Functional brain imaging of swallowing: an activation likelihood estimation meta-analysis

Repetitive Transcranial Magnetic Stimulation on Individualized Spots Based on Task functional Magnetic Resonance Imaging Improves Swallowing Function in Poststroke Dysphagia

Background: Functional magnetic resonance imaging (fMRI) has not previously been used to localize the swallowing functional area in repetitive transcranial magnetic stimulation (rTMS) treatment for poststroke dysphagia; Traditionally, the target area for rTMS is the hotspot, which is defined as the specific region of the brain identified as the optimal location for transcranial magnetic stimulation (TMS). This study aims to compare the network differences between the TMS hotspot and the saliva swallowing fMRI activation to determine the better rTMS treatment site and investigate changes in functional connectivity related to poststroke dysphagia using resting-state fMRI. Methods: Using an information-based approach, we conducted a single case study to explore neural functional connectivity in a patient with poststroke dysphagia before, immediately after rTMS, and 4 weeks after rTMS intervention. A total of 20 healthy participants underwent fMRI and TMS hotspot localization as a control group. Neural network alterations were assessed, and functional connections related to poststroke dysphagia were examined using resting-state fMRI. Results: Compared to the TMS-induced hotspots, the fMRI activation peaks were located significantly more posteriorly and exhibited stronger functional connectivity with bilateral postcentral gyri. Following rTMS treatment, this patient developed functional connection between the brainstem and the bilateral insula, caudate, anterior cingulate cortex, and cerebellum. Conclusion: The saliva swallowing fMRI activation peaks show more intense functional connectivity with bilateral postcentral gyri compared to the TMS hotspots. Activation peak-guided rTMS treatment improves swallowing function in poststroke dysphagia. This study proposes a novel and potentially more efficacious therapeutic target for rTMS, expanding its therapeutic options for treating poststroke dysphagia.

Revealing Goal-Directed Neural Control of the Pharyngeal Phase of Swallowing

Swallowing is considered a three-phase mechanism involving the oral, pharyngeal, and esophageal phases. The pharyngeal phase relies on highly coordinated movements in the pharynx and larynx to move food through the aerodigestive crossing. While the brainstem has been identified as the primary control center for the pharyngeal phase of swallowing, existing evidence suggests that the higher brain regions can contribute to controlling the pharyngeal phase of swallowing to match the motor response to the current context and task at hand. This suggests that the pharyngeal phase of swallowing cannot be exclusively reflexive or voluntary but can be regulated by the two neural controlling systems, goal-directed and non-goal-directed. This capability allows the pharyngeal phase of swallowing to adjust appropriately based on cognitive input, learned knowledge, and predictions. This paper reviews existing evidence and accordingly develops a novel perspective to explain these capabilities of the pharyngeal phase of swallowing. This paper aims (1) to integrate and comprehend the neurophysiological mechanisms involved in the pharyngeal phase of swallowing, (2) to explore the reflexive (non-goal-directed) and voluntary (goal-directed) neural systems of controlling the pharyngeal phase of swallowing, (3) to provide a clinical translation regarding the pathologies of these two systems, and (4) to highlight the existing gaps in this area that require attention in future research. This paper, in particular, aims to explore the complex neurophysiology of the pharyngeal phase of swallowing, as its breakdown can lead to serious consequences such as aspiration pneumonia or death.

Simultaneous Four Supratentorial Lesions Predict Tube Dependency Due to an Impaired Anticipatory Phase of Ingestion

This study aimed to identify the neuroanatomical predictors of oropharyngeal dysphagia and tube dependency in patients with supratentorial or infratentorial ischemic strokes. Patients with acute ischemic stroke were enrolled and were classified into 3 groups: right supratentorial (n = 61), left supratentorial (n = 89), and infratentorial stroke (n = 50). Dysphagia was evaluated by a modified water swallowing test and the Food Intake LEVEL Scale to evaluate oropharyngeal dysphagia and tube dependency, respectively. As two dysphagia parameters, we evaluated the durations from onset of stroke to (1) success in the modified water swallowing test and to (2) rating 7 points or above on the Food Intake LEVEL Scale: patients regained sufficient oral intake and were not tube-dependent. Voxel-based lesion-symptom mapping analysis was performed for a spatially normalized lesion map of magnetic resonance imaging to explore the anatomies that are associated with the two dysphagia parameters for each stroke group. The right precentral gyrus and parts of the internal capsule are associated with oropharyngeal dysphagia. The four supratentorial areas are associated with tube dependency. The dorsal upper medulla is associated with both oropharyngeal dysphagia and tube dependency. These results suggest that supratentorial stroke patients can be tube-dependent due to an impaired anticipatory phase of ingestion. The simultaneous damage in the four supratentorial areas: the inferior part of the precentral gyrus, lenticular nucleus, caudate head, and anterior insular cortex, predicts tube dependency. In contrast, infratentorial stroke patients can be tube-dependent due to oropharyngeal dysphagia caused by lesions in the dorsal upper medulla, damaging the swallowing-related nucleus.

The potential positive effect of periodontal treatment on brain function activity using functional magnetic resonance imaging analysis

Background/purpose

There are reports on the relationship between periodontal treatment and the whole body. The purpose of the present study was to investigate the effect of periodontal initial treatment on brain function activity by improving periodontal tissue and the occlusal status of subjects with periodontitis.

Materials and methods

The subjects were 13 patients with periodontitis. Following the patient's informed written consent, the periodontal initial treatment provided to the patient included tooth brushing instruction, scaling and root planning, however, occlusal adjustment was not performed at this stage. Periodontal examination, occlusal force examination and fMRI results were also evaluated at the initial and the reevaluation examinations.

Results

After the periodontal initial treatment had been performed, periodontal tissue had significantly improved. In addition, cerebral blood flow in the insula and primary motor cortex was also improved, as confirmed by fMRI.

Conclusion

This result suggests that the periodontal ligament has recovered and the periodontal ligament neuron have been further subjected to clenching in the insula.

The Cortical and Subcortical Neural Control of Swallowing: A Narrative Review

Swallowing is a sophisticated process involving the precise and timely coordination of the central and peripheral nervous systems, along with the musculatures of the oral cavity, pharynx, and airway. The role of the infratentorial neural structure, including the swallowing central pattern generator and cranial nerve nuclei, has been described in greater detail compared with both the cortical and subcortical neural structures. Nonetheless, accumulated data from analysis of swallowing performance in patients with different neurological diseases and conditions, along with results from neurophysiological studies of normal swallowing have gradually enhanced understanding of the role of cortical and subcortical neural structures in swallowing, potentially leading to the development of treatment modalities for patients suffering from dysphagia. This review article summarizes findings about the role of both cortical and subcortical neural structures in swallowing based on results from neurophysiological studies and studies of various neurological diseases. In sum, cortical regions are mainly in charge of initiation and coordination of swallowing after receiving afferent information, while subcortical structures including basal ganglia and thalamus are responsible for movement control and regulation during swallowing through the cortico-basal ganglia-thalamo-cortical loop. This article also presents how cortical and subcortical neural structures interact with each other to generate the swallowing response. In addition, we provided the updated evidence about the clinical applications and efficacy of neuromodulation techniques, including both non-invasive brain stimulation and deep brain stimulation on dysphagia.

Swallowing performance in older adults: Associated cognitive, neuroanatomical and demographic factors

BACKGROUND

Swallowing problems are frequently seen in older adults, especially in individuals with cognitive impairment (CI). The brain plays a crucial role in both cognition and swallowing. Using magnetic resonance imaging (MRI) data, researchers identified regions associated with swallowing. However, it is not yet fully elucidated which factors influence the swallowing performance in older adults.

OBJECTIVES

The current study investigated which factors, such as cognitive function, neuroanatomical factors (e.g., the cortical thickness and volume of specific brain regions) and demographical factors are associated with swallowing performance in older adults. Secondly, it was investigated whether there is a difference in neuroanatomical factors between individuals with and without CI.

RESEARCH DESIGN AND METHODS

In total, 15 CI individuals (73.1 ± 9.1 years; 46.7% male) and 48 non-CI controls (69.0 ± 5.1 years; 29.2% male) were included. The repetitive saliva swallowing test (RSST) was performed, and an MRI scan was acquired from the participants.

