Dosages of swallowing exercises in stroke rehabilitation: a systematic review

A survey of dysphagia services practice in China

BACKGROUND

Dysphagia services have only recently been formalised within Chinese health services. There has been no comprehensive evaluation of all aspects of dysphagia services practice in China.

AIMS

To provide a profile for the dysphagia practice in China by assessing various facets of dysphagia services.

METHODS AND PROCEDURES

This is a survey study carried out from December 2022 to May 2023 online in China. One hundred fifty-nine respondents comprising doctors, nurses or therapists involved in the field of dysphagia rehabilitation completed a questionnaire via Sojump. The questionnaire included dichotomous (e.g., yes/no) and multiple-choice questions related to participants' general information and their provision of dysphagia management services. Results were analysed descriptively and the differences among different levels of hospitals were analysed.

OUTCOMES AND RESULTS

Approximately two-thirds of hospitals (67.9%) started dysphagia services within the last 5 years. A significant difference in the initiation of dysphagia rehabilitation was observed across different hospital levels (χ2  = 32.70;p < 0.001). Routine dysphagia screening was a standard practice in most hospitals (71.7%), with the most frequently employed screening method being the water swallow test (95.6%). Clinical swallowing evaluation emerged as the preferred initial assessment method (80.5%) and the most utilised assessment method (91.8%). Video fluoroscopic swallow study and flexible endoscopic evaluation swallowing were used by 22.7% and 12.6% of respondents. A significant difference was observed in the choice of assessment methods across hospitals of different levels (χ2 = 43.397; p < 0.001). The majority of respondents (53.5%) primarily employed rehabilitation as the main intervention method (76%-100%). Most respondents indicated that they would reevaluate patients after treatment (74.8%) and reported routine follow-up with patients (60.4%).

CONCLUSIONS AND IMPLICATIONS

Despite the relatively recent development of dysphagia management in China, the practice patterns uncovered in this study are broadly consistent with Chinese guidelines and consensus. However, the use of instrumental assessments remains low, resulting in a lack of objective evaluation of patient conditions and outcomes. There is a need for policy and resource support in the field of dysphagia rehabilitation in China.

WHAT THIS PAPER ADDS

What is already known on this subject Assessment and treatment methods for dysphagia are various across different patients, medical facilities and settings. There has been no comprehensive evaluation of all aspects of dysphagia rehabilitation practice in China. What this study adds to existing knowledge The study assessed various facets of dysphagia rehabilitation in China through an online survey. We found that the relatively recent development of dysphagia management in China, but the practice patterns uncovered in this study are broadly consistent with Chinese guidelines and consensus. Variations in practice patterns between hospitals of different levels may be attributed to resource constraints and patient needs. Besides, while rehabilitation exercises are the primary intervention method for dysphagia in China, the assessment largely centres on clinical swallowing evaluation. The use of instrumental assessments remains low, resulting in a lack of objective evaluation of patient conditions and outcomes. What are the clinical implications of this work? The study assessed various facets of dysphagia rehabilitation in China, and the results indicate that the use of instrumental assessments needs to be improved and there is a need for policy and resource support in the field of dysphagia rehabilitation in China.

Interventions and their efficacy in supporting language development among preterm children aged 0-3 years - A systematic review

BACKGROUND

Preterm children have a higher risk for linguistic delays than full-term infants but are rarely provided with language intervention at an early age. Knowledge on early language interventions targeted to preterm children is scarce, and efficacy of the interventions is rarely reported.

AIM

This systematic review aims to identify interventions for preterm children aged 0-3 years with at least one language outcome. Efficacy of the interventions and quality of the study reports were evaluated.

STUDY DESIGN

The article search was carried out in six databases: EBSCOhost, Scopus, ERIC, LLBA, Ovid, and Web of Science. Effect sizes (Hedges' g) were calculated for language outcomes. Quality of the study reports was assessed using the levels of evidence system by the American Speech-Language-Hearing Association.

RESULTS

The 28 studies identified were divided into three groups: interventions at Neonatal Intensive Care Unit, interventions during the first year, and interventions during the second and/or third years. Most of the interventions focused on supporting child-care and general development. Of the interventions, 61 % were efficacious in supporting language development of preterm children. The most promising results regarding efficacy were interventions conducted during the second and/or third years (80 %). Quality of the reports varied from high/good (89 %) to low (11 %).

CONCLUSION

The 28 existing studies provide limited evidence of the efficacy of very early interventions promoting language development of preterm children. However, especially the results for interventions conducted during the second and/or third years show promise. More studies, particularly language-focused interventions with longer follow-ups, are needed.

Validation of the conceptual framework and intervention scope of oral function rehabilitation exercise

OBJECTIVES

This study used a Delphi survey to define the concept of oral function rehabilitation exercise (OFRE) based on the International Classification of Functioning, Disability, and Health (ICF) and to categorise intervention domains for community-dwelling older adults.

BACKGROUND

While numerous studies have been conducted to improve oral function through exercise interventions, the conceptual definition of oral exercise remains unclear and there is a lack of systematic categorisation of oral exercise intervention domains.

METHODS

A preliminary model was developed based on the key findings of 19 papers selected from a prior systematic review. Its validity was confirmed through a Delphi survey conducted twice with eight expert panellists. Consensus was achieved by evaluating the validity of the OFRE conceptual framework, the accuracy of OFRE conceptual definitions, and intervention domains.

