Neurogastroenterology & Motility
Neurogastroenterol Motil (2012) 24, 414e206
Effectiveness of chin-down posture to prevent tracheal
aspiration in dysphagia secondary to acquired brain injury.
A videofluoroscopy study
R. TERRE & F. MEARIN
Functional Digestive Rehabilitation Unit, Institut Guttmann, Neurorehabilitation Hospital, University Institute affiliated with the
Autonomous University of Barcelona, Badalona, Spain
Abstract
Background The chin-down posture is generally rec-
ommended in patients with neurogenic dysphagia to
prevent tracheal aspiration; however, its effectiveness
has not been demonstrated. Aim To videofluoroscop-
ically (VDF) assess the effectiveness of chin-down
posture to prevent aspiration in patients with neuro-
genic dysphagia secondary to acquired brain injury.
Methods Randomized, alternating, cross-over study
(with and without the chin-down posture) in 47
patients with a VDF diagnosis of aspiration [31 stroke,
16 traumatic brain injury (TBI)] and 25 controls with-
out aspiration (14 stroke, 11 TBI). Key Results During
the chin-down posture, 55% of patients avoided aspi-
ration (40% preswallow aspiration and 60% aspiration
during swallow). The percentage was similar in both
etiologies (58% stroke and 50% TBI). Fifty-one percent
of patients had silent aspiration; of these, 48% persisted
with aspiration while in the chin-down posture. A sta-
tistically significant relationship was found between
the existence of pharyngeal residue, cricopharyngeal
dysfunction, pharyngeal delay time and bolus volume
with the persistence of aspiration. The chin-down pos-
ture did not change swallow biomechanics in patients
without aspiration. Conclusions & Inferences Only
half the patients with acquired brain injury avoided
aspiration during cervical flexion; 48% of silent aspi-
rators continued to aspire during the maneuver. Several
videofluoroscopic parameters were related to ineffi-
ciency of the maneuver. Therefore, the indication for
Address for Correspondence
Rosa Terre, Functional Digestion Rehabilitation Unit, Institut
Guttmann, Cam de Can Ruti, s/n, 08916 Badalona, Spain.
Tel: +34 93 4977700; fax: +34 93 4977703;
e-mail: rterre@guttmann.com
Received: 11 July 2011
Accepted for publication: 21 December 2011
414
doi: 10.1111/j.1365-2982.2011.01869.x
chin-down posture should be evaluated by videofluo-
roscopic examination.
Keywords aspiration, chin-down posture, stroke,
traumatic brain injury, videofluoroscopy.
INTRODUCTION
Oropharyngeal dysphagia is frequently present during
the acute phase of stroke and traumatic brain injury
(TBI). Dysphagia may manifest as aspiration, defined as
the entry of food or liquid into the airway below the
true vocal folds.1 The reported incidence of dysphagia
ranges 2270% in patients with stroke27 and 3865%
in TBI.4,5,8 Dysphagia has been associated with
increased morbidity and mortality as patients will be
at major risk for malnutrition and respiratory compli-
cations.6 Clearly, the goals in dysphagia therapy are to
reduce the morbidity and mortality associated with
respiratory infections, improve nutritional status and
return patients to a normal diet, with a consequent
improvement in their quality of life.6
Swallowing therapies can be differentiated into
compensatory and rehabilitative strategies.2,3,6 The
former aims to keep patients safe when eating and
drinking, whereas the latter aims to accelerate the
recovery process. Compensatory strategies include
food consistency changes and postural maneuvers
(such as chin tuck, head turn, etc.); head and neck
exercises are included in rehabilitative strategies. The
aim of postural techniques was to redirect the flow of
food and/or liquids to prevent aspiration and eliminate
residue. The chin-down posture involves tucking the
chin into the neck.9 The use of this postural technique
has been indicated to reduce the aspiration that occurs
before and during swallowing. It has been hypothesized
that this protective effect is produced because the
change in head position increases the size of the
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Volume 24, Number 5, May 2012 Chin-down posture to prevent aspiration