RESULTS

Multivariate linear regression analysis showed that the cortical thickness of the right supramarginal gyrus and female gender were positively associated, and a higher age was negatively associated with the RSST in older adults (p < .05). CI was not significantly associated with swallowing performance. Furthermore, it was found that the cortical volume differs more frequently between CI and non-CI than the cortical thickness.

CONCLUSION

A thinner cortex of the right supramarginal gyrus and being an older female are associated with poorer swallowing performance. Secondly, cortical volume was more often found to differ between CI and non-CI individuals than cortical thickness.

Biomechanical and Cortical Control of Tongue Movements During Chewing and Swallowing

Tongue function is vital for chewing and swallowing and lingual dysfunction is often associated with dysphagia. Better treatment of dysphagia depends on a better understanding of hyolingual morphology, biomechanics, and neural control in humans and animal models. Recent research has revealed significant variation among animal models in morphology of the hyoid chain and suprahyoid muscles which may be associated with variation in swallowing mechanisms. The recent deployment of XROMM (X-ray Reconstruction of Moving Morphology) to quantify 3D hyolingual kinematics has revealed new details on flexion and roll of the tongue during chewing in animal models, movements similar to those used by humans. XROMM-based studies of swallowing in macaques have falsified traditional hypotheses of mechanisms of tongue base retraction during swallowing, and literature review suggests that other animal models may employ a diversity of mechanisms of tongue base retraction. There is variation among animal models in distribution of hyolingual proprioceptors but how that might be related to lingual mechanics is unknown. In macaque monkeys, tongue kinematics-shape and movement-are strongly encoded in neural activity in orofacial primary motor cortex, giving optimism for development of brain-machine interfaces for assisting recovery of lingual function after stroke. However, more research on hyolingual biomechanics and control is needed for technologies interfacing the nervous system with the hyolingual apparatus to become a reality.

Drooling disrupts the brain functional connectivity network in Parkinson's disease

AIMS

This study aimed to investigate the causal interaction between significant sensorimotor network (SMN) regions and other brain regions in Parkinson's disease patients with drooling (droolers).

METHODS

Twenty-one droolers, 22 PD patients without drooling (non-droolers), and 22 matched healthy controls underwent 3T-MRI resting-state scans. We performed independent component analysis and Granger causality analysis to determine whether significant SMN regions help predict other brain areas. Pearson's correlation was computed between imaging characteristics and clinical characteristics. ROC curves were plotted to assess the diagnostic performance of effective connectivity (EC).

RESULTS

Compared with non-droolers and healthy controls, droolers showed abnormal EC of the right caudate nucleus (CAU.R) and right postcentral gyrus to extensive brain regions. In droolers, increased EC from the CAU.R to the right middle temporal gyrus was positively correlated with MDS-UPDRS, MDS-UPDRS II, NMSS, and HAMD scores; increased EC from the right inferior parietal lobe to CAU.R was positively correlated with MDS-UPDRS score. ROC curve analysis showed that these abnormal ECs are of great significance in diagnosing drooling in PD.

CONCLUSION

This study identified that PD patients with drooling have abnormal EC in the cortico-limbic-striatal-cerebellar and cortio-cortical networks, which could be potential biomarkers for drooling in PD.

The effects of intermittent theta burst stimulation of the unilateral cerebellar hemisphere on swallowing-related brain regions in healthy subjects

Objective

We aimed to investigate the effects and mechanisms of swallowing-related brain regions using resting-state functional magnetic resonance imaging (rs-fMRI) in healthy subjects who underwent intermittent theta burst stimulation (iTBS) on dominant or non-dominant cerebellar hemispheres.

Methods

Thirty-nine healthy subjects were randomized into three groups that completed different iTBS protocols (dominant cerebellum group, non-dominant cerebellum group and sham group). Before iTBS, the resting motor threshold (rMT) was measured by single-pulse transcranial magnetic stimulation (sTMS) on the cerebellar representation of the suprahyoid muscles, and the dominant cerebellar hemisphere for swallowing was determined. Forty-eight hours after elution, iTBS protocols were completed: in the dominant cerebellum group, iTBS was administered to the dominant cerebellar hemisphere, and the non-dominant cerebellar hemisphere was given sham stimulation; in the non-dominant cerebellum group, iTBS was administered to the non-dominant cerebellar hemisphere, and sham stimulation was delivered to the dominant cerebellar hemisphere; in the sham group, sham stimulation was applied to the cerebellum bilaterally. Rs-fMRI was performed before and after iTBS stimulation to observe changes in the fractional amplitude of low-frequency fluctuation (fALFF) in the whole brain.

Results

Compared with baseline, the dominant cerebellum group showed increased fALFF in the ipsilateral cerebellum, and decreased fALFF in the ipsilateral middle temporal gyrus and contralateral precuneus after iTBS; the iTBS of the non-dominant cerebellum group induced increased fALFF in the ipsilateral superior frontal gyrus, the calcarine fissure and the surrounding cortex, and the contralateral inferior parietal lobule; and in the sham group, there was no significant difference in fALFF. Exploring the effects induced by iTBS among groups, the dominant cerebellum group showed decreased fALFF in the contralateral calcarine fissure, and surrounding cortex compared with the sham group.

Conclusion

Intermittent theta burst stimulation of the dominant cerebellar hemisphere for swallowing excited the ipsilateral cerebellum, and stimulation of the non-dominant cerebellar hemisphere increased the spontaneous neural activity of multiple cerebrocortical areas related to swallowing. In conclusion, regardless of which side of the cerebellum is stimulated, iTBS can facilitate part of the brain neural network related to swallowing. Our findings provide supporting evidence that cerebellar iTBS can be used as a potential method to modulate human swallowing movement.

Brain functional activity of swallowing: A meta-analysis of functional magnetic resonance imaging

BACKGROUND

Swallowing is one of the most important activities in our life and serves the dual roles of nutritional intake and eating enjoyment.

OBJECTIVE

The study aimed to conduct a meta-analysis to investigate the brain activity of swallowing.

METHODS

Studies of swallowing using functional magnetic resonance imaging were reviewed in PubMed, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP) and Wan Fang before 30 November 2021. Two authors analysed the studies for eligibility criteria. The final inclusion of studies was decided by consensus. An activation likelihood estimation (ALE) meta-analysis of these studies was performed with GingerALE, including 16 studies.

RESULTS

For swallowing, clusters with high activation likelihood were found in the bilateral insula, bilateral pre-central gyrus, bilateral post-central gyrus, left transverse temporal gyrus, right medial front gyrus, bilateral inferior frontal gyrus and bilateral cingulate gyrus. For water swallowing, clusters with high activation likelihood were found in the bilateral inferior frontal gyrus and the left pre-central gyrus. For saliva swallowing, clusters with high activation likelihood were found in the bilateral cingulate gyrus, bilateral pre-central gyrus, left post-central gyrus and left transverse gyrus.

CONCLUSION

This meta-analysis reflects that swallowing is regulated by both sensory and motor cortex, and saliva swallowing activates more brain areas than water swallowing, which would promote our knowledge of swallowing and provide some direction for clinical and other research.

The Effect of Swallowing Action Observation Therapy on Resting fMRI in Stroke Patients with Dysphagia

Objective

Many stroke victims have severe swallowing problems. Previous neuroimaging studies have found that several brain regions scattered in the frontal, temporal, and parietal lobes, such as Brodmann's areas (BA) 6, 21, and 40, are associated with swallowing function. This study sought to investigate changes in swallowing function and resting-state functional magnetic resonance imaging (rs-fMRI) in stroke patients with dysphagia following action observation treatment. It also sought to detect changes in brain regions associated with swallowing in stroke patients.

Methods

In this study, 12 healthy controls (HCs) and 12 stroke patients were recruited. Stroke patients were given 4 weeks of action observation therapy. In order to assess the differences in mfALFF values between patients before treatment and HCs, the fractional amplitude of low-frequency fluctuations (fALFF) in three frequency bands (conventional frequency band, slow-4, and slow-5) were calculated for fMRI data. The significant brain regions were selected as regions of interest (ROIs) for subsequent analysis. The mfALFF values were extracted from ROIs of the three groups (patients before and after treatment and HCs) and compared to assess the therapeutic efficacy.

