across patients, an initiative that contributed significantly to management of people with dysphagia. In fact, the use of standard formulas has become so widespread nationally and internationally, that we now need to standardize the terminology we use for thickened liquids and texture-modified foods. With Logemann at the helm, the Communication Sciences and Disorders Clinical Trials Research Group also helped other investigators develop their protocols and popularized the central laboratory concept—the use of a single research laboratory for data collected at multiple institutions to maintain strict standards and controls for data reduction and analysis—now the model for a number of dysphagia researchers. In addition, researchers continue conducting clinical trials on the swallowing strategies Logemann pioneered to enhance quality of life and nutritional outcomes. Future research needs to examine how many of the therapeutic strategies can be optimized across populations: What is the best dosage of treatment? What is the optimal frequency and duration of the various strategies? When is the best time to intervene and how long should the intervention last? And, finally, what about maintenance therapy: how best should we prescribe? But we would likely not even be asking these questions if it weren’t for Logemann’s tireless work laying the foundation. Twenty years after the launch of the Communication Sciences and Disorders Clinical Trials Research Group, and one year after Logemann’s death, her legacy continues. If you need proof, go to ClinicalTrials.gov, the government’s national and international database of registered randomized clinical trials. A search of the topic word “swallowing” yields 299 currently active trials. Jeri would be proud. Sources Brady S., & Donzelli J. (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing..Otolaryngologic Clinics of North America, 46, 1009–1022. Google Scholar Carnaby-Mann G., Crary M. A., Schmalfuss I., & Amdur R. (2012). “Pharyngocise”: Randomized controlled trial of preventative exercises to maintain muscle structure and swallowing function during head-and-neck chemoradiotherapy.International Journal of Radiation Oncology, 83(1), 210–219. Google Scholar Cichero J. (2014). Standardization of Dysphagia Diet Terminology across the Lifespan: An International Perspective.Perspectives on Swallowing and Swallowing Disorders, SIG 13 newsletter. Vol. 23(4), 166–172. ASHAWireGoogle Scholar Colodny N. (2002). Interjudge and intrajudge reliabilities in fiberoptic endoscopic evaluation of swallowing (FEES) using the penetration-aspiration scale: A replication study..Dysphagia, 17, 308–315. Google Scholar da Silva A. P., Lubianca Neto J. F., Santoro P. P. (2010). Comparison between videofluoroscopy and endoscopic evaluation of swallowing for the diagnosis of dysphagia in children..Otolaryngology-Head & Neck Surgery, 143, 204–209. Google Scholar Hoffman M. R., Mielens J. D., Ciucci M. R., Jones C. A., Jiang J. J., & McCulloch T. M. (2012). High-resolution manometry of pharyngeal swallow pressure events associated with effortful swallow and the Mendelsohn maneuver.Dysphagia, 27(3), 418–426. CrossrefMedlineGoogle Scholar Kotz T., Federman A. D., Kao J., Milman L., Packer S., Lopez-Prieto C. … Genden E. M. (2012). Prophylactic swallowing exercises in patients with head and neck cancer undergoing chemoradiation: A randomized trial.Archives of Otolaryngology-Head & Neck Surgery, 138(4), 376–382. CrossrefMedlineGoogle Scholar Langmore S., McCulloch T., Krisciunas G., Lazarus C., Van Daele D., Pauloski B. R., … Doros G. (submitted). Efficacy of electrical stimulation and swallow exercises for dysphagia in head and neck cancer patients: A randomized clinical trial.Head & Neck. Google Scholar Logemann J. A. (1998). The need for clinical trials in dysphagia.Dysphagia, 13, 10–11. Google Scholar Logemann J. A. (2004). Clinical trials: CSDRG overview.Journal of Communication Disorders, 37, 419–423. MedlineGoogle Scholar Logemann J. A., Gensler G., Robbins J., Lindblad A. S., Brandt D., Hind J. A., … Miller Gardner P. J. (2008). A randomized study of three interventions for aspiration of thin liquids in patients with dementia or Parkinson’s disease.Journal of Speech, Language, and Hearing Research, 51, 