vallecular spaces and inverts the epiglottis into a more Table 1 Demographic and clinical data of patients
protective position over entry to the airway. These
Study group Control group
techniques are commonly used temporarily as the
(n = 47) (n = 25)
patient recovers, but in some cases are indicated to be
used permanently to prevent aspiration and improve Sex
Male/female 31/16 19/6
swallowing safety.4
Age (years) 43 (1875) 51 (2176)
However, almost only expert consensus support the Etiology
use of maneuvres, such as chin tuck, and it should be Stroke/TBI 31/16 14/11
Stroke etiology
noted that its efficacy remains controversial.6 Unfor-
Hemorrhagic 18 9
tunately, the existing literature provides scant scien- Ischemic 13 5
tific evidence of this kind of dysphagia therapy.46,10 Stroke location
Anterior vascular territory 7 4
Moreover, when Logemann et al.11 analyzed three
Posterior vascular territory 24 10
interventions to treat aspiration (thin liquids chin- Stroke scale
down posture, nectar-thickened liquids, or honey- FIM 51 59
(23108) (20100)
thickened) and it was eliminated in only 33%
TBI scales
of patients with Parkinson disease and 26% with DRS 14 15
dementia. (718) (819)
RLFC 6 6
The few studies published had some methodologic
(58) (57)
limitations: small number of patients, heterogeneous Pneumonic history feeding mode 27 10
etiology, subjective evaluation, etc. Therefore, the Gastrostomy/NGT 28 15
Gastrostomy + oral 2 1
effectiveness of the chin-down posture cannot be gen-
Oral modified 15 7
eralized to all patients who are neurologically impaired, Oral normal 2 2
specifically those with acquired brain injury. In addi-
tion, it should be remembered that in some patients this TBI, traumatic brain injury; FIM, functional Independence Measure-
ment; DRS, Disability Rating Scale; RLFC, Rancho Los Amigos Level
maneuver is not easy to perform and maintain, thereby Cognitive Function Scale; NGT, nasogastric tube.
impairing their normal eating habits.
The aim of this study was to videofluoroscopically
Videofluoroscopic examination
assess the effectiveness of the chin-down posture to
prevent aspiration in patients with neurogenic dyspha- In randomized, alternating order, the VFS examination was started
with the cervical rachis in the anatomic position (normal
gia secondary to acquired brain injury (stroke and
swallow) or cervical rachis in flexion with sternal-mentonian
trauma). We also evaluated if the effectiveness of chin- contact (chin-down posture). The biomechanical swallow with
down posture in eliminating aspiration was correlated the same boluses (volume and consistency) was analyzed in both
with other videofluoscopic findings. situations.
The examination was carried out with boluses of 3, 5, 10 and
15 mL of pudding, nectar and liquid viscosities, with the patient
seated and X-ray in the lateral projection. The bolus was delivery
PATIENTS AND METHOD
via syringe by a nurse. The full swallowing sequence was high-
A randomized, alternating cross-over study was conducted (with/ power recorded by the Kay Digital Swallowing Workstation (New
without chin-down posture) in patients with neurogenic dyspha- Jersey, USA) at a frame rate of 25 frames s)1. Visipaque (GE
gia and aspiration demonstrated by videofluoroscopic examina- Healthcare Bio-Sciences, SA, Spain) is usually used as a contrast
tion. This study group included 47 patients (31 stroke and 16 TBI). medium and Resource (Novartis, Spain) as a thickener in our
A control group of 25 patients, 14 stroke and 11 TBI, (patients Unit. A complete swallowing sequence was recorded on high-
without aspiration demonstrated by videofluoroscopy) was also resolution videotape. We evaluated oral and pharyngeal function
evaluated; this control group served to ascertain whether the chin- at all viscosities and volumes, defining CP dysfunction and
down posture might be deleterious and induce aspiration or any pharyngeal residue if we observed alteration in any of the bolus
other type of swallowing alteration. Demographic and clinical analyzed. The examination was discontinued if aspiration was
data of both groups are detailed in Table 1. recorded or the patient was unable to cooperate. VFS was always
Inclusion criteria for the study group were: (i) videofluoroscopic performed and analyzed by the same person (RT) with long
diagnosis of tracheal aspiration (before the onset of pharyngeal experience in this diagnostic technique.
swallow and during pharyngeal contraction), (ii) patients with The VFS technique was an adaptation of Logemanns proce-
acquired brain injury (stroke and TBI) able to understand and dure.14 In the oral phase, the following parameters were analyzed:
follow verbal instructions for performing the maneuver, (iii) TBI (i) oral transit time (OTT): time elapsed from the beginning of
patients with a Rancho Los Amigos Level Cognitive Function bolus movement inside the mouth cavity until the bolus head
Scale score >412, and (iv) stroke patients with a Barcelona test passes the point where the jaw crosses the base of the tongue (in
(comprehension) score >15.13 Exclusion criteria were: (i) cognitive- normal individuals: 1.25 s); (ii) tongue control: abnormal tongue
behavioral alteration preventing patients from following the control was defined as any alteration that reduced ability to form
instructions, and (ii) inability to perform the cervical flexion the bolus and propel it toward the rear part of the mouth and
maneuver. pharynx; (iii) reduced palatoglossal closure: defined as when all or