Results

In the conventional band, stroke patients before treatment had higher mfALFF in the inferior temporal gyrus and lower mfALFF in the calcarine fissure and surrounding cortex and thalamus compared to HCs. In the slow-4 band, there was no significant difference in related brain regions between stroke patients before treatment and HCs. In the slow-5 band, stroke patients before treatment had higher mfALFF in inferior cerebellum, inferior temporal gyrus, middle frontal gyrus, and lower mfALFF in calcarine fissure and surrounding cortex compared to HCs. We also assessed changes in aberrant brain activity that occurred both before and after action observation therapy. The mfALFF between stroke patients after therapy was closed to HCs in comparison to the patients before treatment.

Conclusion

Action observation therapy can affect the excitability of certain brain regions. The changes in brain function brought about by this treatment may help to further understand the potential mechanism of network remodeling of swallowing function.

Cortical Activation of Swallowing Using fNIRS: A Proof of Concept Study with Healthy Adults

The purpose of this study was to determine whether functional near-infrared spectroscopy (fNIRS) could reliably identify cortical activation patterns as healthy adults engaged in single sip and continuous swallowing tasks. Thirty-three right-handed adults completed two functional swallowing tasks, one control jaw movement task, and one rest task while being imaged with fNIRS. Swallowing tasks included a single sip of 5 mL of water via syringe and continuous straw drinking. fNIRS patches for acquisition of neuroimaging data were placed parallel over left and right hemispheres. Stimuli presentation was controlled with set time intervals and audio instructions. Using a series of linear mixed effect models, results demonstrated clear cortical activation patterns during swallowing. The continuous swallowing task demonstrated significant differences in blood oxygenation and deoxygenation concentration values across nearly all regions examined, but most notably M1 in both hemispheres. Of note is that there were areas of greater activation, particularly on the right hemisphere, when comparing the single sip swallow to the jaw movement control and rest tasks. Results from the current study support the use of fNIRS during investigation of swallowing. The utilization of healthy adults as a method for acquiring normative data is vital for comparison purposes when investigating individuals with disorders, but also in the development of rehabilitation techniques. Identifying activation areas that pertain to swallowing will have important implications for individuals requiring dysphagia therapy.

Electrophysiological Measures of Swallowing Functions: A Systematic Review

The purpose of this systematic review was to examine the application of event-related potentials (ERPs) to investigate neural processes of swallowing functions in adults with and without dysphagia. Computerized literature searches were performed from three search engines. Studies were screened using Covidence (Cochrane tool) and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards (PRISMA-2009). A total of 759 studies were initially retrieved, of which 12 studies met inclusion criteria. Electrophysiological measures assessing swallowing functions were identified in two major ERP categories: (1) sensory potentials and (2) pre-motor potentials. Approximately 80% of eligible studies demonstrated strong methodological quality, although most employed a case series or case-control study design. Pharyngeal sensory-evoked potentials (PSEPs) were used to assess pharyngeal afferent cortical processing. The temporal sequence of the PSEP waveforms varied based on the sensory stimuli. PSEPs were delayed with localized scalp maps in patients with dysphagia as compared to healthy controls. The pre-motor ERPs assessed the cortical substrates involved in motor planning for swallowing, with the following major neural substrates identified: pre-motor cortex, supplementary motor area, and primary sensorimotor cortex. The pre-motor ERPs differed in amplitude for the swallow task (saliva versus liquid swallow), and the neural networks differed for cued versus non-cued task of swallowing suggesting differences in cognitive processes. This systematic review describes the application of electrophysiological measures to assess swallowing function and the promising application for furthering understanding of the neural substrates of swallowing. Standardization of protocols for use of electrophysiological measures to examine swallowing would allow for aggregation of study data to inform clinical practice for dysphagia rehabilitation.

Cerebral control of swallowing: An update on neurobehavioral evidence

This review aims to update the current knowledge on the cerebral control of swallowing. We review data from both animal and human studies spanning across the fields of neuroanatomy, neurophysiology and neuroimaging to evaluate advancements in our understanding in the brain's role in swallowing. Studies have collectively shown that swallowing is mediated by multiple distinct cortical and subcortical regions and that lesions to these regions can result in dysphagia. These regions are functionally connected in separate groups within and between the two hemispheres. While hemispheric dominance for swallowing has been reported in most human studies, the laterality is inconsistent across individuals. Moreover, there is a shift in activation location and laterality between swallowing preparation and execution, although such activation changes are less well-defined than that for limb motor control. Finally, we discussed recent neurostimulation treatments that may be beneficial for dysphagia after brain injury through promoting the reorganization of the swallowing neural network.

Altered Brain Function Activity in Patients With Dysphagia After Cerebral Infarction: A Resting-State Functional Magnetic Resonance Imaging Study

Objective

Dysphagia after cerebral infarction (DYS) has been detected in several brain regions through resting-state functional magnetic resonance imaging (rs-fMRI). In this study, we used two rs-fMRI measures to investigate the changes in brain function activity in DYS and their correlations with dysphagia severity.

Method

In this study, a total of 22 patients with DYS were compared with 30 patients without dysphagia (non-DYS) and matched for baseline characteristics. Then, rs-fMRI scans were performed in both groups, and regional homogeneity (ReHo) and fractional amplitude of low-frequency fluctuation (fALFF) values were calculated in both groups. The two-sample t-test was used to compare ReHo and fALFF between the groups. Pearson's correlation analysis was used to determine the correlations between the ReHo and fALFF of the abnormal brain regions and the scores of the Functional Oral Intake Scale (FOIS), the Standardized Bedside Swallowing Assessment (SSA), the Videofluoroscopic Swallowing Study (VFSS), and the Penetration-Aspiration Scale (PAS).

Results

Compared with the non-DYS group, the DYS group showed decreased ReHo values in the left thalamus, the left parietal lobe, and the right temporal lobe and significantly decreased fALFF values in the right middle temporal gyrus and the inferior parietal lobule. In the DYS group, the ReHo of the right temporal lobe was positively correlated with the SSA score and the PAS score (r = 0.704, p < 0.001 and r = 0.707, p < 0.001, respectively) but negatively correlated with the VFSS score (r = −0.741, p < 0.001). The ReHo of the left parietal lobe was positively correlated with SSA and PAS (r = 0.621, p = 0.002 and r = 0.682, p < 0.001, respectively) but negatively correlated with VFSS (r = −0.679, p = 0.001).

Conclusion

The changes in the brain function activity of these regions are related to dysphagia severity. The DYS group with high ReHo values in the right temporal and left parietal lobes had severe dysphagia.

Comparing amplitudes of transcranial direct current stimulation (tDCS) to the sensorimotor cortex during swallowing

PURPOSE

Transcranial direct current stimulation (tDCS) can alter cortical excitability, making it a useful tool for promoting neuroplasticity in dysphagia rehabilitation. Clinical trials show functional improvements in swallowing following anodal tDCS despite varying dosing parameters and outcomes. The aim of the current study was to determine the most effective amplitude criterion (e.g., 0 mA [sham/control], 1 mA, 2 mA) of anodal tDCS for upregulating the swallowing sensorimotor cortex.

METHOD

As a novel paradigm, tDCS, functional near-infrared spectroscopy (fNIRS), and surface electromyography (sEMG) were simultaneously administered while participants completed a swallowing task. This allowed for measurement of the cortical hemodynamic response and submental muscle contraction before, during, and after tDCS. At the conclusion of the study, participants were asked to rate their level of discomfort associated with tDCS using a visual analog scale.

RESULTS

There was no significant difference in the hemodynamic response by time or amplitude. However, post-hoc analyses indicated that in the post-stimulation period, changes to the hemodynamic response in the left (stimulated) hemisphere were significantly different for the groups receiving 1 mA and 2 mA of tDCS compared to baseline. Participants receiving 1 mA of tDCS demonstrated reduced hemodynamic response. There was no significant difference in submental muscle contraction during or after tDCS regardless of amplitude. Anodal tDCS was well tolerated in healthy adults with no difference among participant discomfort scores across tDCS amplitude.