173–183. ASHAWireGoogle Scholar Logemann J. A., Rademaker A. W., Pauloski B. R., Kelly A., Stangl-McBreen C., Antinoja J., … Shaker R. (2009). A randomized study comparing the shaker exercise with traditional therapy: Preliminary observations.Dysphagia, 24, 403–411. Google Scholar Logemann J. A., Rademaker A. W., Pauloski B. R., Ohmae Y., & Kahrilas P. J. (1998). Normal swallowing physiology as viewed by videofluoroscopy and videoendoscopy.Folia Phoniatrica et Logopaedica, 50, 311–19. Google Scholar Logemann J. A., Rademaker A. W., Pauloski B. R., Ohmae Y., & Kahrilas P. J. (1999). Interobserver agreement on normal swallowing physiology as viewed by videofluoroscopy and videoendoscopy.Folia Phoniatrica et Logopaedica, 51, 91–98. Google Scholar Logemann J. A., Veis S., & Colangelo L. (1999). A screening procedure for oropharyngeal dysphagia.Dysphagia, 14, 44–51. CrossrefGoogle Scholar Martin-Harris B., Brodsky M. B., Michel Y., Castell D. O., Schleicher M., Sandidge J., … Blair J. (2008). MBS measurement tool for swallow impairment—MBSImp: Establishing a standard.Dysphagia, 23(4), 392–405. CrossrefGoogle Scholar McConnel F. M., Hester T. R., Mendelsohn M. S., & Logemann J. A. (1988). Manofluorography of deglutition after total laryngopharyngectomy.Plastic and Reconstructive Surgery, 81(3), 346–351. Google Scholar McConnel F. M., Mendelsohn M. S., & Logemann J. A. (1987). Manofluorography of deglutition after supraglottic laryngectomy.Head & Neck Surgery, 9(3), 142–150. Google Scholar Mielens J. D., Hoffman M. R., Ciucci M. R., Jiang J. J., & McCulloch T. M. (2011). Automated analysis of pharyngeal pressure data obtained with high-resolution manometry.Dysphagia, 26, 3–12. CrossrefGoogle Scholar Miles A., Moore S., McFarlane M., Lee F., Allen J., & Huckabee M. L. (2013). Comparison of cough reflex test against instrumental assessment of aspiration.Physiology & Behavior, 118, 25–31. CrossrefGoogle Scholar Noordally S. O., Sohawon S., De Gieter M., Bellout H., & Verougstraete G. (2011). A study to determine the correlation between clinical, fiber-optic endoscopic evaluation of swallowing and videofluoroscopic evaluations of swallowing after prolonged intubation..Nutrition in Clinical Practice, 26, 457–462. Google Scholar Mepani Y., Antonik A., Massey B., Kern K., Logemann J., Pauloski B., … Shaker R. (2009). Augmentation of deglutitive thyrohyoid muscle shortening by the Shaker exercise.Dysphagia, 24, 26–31. Google Scholar Robbins J., Gangnon R. E., Theis S. M., Kays S. A., Hewitt A. L., & Hind J. A. (2005). The effects of lingual exercise on swallowing in older adults.Journal of the American Geriatrics Society, 53(9), 1483–1489. CrossrefGoogle Scholar Robbins J., Gensler G., Hind J., Logemann J. A., Lindblad A. S., Brandt D., … Miller Gardner P. J. (2008). Comparison of 2 interventions for liquid aspiration on pneumonia incidence: A randomized trial.Annals of Internal Medicine, 188, 509–518. Google Scholar Robbins J., Kays S. A., Gangnon R. E., Hind J. A., Hewitt A. L., Gentry L. R., & Taylor A. J. (2007). The effects of lingual exercise in stroke patients with dysphagia.Archives of Physical Medicine and Rehabilitation, 88(2), 150–158. CrossrefGoogle Scholar Rosenbek J. C., Robbins J. A., Roecker E. B., Coyle J. L., & Wood J. L. (1996). A penetration–aspiration scale.Dysphagia, 11, 93–98. CrossrefGoogle Scholar Sarraf Shirazi S., Buchel C., Daun R., Lenton L., & Moussavi Z. (2012). Detection of swallows with silent aspiration using swallowing and breath sound analysis..Medical & Biological Engineering & Computing, 50, l261–1268. Google Scholar Author Notes Cathy Lazarus, PhD, CCC-SLP, is an associate professor in the Department of Otolaryngology-Head and Neck Surgery at the Icahn School of Medicine at Mount Sinai and research director at the Thyroid Head and Neck Cancer (THANC) Foundation at Mount Sinai Beth Israel in New York City. She is an affiliate of ASHA Special Interest Group 13, Swallowing and Swallowing Disorders (Dyphagia). [email protected] Barb Pauloski, PhD, CCC-SLP, is an associate professor in the Department of Communication Sciences and Disorders in the College of Health Sciences at the University of Wisconsin-Milwaukee. She is an affiliate of SIG 13. 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