 2012 Blackwell Publishing Ltd 415

R. Terre & F. Mearin
part of the bolus falls into the pharynx prematurely (before
activation of the swallowing reflex); and (iv) piecemeal degluti-
tion: considered present when the patient swallows the bolus in
various portions.
In the pharyngeal phase, we evaluated: (i) nasopharyngeal
penetration, which occurs as a result of inadequate velopharyn-
geal closure or inability of the bolus to pass through the upper
esophageal sphincter (UES) causing it to ascend the nasopharyn-
geal tract; (ii) residue in the pharyngeal cavity after swallowing
(vallecula and pyriform sinuses); the amount of residue was
classified as severe if 75100% of the bolus remained, moderate if
5075%, mild if 2550%, and no residue if less than 25%14; (iii)
laryngeal elevation: maximum approximation of the larynx and
hyoid during the swallow (considered to be pathologic below
1.3 cm in men and 1.08 cm in women)15; (iv) cricopharyngeal
dysfunction: defined as any reduction in normal UES opening
during the transsphincteric flow of the bolus; (v) pharyngeal delay
time (PDT): defined as time from bolus head arrival at the point
where the shadow of the longer edge of the mandible crosses the
tongue base until pharyngeal swallow is triggered. Triggering or
onset of pharyngeal swallow is defined as the first video frame
showing laryngeal elevation as part of the pharyngeal swallowing
complex (considered to be normal below 0.24 s)16; (vi) pharyngeal
transit time (PTT): time elapsed from when the head of the bolus
leaves the base of the tongue until the tail of the bolus passes
through the cricopharyngeal region (less than 1 s considered
normal); and (vii) penetration/aspiration: penetration was defined
as passage of the bolus content into the laryngeal vestibule above
the vocal cords. When food crossed the vocal cords and entered the
airways, it was considered aspiration. The moment aspiration
occurred (before onset of pharyngeal swallow, during pharyngeal
contraction or after swallowing) was recorded. Consideration was
also given to the appearance or not of cough during aspiration.
Silent aspiration was defined as the entry of food below the level
of the true vocal cords, without cough or any outward sign of
difficulty.
We considered a patient as having no aspiration on VFS when
none of the bolus and viscosities analyzed crossed the vocal cords
and entered the airways. For temporal measurements (OTT, PDT
and PTT) evaluation results obtained with 5 mL bolus of nectar
were taken and compared with normal values using the same
volume and viscosity.13 For laryngeal elevation results obtained
with 3 mL bolus of nectar were taken and compared with normal
values using the same volume and viscosity.15
Videofluoroscopy is a diagnostic tool available at our healthcare
practice to assess patients with clinically suspected neurogenic
dysphagia. When introduced (1999), this examination procedure
was approved by the Ethics Committee of the Institut Guttmann.
The present investigation was submitted and approved by the
Investigation Committee. The patients were informed and
accepted to participate in the study.
Statistical analysis
Statistical analyses consisted of a descriptive analysis (study
group/control group) and a bivariate analysis comparing preven-
tion of aspiration in the chin-down posture (yes/no) with etiology