CONCLUSIONS

During a swallowing task, healthy volunteers receiving 1 mA of anodal tDCS demonstrated a suppressed hemodynamic response during and after stimulation whereas those receiving 2 mA of anodal tDCS had an increase in the hemodynamic response. tDCS remains a promising tool in dysphagia rehabilitation, but dosing parameters require further clarification.

The Alteration of Brain Function by the Improvement of Periodontal Tissues and Occlusal State

Objective

In this study, we have introduced a case in which the effective blood oxygenation level-dependent signal on functional magnetic resonance imaging (fMRI) was altered by the improvement of periodontal tissue and occlusal function in a patient with periodontitis Stage II Grade B. Material and Methods. A 61-year-old female patient requiring periodontal treatment was diagnosed as having periodontitis Stage II Grade B via clinical and radiographic examinations. Her past medical history included type 2 diabetes, hypertension, and hyperlipidemia. Following the patient's informed written consent, the periodontal initial treatment provided to the patient included tooth brushing instruction and scaling and root planing; however, occlusal adjustment was not performed at this stage. Occlusal force and fMRI results were also evaluated at the initial and reevaluation examinations.

Results

After the periodontal initial treatment had been performed, it was noted that the patient's periodontal tissue and occlusal force had improved. It was also evident from fMRI that cerebral blood flow had been activated in the insula, primary motor cortex, and premotor cortex.

Conclusion

This result suggested that the periodontal ligament had recovered and the periodontal ligament neuron had been further subjected to clenching in the insula so that the muscle spindle sensation impacted the motor cortex.

Heart rate and heart rate variability in patients with chronic inflammatory joint disease: the role of pain duration and the insular cortex

Background

Chronic inflammatory joint diseases (CIJD) have been linked to increased cardiovascular morbidity and mortality. A decisive reason could be a dysregulation of the autonomic nervous system, which is responsible for the control of cardiovascular function. So far, the cause of changes in autonomic nervous system functions remains elusive. In this study, we investigate the role of chronic pain and the insular cortex in autonomic control of cardiac functioning in patients with CIJD.

Methods

We studied the autonomic nervous system through the assessment of heart rate and heart rate variability (HRV) at rest and under cognitive stimulation. Furthermore, we investigated insular cortex volume by performing surface-based brain morphometry with FreeSurfer. For this study, 47 participants were recruited, 22 individual age- and sex-matched pairs for the magnetic resonance imaging analyses and 14 for the HRV analyses. All available patients’ data were used for analysis.

Results

Pain duration was negatively correlated with the resting heart rate in patients with chronic inflammatory joint diseases (n = 20). In a multiple linear regression model including only CIJD patients with heart rate at rest as a dependent variable, we found a significant positive relationship between heart rate at rest and the volume of the left insular cortex and a significant negative relationship between heart rate at rest and the volume of the right insular cortex. However, we found no significant differences in HRV parameters or insular cortex volumes between both groups.

Conclusions

In this study we provide evidence to suggest insular cortex involvement in the process of ANS changes due to chronic pain in CIJD patients.

The study was preregistered with the German Clinical Trials Register (https://www.drks.de; DRKS00012791; date of registration: 28 July 2017).

Fabrication of Skin-Mountable Flexible Sensor Patch for Monitoring of Swallowing Function

Swallowing is a critical function that enables humans to sustain life. When swallowing is compromised, the consequences can be devastating and include malnutrition, dehydration, respiratory compromise, and even death. Swallowing disorders (i.e., dysphagia) are very common in many disorders and diseases, such as stroke, ALS, Parkinson disease, and more, and in fact millions of people across the world are diagnosed with oropharyngeal swallowing disorders every year. Current rehabilitative interventions for dysphagia can be effective, but require daily performance of swallowing exercises that primarily rely on expensive biofeedback devices (e.g., oral manometers, electromyographic (EMG) devices, and endoscopic devices). These types of devices are often only available in medical facilities. However, it is not feasible or economically viable for patients to make multiple visits per day or week to a clinic to receive intensive treatment, especially given mobility limitations that many affected patients often experience. This can reduce treatment adherence and result in decreased rehabilitation potential, re-hospitalizations, and increased healthcare costs. To address this gap, we designed a novel specialized portable skin-mounted flexible sensor system that allows remote signal acquisition of swallowing-related signals. Herein, we report technical details for the fabrication of the skin-mounted flexible sensor patch that is tailored for the human submental (under the chin) area, enabling the continuous, reliable monitoring of both muscles' activity (i.e., EMG signals) and laryngeal movements during swallowing events. The sensor patch is wired to a portable reusable wireless (Bluetooth) unit compatible with smart watches, phones, and tablets for post-data analysis and reporting through a cloud server, which would potentially enable telemonitoring of patients with dysphagia.

Altered Gesture Imitation and Brain Anatomy in Adult Prader-Willi Syndrome Patients

OBJECTIVE

To explore motor praxis in adults with Prader-Willi syndrome (PWS) in comparison with a control group of people with intellectual disability (ID) and to examine the relationship with brain structural measurements.

METHOD

Thirty adult participants with PWS and 132 with ID of nongenetic etiology (matched by age, sex, and ID level) were assessed using a comprehensive evaluation of the praxis function, which included pantomime of tool use, imitation of meaningful and meaningless gestures, motor sequencing, and constructional praxis.

RESULTS

Results support specific praxis difficulties in PWS, with worse performance in the imitation of motor actions and better performance in constructional praxis than ID peers. Compared with both control groups, PWS showed increased gray matter volume in sensorimotor and subcortical regions. However, we found no obvious association between these alterations and praxis performance. Instead, praxis scores correlated with regional volume measures in distributed apparently normal brain areas.

CONCLUSIONS

Our findings are consistent in showing significant impairment in gesture imitation abilities in PWS and, otherwise, further indicate that the visuospatial praxis domain is relatively preserved. Praxis disability in PWS was not associated with a specific, focal alteration of brain anatomy. Altered imitation gestures could, therefore, be a consequence of widespread brain dysfunction. However, the specific contribution of key brain structures (e.g., areas containing mirror neurons) should be more finely tested in future research.

Comparison of Oropharyngeal Dysphagia in Brazilian Children with Prenatal Exposure to Zika Virus, With and Without Microcephaly

Severe brain damage associated with Zika-related microcephaly (ZRM) have been reported to result in oropharyngeal dysphagia (OPD); however, it is unknown if OPD presents in children with prenatal Zika virus (ZIKV) exposure but only mild or undetectable abnormalities. The aims of this study were: to compare the frequency and characteristics of OPD in children with ZRM and in children without microcephaly born to mothers who tested polymerase chain reaction positive (PCR+) for ZIKV during pregnancy; and to investigate the concordance of caregiver reports of OPD with the diagnosis from the clinical swallowing assessment (CSA). Between Mar/2017 and May/2018, we evaluated 116 children (n = 58 with microcephaly, n = 58 children without microcephaly born to ZIKV PCR + mothers) participating in the Microcephaly Epidemic Research Group (MERG) cohort of children born during the 2015-2016 ZIKV epidemic in Pernambuco, Brazil. To assess OPD we used: a CSA; a clinical assessment of the stomatognathic system; and a questionnaire administered to caregivers. The frequency of OPD was markedly higher in children with ZRM (79.3%) than in the exposed but normocephalic group (8.6%). The children with microcephaly also presented more frequently with anatomic and functional abnormalities in the stomatognathic system. There was a high degree of agreement between the caregiver reports of OPD and the CSA (κ = 0.92). In conclusion, our findings confirm that OPD is a feature of Congenital Zika Syndrome that primarily occurs in children with microcephaly and provide support for policies in which children are referred for rehabilitation with an OPD diagnosis based on caregiver report.

Functional MRI of Native and Non-native Speech Sound Production in Sequential German-English Bilinguals

Bilingualism and multilingualism are highly prevalent. Non-invasive brain imaging has been used to study the neural correlates of native and non-native speech and language production, mainly on the lexical and syntactic level. Here, we acquired continuous fast event-related FMRI during visually cued overt production of exclusively German and English vowels and syllables. We analyzed data from 13 university students, native speakers of German and sequential English bilinguals. The production of non-native English sounds was associated with increased activity of the left primary sensorimotor cortex, bilateral cerebellar hemispheres (lobule VI), left inferior frontal gyrus, and left anterior insula compared to native German sounds. The contrast German > English sounds was not statistically significant. Our results emphasize that the production of non-native speech requires additional neural resources already on a basic phonological level in sequential bilinguals.

Validation of the munich swallowing score (mucss) in patients with neurogenic dysphagia: A preliminary study

BACKGROUND

The Munich Swallowing Score (MUCSS) is a clinician rated scale for the assessment of the functional level of swallowing saliva/secretions, food and liquids. The MUCSS consists of two eight-point subscales, MUCSS-Saliva and MUCSS-Nutrition. In a previous article, content validity and interrater reliability were described.

OBJECTIVE

The aim of the present study was to investigate criterion validity and sensitivity to change of the MUCSS.

METHODS

The research was conducted at a tertiary care academic hospital. Data were collected retrospectively in a cohort of 100 acute and subacute neurologic patients. Criterion validity was judged by comparison to the Gugging Swallowing Screen (GUSS), the Barthel Index (BI), Early Rehabilitation Barthel Index (ERI), Extended Barthel Index (EBI) and also by comparison to three physiological scales drawn from FEES videos: The Penetration - Aspiration Scale (PAS), the Yale Pharyngeal Residue Severity Rating Scale (YPR) and the Murray Secretion Scale (MSS). Changes in oral intake and saliva swallowing were followed up for three months.

RESULTS

Between MUCSS and scores directly reflecting dysphagic symptoms (GUSS, PAS, YPR, MSS, ERI), strong to moderate correlations were found, weaker but statistically significant associations were seen with global measures of disability (BI isolated, EBI-subscale cognitive functions). MUCSS was sensitive to positive change of saliva swallowing and oral intake during the recovery period.

CONCLUSIONS

These preliminary data suggest that the MUCCS is a valid scale and may be appropriate for documenting clinical change in swallowing abilities of patients with neurogenic dysphagia.

Swallowing-related neural oscillation: an intracranial EEG study

OBJECTIVE

Swallowing is a unique movement due to the indispensable orchestration of voluntary and involuntary movements. The transition from voluntary to involuntary swallowing is executed within milliseconds. We hypothesized that the underlying neural mechanism of swallowing would be revealed by high-frequency cortical activities.

METHODS

Eight epileptic participants fitted with intracranial electrodes over the orofacial cortex were asked to swallow a water bolus and cortical oscillatory changes, including the high γ band (75-150 Hz) and β band (13-30 Hz), were investigated at the time of mouth opening, water injection, and swallowing.

RESULTS

Increases in high γ power associated with mouth opening were observed in the ventrolateral prefrontal cortex (VLPFC) with water injection in the lateral central sulcus and with swallowing in the region along the Sylvian fissure. Mouth opening induced a decrease in β power, which continued until the completion of swallowing. The high γ burst of activity was focal and specific to swallowing; however, the β activities were extensive and not specific to swallowing. In the interim between voluntary and involuntary swallowing, swallowing-related high γ power achieved its peak, and subsequently, the power decreased.

INTERPRETATION

We demonstrated three distinct activities related to mouth opening, water injection, and swallowing induced at different timings using high γ activities. The peak of high γ power related to swallowing suggests that during voluntary swallowing phases, the cortex is the main driving force for swallowing as opposed to the brain stem.

Repetitive Transcranial Magnetic Stimulation on the Supplementary Motor Area Changes Brain Connectivity in Functional Dysphagia

Background: Previous studies arguing that functional dysphagia could be explained by underlying neurobiological mechanisms are insufficient to explain brain regions that functionally interact in patients with functional dysphagia. Therefore, we investigated functional connectivity changes associated with functional dysphagia after applying facilitatory repetitive transcranial magnetic stimulation (rTMS) on the supplementary motor area (SMA). Materials and Methods: A patient with severe long-lasting functional dysphagia and 15 healthy controls participated in this study. A facilitatory 5 Hz rTMS protocol was applied to the patient's SMA. We performed functional magnetic resonance imaging (fMRI) using volitional swallowing tasks to investigate neural network changes before rTMS (pre-rTMS), immediately after rTMS, and 3 months later. Results: The pre-rTMS fMRI results of the patient showed extensive overactivation in the left-lateralized regions related to volitional swallowing compared with the healthy controls. Following rTMS, dysphagia symptoms partially improved. The patient showed positive connectivity with the bilateral cerebellum in the bilateral SMA seeds before rTMS treatment. Furthermore, left-lateralized overactivation was washed out immediately after completion of rTMS, and connectivity between the left SMA and left precentral gyrus recovered 3 months after rTMS treatment. Conclusion: Our findings confirm that functional dysphagia might be a neurobiological manifestation caused by maladaptive functional connectivity changes in brain structures related to swallowing. Furthermore, noninvasive brain modulation with rTMS over the SMA may facilitate functional connectivity changes between the cortical and subcortical regions. Accordingly, these changes will allow control of the movements related to swallowing and may lead to improved clinical symptoms.

Brainstem Encephalitis Caused by Listeria monocytogenes

International outbreaks of listerial infections have become more frequent in recent years. Listeria monocytogenes, which usually contaminates food, can cause potentially fatal infections. Listerial cerebritis is a rare disease that is encountered mostly in immunocompromised or elderly patients. However, listerial brainstem encephalitis (mesenrhombencephalitis or rhombencephalitis) is found in persons who were formerly in good health, and recognizing this disease, particularly at its early stages, is challenging. Listerial brainstem encephalitis has high mortality, and serious sequelae are frequently reported in survivors. Early recognition and correct diagnosis, as well as the timely use of appropriate antibiotics, can reduce the severity of listerial infections. The trigeminal nerve is proposed as a pathway through which L. monocytogenes reaches the brainstem after entering damaged oropharyngeal mucosa or periodontal tissues. This review introduces the clinical manifestations, pathology, magnetic resonance imaging (MRI) findings, diagnosis, and treatment of listerial brainstem encephalitis. Moreover, it proposes that L. monocytogenes may also invade the brainstem along the vagus nerve after it infects enteric neurons in the walls of the gastrointestinal tract.

Targeting Chemosensory Ion Channels in Peripheral Swallowing-Related Regions for the Management of Oropharyngeal Dysphagia

Oropharyngeal dysphagia, or difficulty in swallowing, is a major health problem that can lead to serious complications, such as pulmonary aspiration, malnutrition, dehydration, and pneumonia. The current clinical management of oropharyngeal dysphagia mainly focuses on compensatory strategies and swallowing exercises/maneuvers; however, studies have suggested their limited effectiveness for recovering swallowing physiology and for promoting neuroplasticity in swallowing-related neuronal networks. Several new and innovative strategies based on neurostimulation in peripheral and cortical swallowing-related regions have been investigated, and appear promising for the management of oropharyngeal dysphagia. The peripheral chemical neurostimulation strategy is one of the innovative strategies, and targets chemosensory ion channels expressed in peripheral swallowing-related regions. A considerable number of animal and human studies, including randomized clinical trials in patients with oropharyngeal dysphagia, have reported improvements in the efficacy, safety, and physiology of swallowing using this strategy. There is also evidence that neuroplasticity is promoted in swallowing-related neuronal networks with this strategy. The targeting of chemosensory ion channels in peripheral swallowing-related regions may therefore be a promising pharmacological treatment strategy for the management of oropharyngeal dysphagia. In this review, we focus on this strategy, including its possible neurophysiological and molecular mechanisms.

Comparison of Activation Patterns in Mirror Neurons and the Swallowing Network During Action Observation and Execution: A Task-Based fMRI Study

BACKGROUND

Observation of a goal-directed motor action can excite the respective mirror neurons, and this is the theoretical basis for action observation (AO) as a novel tool for functional recovery during stroke rehabilitation. To explore the therapeutic potential of AO for dysphagia, we conducted a task-based functional magnetic resonance imaging (fMRI) study to identify the brain areas activated during observation and execution of swallowing in healthy participants.