(stroke/TBI) and VFS findings to determine the predictive factors
for aspiration prevention. Sensitivity (probability of compensating
aspiration when swallowing in the chin-down position) and
specificity (probability of not compensating aspiration when
swallowing with the cervical rachis in the anatomic position) of
the chin-down posture were also analyzed.
When the predictive variable was categorical, the chi-square
test was applied, and when continuous, either Students t-test or
ANOVA, with the significance value set at P < 0.05.
416
Neurogastroenterology and Motility
RESULTS
Videofluoroscopic findings
In the study group, the examination was started in the
anatomic position in 23 patients and chin-down
posture in 24 and control group in 13 and 12, respec-
tively (Fig. 1). Videofluoroscopic findings in both
groups are detailed in Table 2.
Several videofluoroscopic abnormalities were found
in the study group. In the oral phase, the most
significant were: an increase in OTT in 34% of
patients, tongue control disorder in 47% and impaired
palatoglossal closure in 48%. In the pharyngeal phase,
the most relevant were: PDT in 64% of patients,
laryngeal elevation reduction in 62% and increased
PTT in 57%. Aspiration occurred prior to swallowing
in 21% of patients and during pharyngeal contraction
in 79%. Fifty-one percent of patients who had aspira-
tion were silent aspirators (Table 2). Videofluoroscopic
findings were similar regardless of whether the exam-
ination was started in the anatomic position or in chin-
down posture.
As expected, in the control group, VDF abnormali-
ties were lesser with the more prevalent abnormalities
in the oral phase being tongue control alteration in
36% of patients and mild pharyngeal residue in 32% in
the pharyngeal phase. No patients had tracheal aspira-
tion either during the examination in chin-down
posture or the anatomic position. It is of note that in
this group, the chin-down posture did not change
swallow biomechanics (Table 2).
In the study group, the VDF findings according to
whether the patient avoided aspiration or not during
the chin-down posture are shown in Table 3. The
most significant differences between groups were:
pharyngeal residue 30% vs 70%, cricopharyngeal
dysfunction 18% vs 83% and PDT 54% vs 76%. It
should be emphasized that only 55% of patients
avoided aspiration during the chin-down maneuver.
When aspiration occurred before swallowing, it was
prevented by the chin-down posture in 40% of cases,
whereas when aspiration occurred during pharyngeal
contraction, it was prevented in 60%. Fifty-one
percent of patients were found to have silent aspira-
tion (20% aspiration before and 80% during swallow);
in this group the chin-down posture avoided aspira-
tion in only 52% of cases.
When prevention of aspiration by the maneuver was
analyzed in relation to bolus viscosity and volume,
some interesting findings emerged: patients with aspi-
ration at larger volumes responded better to the chin-
down posture, whereas viscosity had no influence
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Volume 24, Number 5, May 2012 Chin-down posture to prevent aspiration

Aspiration
N = 23
Aspiration
N=8 Anatomical
Chin-down
N = 23 No aspiration
No aspiration
N=0
N = 15
Study group
N = 47 Aspiration
Aspiration
N = 13
N = 24 Chin-down
Anatomical
N = 24
No aspiration No aspiration
N=0 N = 11