METHODS

Twenty-nine healthy volunteers viewed the following stimuli during fMRI scanning: an action-video of swallowing (condition 1, defined as AO), a neutral image with a Chinese word for "watching" (condition 2), and a neutral image with a Chinese word for "swallowing" (condition 3). Action execution (AE) was defined as condition 3 minus condition 2. One-sample t-tests were performed to define the brain regions activated during AO and AE.

RESULTS

Many brain regions were activated during AO, including the middle temporal gyrus, inferior frontal gyrus, pre- and postcentral gyrus, supplementary motor area, hippocampus, brainstem, and pons. AE resulted in activation of motor areas as well as other brain areas, including the inferior parietal lobule, vermis, middle frontal gyrus, and middle temporal gyrus. Two brain areas, BA6 and BA21, were activated with both AO and AE.

CONCLUSION

The left supplementary motor area (BA6) and left middle temporal gyrus (BA21), which contains mirror neurons, were activated in both AO and AE of swallowing. In this study, AO activated mirror neurons and the swallowing network in healthy participants, supporting its potential value in the treatment of dysphagia.

Brain Network Underlying Executive Functions in Gambling and Alcohol Use Disorders: An Activation Likelihood Estimation Meta-Analysis of fMRI Studies

BACKGROUND

Neuroimaging and neuropsychological studies have suggested that common features characterize both Gambling Disorder (GD) and Alcohol Use Disorder (AUD), but these conditions have rarely been compared.

METHODS

We provide evidence for the similarities and differences between GD and AUD in neural correlates of executive functions by performing an activation likelihood estimation meta-analysis of 34 functional magnetic resonance imaging studies involving executive function processes in individuals diagnosed with GD and AUD and healthy controls (HC).

RESULTS

GD showed greater bilateral clusters of activation compared with HC, mainly located in the head and body of the caudate, right middle frontal gyrus, right putamen, and hypothalamus. Differently, AUD showed enhanced activation compared with HC in the right lentiform nucleus, right middle frontal gyrus, and the precuneus; it also showed clusters of deactivation in the bilateral middle frontal gyrus, left middle cingulate cortex, and inferior portion of the left putamen.

CONCLUSIONS

Going beyond the limitations of a single study approach, these findings provide evidence, for the first time, that both disorders are associated with specific neural alterations in the neural network for executive functions.

Regional brain responses associated with using imagination to evoke and satiate thirst

In response to dehydration, humans experience thirst. This subjective state is fundamental to survival as it motivates drinking, which subsequently corrects the fluid deficit. To elicit thirst, previous studies have manipulated blood chemistry to produce a physiological thirst stimulus. In the present study, we investigated whether a physiological stimulus is indeed required for thirst to be experienced. Functional MRI (fMRI) was used to scan fully hydrated participants while they imagined a state of intense thirst and while they imagined drinking to satiate thirst. Subjective ratings of thirst were significantly higher for imagining thirst compared with imagining drinking or baseline, revealing a successful dissociation of thirst from underlying physiology. The imagine thirst condition activated brain regions similar to those reported in previous studies of physiologically evoked thirst, including the anterior midcingulate cortex (aMCC), anterior insula, precentral gyrus, inferior frontal gyrus, middle frontal gyrus, and operculum, indicating a similar neural network underlies both imagined thirst and physiologically evoked thirst. Analogous brain regions were also activated during imagined drinking, suggesting the neural representation of thirst contains a drinking-related component. Finally, the aMCC showed an increase in functional connectivity with the insula during imagined thirst relative to imagined drinking, implying functional connectivity between these two regions is needed before thirst can be experienced. As a result of these findings, this study provides important insight into how the neural representation of subjective thirst is generated and how it subsequently motivates drinking behavior.

Model-Based and Model-Free Analyses of the Neural Correlates of Tongue Movements

The tongue performs movements in all directions to subserve its diverse functions in chewing, swallowing, and speech production. Using task-based functional MRI in a group of 17 healthy young participants, we studied (1) potential differences in the cerebral control of frontal (protrusion), horizontal (side to side), and vertical (elevation) tongue movements and (2) inter-individual differences in tongue motor control. To investigate differences between different tongue movements, we performed voxel-wise multiple linear regressions. To investigate inter-individual differences, we applied a novel approach, spatio-temporal filtering of independent components. For this approach, individual functional data were decomposed into spatially independent components and corresponding time courses using independent component analysis. A temporal filter (correlation with the expected brain response) was used to identify independent components time-locked to the tongue motor tasks. A spatial filter (cross-correlation with established neurofunctional systems) was used to identify brain activity not time-locked to the tasks. Our results confirm the importance of an extended bilateral cortical and subcortical network for the control of tongue movements. Frontal (protrusion) tongue movements, highly overlearned movements related to speech production, showed less activity in the frontal and parietal lobes compared to horizontal (side to side) and vertical (elevation) movements and greater activity in the left frontal and temporal lobes compared to vertical movements (cluster-forming threshold of Z > 3.1, cluster significance threshold of p < 0.01, corrected for multiple comparisons). The investigation of inter-individual differences revealed a component representing the tongue primary sensorimotor cortex time-locked to the task in all participants. Using the spatial filter, we found the default mode network in 16 of 17 participants, the left fronto-parietal network in 16, the right fronto-parietal network in 8, and the executive control network in four participants (Pearson's r > 0.4 between neurofunctional systems and individual components). These results demonstrate that spatio-temporal filtering of independent components allows to identify individual brain activity related to a specific task and also structured spatiotemporal processes representing known neurofunctional systems on an individual basis. This novel approach may be useful for the assessment of individual patients and results may be related to individual clinical, behavioral, and genetic information.

Functional Adaptation of Oromotor Functions and Aging: A Focused Review of the Evidence From Brain Neuroimaging Research

“Practice makes perfect” is a principle widely applied when one is acquiring a new sensorimotor skill to cope with challenges from a new environment. In terms of oral healthcare, the traditional view holds that restoring decayed structures is one of the primary aims of treatment. This assumes that the patient’s oromotor functions would be recovered back to normal levels after the restoration. However, in older patients, such a structural–functional coupling after dental treatment shows a great degree of individual variations. For example, after prosthodontic treatment, some patients would adapt themselves quickly to the new dentures, while others would not. In this Focused Review, I argue that the functional aspects of adaptation—which would be predominantly associated with the brain mechanisms of cognitive processing and motor learning—play a critical role in the individual differences in the adaptive behaviors of oromotor functions. This thesis is critical to geriatric oral healthcare since the variation in the capacity of cognitive processing and motor learning is critically associated with aging. In this review, (a) the association between aging and the brain-stomatognathic axis will be introduced; (b) the brain mechanisms underlying the association between aging, compensatory behavior, and motor learning will be briefly summarized; (c) the neuroimaging evidence that suggests the role of cognitive processing and motor learning in oromotor functions will be summarized, and critically, the brain mechanisms underlying mastication and swallowing in older people will be discussed; and (d) based on the current knowledge, an experimental framework for investigating the association between aging and the functional adaptation of oromotor functions will be proposed. Finally, I will comment on the practical implications of this framework and postulate questions open for future research.

Flexible submental sensor patch with remote monitoring controls for management of oropharyngeal swallowing disorders

Successful rehabilitation of oropharyngeal swallowing disorders (i.e., dysphagia) requires frequent performance of head/neck exercises that primarily rely on expensive biofeedback devices, often only available in large medical centers. This directly affects treatment compliance and outcomes, and highlights the need to develop a portable and inexpensive remote monitoring system for the telerehabilitation of dysphagia. Here, we present the development and preliminarily validation of a skin-mountable sensor patch that can fit on the curvature of the submental (under the chin) area noninvasively and provide simultaneous remote monitoring of muscle activity and laryngeal movement during swallowing tasks and maneuvers. This sensor patch incorporates an optimal design that allows for the accurate recording of submental muscle activity during swallowing and is characterized by ease of use, accessibility, reusability, and cost-effectiveness. Preliminary studies on a patient with Parkinson's disease and dysphagia, and on a healthy control participant demonstrate the feasibility and effectiveness of this system.

Effects of Motor Imagery and Visual Neurofeedback on Activation in the Swallowing Network: A Real-Time fMRI Study

Motor imagery of movements is used as mental strategy in neurofeedback applications to gain voluntary control over activity in motor areas of the brain. In the present functional magnetic resonance imaging (fMRI) study, we first addressed the question whether motor imagery and execution of swallowing activate comparable brain areas, which has been already proven for hand and foot movements. Prior near-infrared spectroscopy (NIRS) studies provide evidence that this is the case in the outer layer of the cortex. With the present fMRI study, we want to expand these prior NIRS findings to the whole brain. Second, we used motor imagery of swallowing as mental strategy during visual neurofeedback to investigate whether one can learn to modulate voluntarily activity in brain regions, which are associated with active swallowing, using real-time fMRI. Eleven healthy adults performed one offline session, in which they executed swallowing movements and imagined swallowing on command during fMRI scanning. Based on this functional localizer task, we identified brain areas active during both tasks and defined individually regions for feedback. During the second session, participants performed two real-time fMRI neurofeedback runs (each run comprised 10 motor imagery trials), in which they should increase voluntarily the activity in the left precentral gyrus by means of motor imagery of swallowing while receiving visual feedback (the visual feedback depicted one's own fMRI signal changes in real-time). Motor execution and imagery of swallowing activated a comparable network of brain areas including the bilateral pre- and postcentral gyrus, inferior frontal gyrus, basal ganglia, insula, SMA, and the cerebellum compared to a resting condition. During neurofeedback training, participants were able to increase the activity in the feedback region (left lateral precentral gyrus) but also in other brain regions, which are generally active during swallowing, compared to the motor imagery offline task. Our results indicate that motor imagery of swallowing is an adequate mental strategy to activate the swallowing network of the whole brain, which might be useful for future treatments of swallowing disorders.

Which Factors Affect the Severity of Dysphagia in Lateral Medullary Infarction?

The purpose of this study was to identify factors associated with the severity of dysphagia after lateral medullary infarction (LMI). Patients with dysphagia after lateral medullary infarction who were admitted to a rehabilitation unit were included and divided into two groups (non-severe vs. severe). Severe dysphagia was defined as the condition showing decreased bilateral pharyngeal constriction without esophageal passage in a videofluoroscopic swallowing study that initially required enteral tube feeding. Their clinical data (age, sex, lesion side, duration of the illness, penetration-aspiration scale, functional oral intake scale, Modified Barthel index, National Institutes of Health Stroke Scale, and anatomical lesion on diffusion-weighted MRI) were compared to find differences between the two groups. Twelve patients had absence of esophageal passage among a total of 30 patients with dysphagia after LMI. Only anatomical lesion location and extent were significantly different between the two groups. The severe group showed posterolateral involvement in the upper and lower parts of the medulla. Otherwise, there were no significant differences between the two groups. The location and extent of involvement in the medulla were the most important factors associated with the severity of dysphagia after LMI.

The Effect of High-Frequency Repetitive Transcranial Magnetic Stimulation on Advancing Parkinson’s Disease With Dysphagia: Double Blind Randomized Clinical Trial

We investigate if rTMS has a therapeutic role in the treatment of dysphagia in patients with Parkinson’s disease (PD). Material and Methods. Thirty-three patients with PD and dysphagia were randomly classified with ratio 1:2 to receive sham or real rTMS (2000 pulses; 20 Hz; 90% resting motor threshold; 10 trains of 10 seconds with 25 seconds between each train) over the hand area of each motor cortex (5 minutes between hemispheres) for 10 days (5 days per week) followed by 5 booster sessions every month for 3 months. Assessments included the Unified Parkinson’s Disease Rating Scale part III (UPDRS), Instrumental Activities of Daily Living (IADL), and Arabic–Dysphagia Handicap Index (A-DHI) before, after the last session, and 3 months later. Video-fluoroscopy measures of pharyngeal transit time (PTT) and time to maximal hyoid elevation (H1-H2) were taken before and after the treatment sessions. Results. There were no significant differences between groups. There was a significant improvement on all rating scales (analysis of variance) after real rTMS with a significant time × group interaction. In particular, there was a significant and long-lasting (3 months) effect of time on all subitems of the A-DHI (functional, P = .0001; physical, P = .0001; emotional, P = .02) but not in the sham group. This was associated with significant improvement in H1-H2 ( P = .03) and PTT ( P = .01) during solid swallows in the real rTMS but not the sham group. Conclusion. Real rTMS improves dysphagia in PD as documented by A-DHI scores and by video-fluoroscopy.

Effect of individual food preferences on oscillatory brain activity

OBJECTIVES

During the anticipatory stage of swallowing, sensory stimuli related to food play an important role in the behavioral and neurophysiological aspects of swallowing. However, few studies have focused on the relationship between food preferences and oscillatory brain activity during the anticipatory stage of swallowing. Therefore, to clarify the effect of individual food preferences on oscillatory brain activity, we investigated the relationship between food preferences and oscillatory brain activity during the observation of food images.

METHODS

Here we examined this relationship using visual food stimuli and electroencephalography (EEG). Nineteen healthy participants were presented 150 images of food in a random order and asked to rate their subjective preference for that food on a 4-point scale ranging from 1 (don't want to eat) to 4 (want to eat). Oscillation analysis was performed using a Hilbert transformation for bandpass-filtered EEG signals.

RESULTS

The results showed that the oscillatory beta band power on C3 significantly decreased in response to favorite foods compared to disliked food.

CONCLUSION

This result suggests that food preferences may impact oscillatory brain activity related to swallowing during the anticipatory stage of swallowing. This finding may lead to the development of new swallowing rehabilitation techniques for patients with dysphagia by applying food preferences to modulate oscillatory brain activity.

The After-Effects of Theta Burst Stimulation Over the Cortex of the Suprahyoid Muscle on Regional Homogeneity in Healthy Subjects

Theta burst stimulation (TBS) is a powerful variant of repetitive transcranial magnetic stimulation (rTMS), making it potentially useful for the treatment of swallowing disorders. However, how dose TBS modulate human swallowing cortical excitability remains unclear. Here, we aim to measure the after-effects of spontaneous brain activity at resting-state using the regional homogeneity (ReHo) approach in healthy subjects who underwent different TBS protocols over the suprahyoid muscle cortex. Sixty healthy subjects (23.45 ± 2.73 years, 30 males) were randomized into three groups which completed different TBS protocols. The TMS coil was applied over the cortex of the suprahyoid muscles. Data of resting-state functional MRI (Rs-fMRI) of the subjects were acquired before and after TBS. The ReHo was compared across sessions [continuous TBS (cTBS), intermittent TBS (iTBS) and cTBS/iTBS] and runs (pre/post TBS). In the comparison between pre- and post-TBS, increased ReHo was observed in the right lingual gyrus and right precuneus and decreased ReHo in the left cingulate gyrus in the cTBS group. In the iTBS group, increased ReHo values were seen in the pre-/postcentral gyrus and cuneus, and decreased ReHo was observed in the left cerebellum, brainstem, bilateral temporal gyrus, insula and left inferior frontal gyrus. In the cTBS/iTBS group, increased ReHo was found in the precuneus and decreased ReHo in the right cerebellum posterior lobe, left anterior cerebellum lobe, and right inferior frontal gyrus. In the post-TBS inter-groups comparison, increased ReHo was seen in right middle occipital gyrus and decreased ReHo in right middle frontal gyrus and right postcentral gyrus (cTBS vs. cTBS/iTBS). Increased ReHo was shown in left inferior parietal lobule and left middle frontal gyrus (cTBS vs. iTBS). Increased ReHo was shown in right medial superior frontal gyrus and decreased ReHo in right cuneus (cTBS/iTBS vs. iTBS). Our findings indicate cTBS had no significant influence on ReHo in the primary sensorimotor cortex, iTBS facilitates an increased ReHo in the bilateral sensorimotor cortex and a decreased ReHo in multiple subcortical areas, and no reverse effect exhibits when iTBS followed the contralateral cTBS over the suprahyoid motor cortex. The results provide a novel insight into the neural mechanisms of TBS on swallowing cortex.