Aspiration
N=0
Aspiration
N=0 Anatomical
Chin-down
N = 12 No aspiration
No aspiration
N = 12
N = 12
Control group
N = 25 Aspiration
Aspiration
N=0
N=0 Chin-down
Anatomical
N = 13
No aspiration No aspiration
N = 13 N = 13

N = number of patients

Figure 1 Videofluoroscopic examination performed in randomized order alternating chin-down and anatomic positions. Patient distribution in both
groups (study and control) and the number of patients with aspiration in each situation are shown. Note that, in the control group, no patients had
tracheal aspiration during the examination in either the chindown posture or anatomic position.

(Fig. 2). Only two patients had aspiration at 3 mL (one
with liquid and the other with nectar).
The quantitative temporal measurements in the
chin-down posture to prevent aspiration or not are
detailed in Table 3. The patients who continued aspi-
rating during the chin-down maneuver had more
prolonged PDT compared with patients without aspi-
ration; OTT and PTT did not differ significantly
between patients with and without aspiration.
Relationship between aspiration prevention with
the chin-down posture and etiology (stroke/TBI),
feeding mode and VFS findings
When VFS findings in relation to etiology were
analyzed, a similar percentage of patients who did not
aspire during swallowing in cervical flexion was found
in both groups: 58% of stroke and 50% of TBI patients.
When feeding mode and videofluoroscopic findings
were correlated with aspiration prevention or not with
the chin-down posture, a statistically significant rela-
tionship was found between bolus volume (P = 0.0001),
pharyngeal residue (P = 0.012) and cricopharyngeal
dysfunction (P = 0.05); a trend toward palatoglossal
closure dysfunction was also observed (P = 0.058).
A positive relationship was found between PDT
(P = 0.046) and aspiration prevention: 76% of patients
who had aspiration during the chin-down posture had
increased PDT vs 24% of patients with normal PDT;
no correlation was found with OTT, PTT or any of the
remaining parameters (Table 3).
Sensitivity and specificity of the chin-down
posture
Sensitivity (probability of patients swallowing in the
chin-down posture compensating the aspiration) and
specificity (probability of those swallowing with cer-
vical rachis in the anatomic position without flexion
not compensating the aspiration) of the chin-down
maneuver to prevent tracheal aspiration were 65% and
54%, respectively.
DISCUSSION
Swallowing therapy to improve disordered oropharyn-
geal deglutition has traditionally focused on behavioral
interventions, including compensatory and rehabilita-
tive strategies, with the aim of facilitating safe and
efficient oral feeding. Compensatory strategies are

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R. Terre & F. Mearin Neurogastroenterology and Motility

Table 2 Videofluoroscopic abnormalities in the study and control Table 3 Videofluoroscopic abnormalities, moment of aspiration and
groups globally and whether the examination was started in the ana- temporal measurements in the study group according to prevention or
tomic position or in cervical flexion not of aspiration during the chin-down maneuver

Study group n = 47 Control group n = 25 Aspiration No aspiration

prevention prevention
Videofluoroscopic CDP AP CDP AP Videofluoroscopic findings (%) n = 26 (%) n = 21(%)
findings (%) Total n = 23 n = 24 Total n = 12 n = 13
Increase in OTT 50 50
Increase in OTT 34 52 37 16 17 15 Tongue control alteration 54 46
Tongue control 47 52 42 36 50 23 Piecemeal deglutition 47 53
alteration Reduced palatoglossal closure 43 57
Piecemeal deglutition 40 43 38 32 41 23 Pharyngeal residue 30 70
Reduced palatoglossal 48 48 42 8 8 8 Mild 33 68
closure Moderate 0 100
Pharyngeal residue 36 22 50 32 30 31 Cricopharyngeal dysfunction 18 83
Mild 32 22 42 32 30 31 Reduction laryngeal elevation 48 52
Moderate 4 - 8 0 0 0 Increase in PDT 54 76
Cricopharyngeal 13 13 13 0 0 0 Increase in PTT 48 52
dysfunction Airway penetration 69 30
Reduction in 62 52 71 12 17 8 Aspiration 55 45
laryngeal elevation Cough 52 48
Increase in PDT 64 65 62.5 4 8 0 Moment of aspiration
Increase in PTT 57 60 54 8 8 8 Preswallowing 40 60
Airway penetration 28 22 33 12 17 8 During swallowing 60 40
Airway aspiration 100 100 100 0 0 0 Temporal measurements (s)*
Cough 49 44 54 0 0 0 OTT (1.5) 1.44 (0.127) 1.45 (0.166)
Moment of aspiration PDT (0.24) 0.52 (0.041.92) 0.91 (0.065.8)
Preswallowing 21 26 17 0 0 0 PTT (1) 1.31 (0.583.6) 1.69 (0.66)
During swallowing 79 74 83 0 0 0
Temporal measurements (s)* OTT, oral transit time. PDT, pharyngeal delay time. PTT, pharyngeal
OTT (1.5) 1.44 (0.127) 1 (0.141.64) transit time.
PDT (0.24) 0.7 (0.045) 0.13 (0.060.27) *Mean and range.
PTT (1) 1.49 (0.586.2) 0.88 (0.61.16)
phagia secondary to acquired brain injury (stroke and
OTT, oral transit time. PDT, pharyngeal delay time. PTT, pharyngeal
transit time; CDP/AT, chin-down posture/anatomic position.
TBI). The main physiopathologic swallowing altera-
*Mean and range. tions were delayed swallowing reflex, laryngeal eleva-
tion reduction and an increase in PTT, occurring in
aimed at modifying oral and pharyngeal physiology. more than half the patients; most of the aspirations
Initial observations of videofluorographic studies of occurred during pharyngeal contraction. During the
dysphagic patients using the chin-down posture led chin-down maneuver, aspiration was prevented in only
clinicians to believe that the effectiveness of this 55% of patients; however, it should be emphasized that
posture in preventing aspiration resulted from enlarge- prevention by the maneuver is more efficient in
ment of the vallecular space with the chin down and a patients with aspiration during pharyngeal contraction
posterior shift of the epiglottis to a more protective than in those with preswallow aspiration.
position over the airway.17 It is also noteworthy that half the patients were
Unfortunately, there is a paucity of scientific evi- silent aspirators. Published data indicate that the
dence supporting the usefulness of behavioral inter- incidence of silent aspirators ranged from 30% to
ventions in selected groups of individuals with 60%.2024 In a previous report, we found more than
neurologically induced dysphagia.4,5,10,18 To date, no one-third of the patients with dysphagia secondary to
study has specifically analyzed the effectiveness of the TBI and stroke to be silent aspirators, with different
chin-down maneuver in patients with acquired brain prevalence in relation to the vascular territory
injury. Previously, the reported incidence of aspiration affected.25,26 In the present study, only 52% of silent
prevention during the chin-down maneuver ranged aspirators avoided aspiration during the chin-down
from 50% to 8%17,19; however, those studies were position, which implies a high risk of respiratory
performed in heterogeneous groups of patients with complications with consequent associated morbidity
different neurologic17 and neurodegenerative dis- and mortality. The association between aspiration and
eases.19 The present study provides objective data on pneumonia, with a major prevalence in silent aspira-
the low effectiveness of the chin-down posture to tors, has been clearly demonstrated.7
prevent aspiration that occurs before and during pha- Biomechanical measurements of oropharyngeal
ryngeal contraction in patients with neurogenic dys- swallow provide an objective measurement of several

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Volume 24, Number 5, May 2012 Chin-down posture to prevent aspiration