Clinical Effects and Differences in Neural Function Connectivity Revealed by MRI in Subacute Hemispheric and Brainstem Infarction Patients With Dysphagia After Swallowing Therapy

Background: Early detection and intervention for post-stroke dysphagia could reduce the incidence of pulmonary complications and mortality. The aims of this study were to investigate the benefits of swallowing therapy in swallowing function and brain neuro-plasticity and to explore the relationship between swallowing function recovery and neuroplasticity after swallowing therapy in cerebral and brainstem stroke patients with dysphagia.

Methods: We collected 17 subacute stroke patients with dysphagia (11 cerebral stroke patients with a median age of 76 years and 6 brainstem stroke patients with a median age of 70 years). Each patient received swallowing therapies during hospitalization. For each patient, functional oral intake scale (FOIS), functional dysphagia scale (FDS) and 8-point penetration-aspiration scale (PAS) in videofluoroscopy swallowing study (VFSS), and brain functional magnetic resonance imaging (fMRI) were evaluated before and after treatment.

Results: FOIS (p = 0.003 in hemispheric group and p = 0.039 in brainstem group) and FDS (p = 0.006 in hemispheric group and p = 0.028 in brainstem group) were both significantly improved after treatment in hemispheric and brainstem stroke patients. In hemispheric stroke patients, changes in FOIS were related to changes of functional brain connectivity in the ventral default mode network (vDMN) of the precuneus in brain functional MRI (fMRI). In brainstem stroke patients, changes in FOIS were related to changes of functional brain connectivity in the left sensorimotor network (LSMN) of the left postcentral region characterized by brain fMRI.

Conclusion: Both hemispheric and brainstem stroke patients with different swallowing difficulties showed improvements after swallowing training. For these two dysphagic stroke groups with corresponding etiologies, swallowing therapy could contribute to different functional neuroplasticity.

Effect of peripherally and cortically evoked swallows on jaw reflex responses in anesthetized rabbits

This study aimed to investigate whether the jaw-opening (JOR) and jaw-closing reflexes (JCR) are modulated during not only peripherally, but also centrally, evoked swallowing. Experiments were carried out on 24 adult male Japanese white rabbits. JORs were evoked by trigeminal stimulation at 1 Hz for 30 s. In the middle 10 s, either the superior laryngeal nerve (SLN) or cortical swallowing area (Cx) was simultaneously stimulated to evoke swallowing. The peak-to-peak JOR amplitude was reduced during the middle and late 10-s periods (i.e., during and after SLN or Cx stimulation), and the reduction was dependent on the current intensity of SLN/Cx stimulation: greater SLN/Cx stimulus current resulted in greater JOR inhibition. The reduction rate was significantly greater during Cx stimulation than during SLN stimulation. The amplitude returned to baseline 2 min after 10-s SLN/Cx stimulation. The effect of co-stimulation of SLN and Cx was significantly greater than that of SLN stimulation alone. There were no significant differences in any parameters of the JCR between conditions. These results clearly showed that JOR responses were significantly suppressed, not only during peripherally evoked swallowing but also during centrally evoked swallowing, and that the inhibitory effect is likely to be larger during centrally compared with peripherally evoked swallowing. The functional implications of these results are discussed.

Influence of anterior midcingulate cortex on drinking behavior during thirst and following satiation

This study provides important insight into how the human brain regulates fluid intake in response to changes in hydration status. The findings presented here reveal that activity in the anterior midcingulate cortex (aMCC) is associated with drinking responses during a state of thirst, and that this region is likely to contribute to the facilitation of drinking during this state. These results are consistent with a reduction in the influence of the aMCC contributing to the conclusion of drinking during a state of satiation. Because drinking stops before changes in blood volume and chemistry signal the restoration of fluid balance, these results implicate the aMCC in the regulation of drinking behavior before these changes manifest within the circulatory system.

In humans, activity in the anterior midcingulate cortex (aMCC) is associated with both subjective thirst and swallowing. This region is therefore likely to play a prominent role in the regulation of drinking in response to dehydration. Using functional MRI, we investigated this possibility during a period of “drinking behavior” represented by a conjunction of preswallow and swallowing events. These events were examined in the context of a thirsty condition and an “oversated” condition, the latter induced by compliant ingestion of excess fluid. Brain regions associated with swallowing showed increased activity for drinking behavior in the thirsty condition relative to the oversated condition. These regions included the cingulate cortex, premotor areas, primary sensorimotor cortices, the parietal operculum, and the supplementary motor area. Psychophysical interaction analyses revealed increased functional connectivity between the same regions and the aMCC during drinking behavior in the thirsty condition. Functional connectivity during drinking behavior was also greater for the thirsty condition relative to the oversated condition between the aMCC and two subcortical regions, the cerebellum and the rostroventral medulla, the latter containing nuclei responsible for the swallowing reflex. Finally, during drinking behavior in the oversated condition, ratings of swallowing effort showed a negative association with functional connectivity between the aMCC and two cortical regions, the sensorimotor cortex and the supramarginal gyrus. The results of this study provide evidence that the aMCC helps facilitate swallowing during a state of thirst and is therefore likely to contribute to the regulation of drinking after dehydration.

Pharyngeal electrical stimulation device for the treatment of neurogenic dysphagia: technology update

Neurogenic dysphagia (ND) can occur in patients with nervous system diseases of varying etiologies. Moreover, recovery from ND is not guaranteed. The therapeutic approaches for oropharyngeal ND have drastically changed over the last decade, mainly due to a better knowledge of the neurophysiology of swallowing along with the progress of neuroimaging and neurophysiological studies. For this reason, it is a priority to develop a treatment that is repeatable, safe, and can be carried out at the bedside as well as for outpatients. Pharyngeal electrical stimulation (PES) is a novel rehabilitation treatment for ND. PES is carried out via location-specific intraluminal catheters that are introduced transnasally and enable clinicians to stimulate the pharynx directly. This technique has demonstrated increasingly promising evidence in improving swallowing performance in patients with ND associated with stroke and multiple sclerosis, probably by increasing the corticobulbar excitability and inducing cortical reorganization of swallowing motor cortex. In this article, we update the reader as to both the physiologic background and past and current studies of PES in an effort to highlight the clinical progress of this important technique.

Alterations of the amplitude of low-frequency fluctuation in healthy subjects with theta-burst stimulation of the cortex of the suprahyoid muscles

Theta burst stimulation (TBS) has emerged as a promising tool for the treatment of swallowing disorders; however, the short-term after-effects of brain activation induced by TBS remain unknown. Here, we measured the changes in spontaneous brain activation using the amplitude of low-frequency fluctuation (ALFF) approach in subjects who underwent different TBS protocols. Sixty right-handed healthy participants (male, n=30; female, n=30; mean age=23.5y) were recruited in this study and randomly assigned to three groups that underwent three different TBS protocols. In group 1, continuous TBS (cTBS) was positioned on the left hemisphere of the suprahyoid muscle cortex. For group 2, intermittent TBS (iTBS) was placed on the left hemisphere of the suprahyoid muscle cortex. Group 3 underwent combined cTBS/iTBS protocols in which iTBS on the right hemisphere was performed immediately after completing cTBS on the left suprahyoid muscle cortex. Compared to pre-TBS, post-cTBS showed decreased ALFF in the anterior cingulate gyrus (BA 32); post-iTBS induced an increase in ALFF in the bilateral precuneus (BA 7); and post-cTBS/iTBS induced a decrease in ALFF in the brainstem, and resulted in increased ALFF in the middle cingulate gyrus (BA 24) as well as the left precentral gyrus (BA 6). Compared the effect of post-TBS protocols, increased ALFF was found in left posterior cerebellum lobe and left inferior parietal lobule (BA 40) (post-cTBS vs post-iTBS), and decreased ALFF exhibited in paracentral lobule (BA 4) (post-iTBS vs post-cTBS/iTBS). These findings indicate that multiple brain areas involved in swallowing regulation after stimulation of TBS over the suprahyoid muscles. cTBS induces decreased after-effects while iTBS results in increased after-effects on spontaneous brain activation. Moreover, iTBS can eliminate the after-effects of cTBS applied on the contralateral swallowing cortex and alter the activity of contralateral motor cortex and brainstem. Our findings provide a novel evidence for the short-term effect of TBS on spontaneous brain activation.