100

% of patients without aspiration

% of patients without aspiration

100
80
80
60
60

40 40

Pudding
Nectar
Liquid

35 mL
20

10 mL

15 mL
20

0 0
Liquid Nectar Pudding* Viscosity Volume
35 mL 10 mL 15 mL
P = 0. 014 P = 0.7 P = 0.001
* No patient had aspiration at 15 mL pudding

Figure 2 Prevention of aspiration with the chin-down posture in relation to bolus viscosity and volume. Percentage of patients with aspiration
decreased with larger bolus volumes regardless of the viscosity. Note that patients with aspiration at larger volumes responded better to the chin-
down posture, whereas viscosity had no influence.

parameters for a more precise definition of the nature study design allowed us to compare VDF results
of deglutition disorders. The results of our study between patients with and without aspiration, and
suggest that some VFS variables may allow us to demonstrate that the chin-down posture did not
predict whether aspiration will persist or disappear change swallow biomechanics or induce aspiration in
with the chin-down maneuver. We found persisting patients not having it in the anatomic position.
aspiration to be significantly related to PDT, pharyn- Thirdly, the temporal quantitative VDF analysis,
geal residue, cricopharyngeal dysfunction and bolus together with the qualitative analysis, allowed us to
volume. All these findings indicate that patients with estimate some predictive factors to avoid aspiration
more severe biomechanical swallowing alterations during the chin-down maneuver. Limitations include
respond more poorly to the chin-down posture. It the absence of long-term clinical evaluation as well as
should be remembered that the VFS findings correlat- the fact that VDF is not universally available. Another
ing with prevention or not of aspiration during swallow possible pitfall is that videofluoroscopic images inter-
in cervical flexion (pharyngeal residue, cricopharyngeal pretation depends on visual judgments and is somehow
dysfunction and PDT) cannot be detected with cer- subjective. Some studies revealed not only poor inter-
tainty by clinical examination (laryngeal ascent, cough observer but also intra-observer reliability in video-
and palatoglossal closure dysfunction).1,2,4 fluoroscopic assessments. Nevertheless, aspiration and
Our results yielded sensitivity and specificity of the measures for oral and pharyngeal phase transit times
chin-down maneuver to prevent aspiration in patients (some of the most relevant issues of our study) had a
with acquired brain injury of 65% and 54%, respec- high reliability (over 90%).2729
tively. Thus, although this maneuver can help to In summary, the indication of chin-down maneuver
increase swallow safety in a significant group of to prevent aspiration in patients with dysphagia
patients, it is not universally applicable to all dyspha- secondary to acquired brain injury cannot be general-
gic patients. Nevertheless, from a clinical standpoint ized as only half of patients avoid aspiration during this
the chin-down maneuver cannot be advised based on maneuver (with 48% of silent aspirators that continue
videofluoroscopic findings as this technique is not to aspirate during the maneuver). The patients who
available in many centers. Thus, we suggest than in continued to aspirate during cervical flexion were
patients with clinical symptoms of aspiration the those with aspiration at smaller volumes and more
maneuver should be done for some time but only pharyngeal residue, cricopharyngeal dysfunction and
maintained if aspiration is avoided. If not, and based on PDT. Appropriate indication of the chin-down posture
our results, this maneuver should not be generalize to should be evaluated by VDF examination.
all patients with dysphagia given that swallowing in
cervical flexion can be uncomfortable and require
ACKNOWLEDGMENTS
especial collaboration.
This study has some strengths and some limitations. We thank Ms. Raquel Lopez for statistical analysis. We are also
indebted to Ms. Christine OHara who helped to prepare the
Firstly, a large and homogeneous group of patients with
manuscript.
acquired brain injury was evaluated. Secondly, the

 2012 Blackwell Publishing Ltd 419

R. Terre & F. Mearin
FUNDING
No funding declared.
DISCLOSURES
No competing interests declared.
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AUTHOR CONTRIBUTION
R. Terre designed the research study, performed the research,
analyzed the data and wrote the paper; F. Mearin designed the
research study, analyzed the data and wrote the paper.
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