RESULTS

Through expert consensus, an ICF-based OFRE conceptual framework was developed that includes 21 factors that affect the oral health status of the older adults. The OFRE intervention domain for improving the health status consisted of oral function rehabilitation warm-up exercise, masticatory function exercise, swallowing function exercise, articulatory function exercise, salivary function exercise, and oral function rehabilitation cool-down exercise, and 11 specific intervention methods were derived.

CONCLUSIONS

The OFRE intervention can be used for planning and applying successful interventions to improve oral function and life function of older adults.

Factors influencing speech pathology practice in dysphagia after stroke: A qualitative focus group study

BACKGROUND

Dysphagia affects over half of adults after stroke. Dysphagia rehabilitation aims to improve swallowing and reduce negative outcomes for these adults. However, significant variability exists in dysphagia rehabilitation. Research is needed to explore the underlying clinician-specific and workplace factors that contribute to variability in dysphagia rehabilitation after stroke.

AIM

To explore factors influencing speech pathology practice in dysphagia rehabilitation after stroke.

METHODS & PROCEDURES

We used a phenomenological approach with an interpretivist perspective. Twenty speech pathologists working in dysphagia rehabilitation participated from different workplace settings around Australia. Five semi-structured focus groups were conducted online. Data were inductively analysed using thematic analysis with a coding reliability method.

OUTCOMES & RESULTS

Four themes were discussed within focus groups: (1) relationship between experienced and less experienced clinicians: 'Following what other people have done', (2) need for collaborative learning: 'A safe space to share and train', (3) variation between settings impacts on continuity of care: 'There's a difference between community and acute', and (4) working effectively with multidisciplinary teams (MDT): 'An MDT which can listen to the voice of speech pathology'.

CONCLUSIONS & IMPLICATIONS

Relationships between senior and junior speech pathologists, within speech pathology and MDT, and across inpatient and community settings influenced speech pathology practice. Flattened hierarchies in speech pathology, collaborative learning in workplaces, mutual respect within teams and connection across inpatient and community settings could improve the quality and consistency of dysphagia rehabilitation after stroke.

WHAT THIS PAPER ADDS

What is already known on this subject Dysphagia rehabilitation can improve swallowing after a stroke. However, dysphagia rehabilitation is characterised by variability in clinical practice. Clinician-specific and workplace factors influence clinical practice and may contribute to variability in dysphagia rehabilitation. What this study adds Professional relationships influence speech pathologists' clinical practice, including relationships between senior and junior clinicians, between inpatient and community settings and with peers and multidisciplinary teams. Workplace norms and hierarchies, poor continuity of care between settings and competing priorities from other disciplines can hinder dysphagia rehabilitation. However, collaborative learning, positive workplace cultures and respectful transdisciplinary care can improve the quality and consistency of clinical practice. What are the clinical implications of this work? Flattening hierarchies in the workplace can foster a safe learning space. Further, questioning workplace norms and seeking out peer learning within and across settings can build clinical skills and confidence. Developing positive workplace cultures that support continuous development may be key for empowering speech pathologists to provide high-quality and consistent dysphagia rehabilitation.

"One of the biggest grey areas": A focus group study exploring dosage of swallowing exercises from speech-language pathologist perspectives

Purpose: To explore the perspectives and practices of speech-language pathologists on dosage of swallowing exercises in stroke rehabilitation.Method: Online focus groups involved 20 speech-language pathologists working in various settings across Australia. Focus group data were recorded, deidentified, and analysed using inductive thematic analysis guided by an interpretivist phenomenological approach.Result: Analysis resulted in four main themes: (1) "Getting the most bang for your buck": Importance of dosage in swallowing, (2) "No patient is identical": Personalising swallowing exercise dosage to the patient, (3) "You've got what you should do, and then what you can do": Gap between recommendations and practical application, and (4) "Not much guidance out there about dosage": More research needed to guide dosage. Speech-language pathologists agreed that dosage was theoretically important for swallowing exercises, but practical application of dosage was impacted by patient factors, limited access to resources, and lack of research-based guidelines.Conclusion: Speech-language pathologists reported trying to provide optimal care despite multiple barriers to prescribing dosages of swallowing exercises in practice. Personalising exercise dosage to the patient, creative clinician strategies, improved and equitable access to resources, and research-based guidelines on swallowing exercise dosages are needed to address these barriers.

Understanding task "challenge" in stroke rehabilitation: an interdisciplinary concept analysis

PURPOSE

Rehabilitation plays a critical role in minimising disability after stroke, with the concept of "challenge" proposed to be essential to rehabilitation efficacy and outcomes. This review unpacks how challenge is conceptualised in stroke rehabilitation literature from the perspectives of physiotherapy, occupational therapy, speech-language therapy and people with stroke. A secondary purpose was to provide a definition of challenge that is applicable to stroke rehabilitation.

METHODS

Principle-based concept analysis was utilised to examine challenge within the stroke rehabilitation literature. Forty-two papers were included. Data analysis involved immersion, analytical questioning, coding and synthesis to elicit the conceptual components of challenge.

RESULTS

Challenge was understood as a multidimensional and dynamic concept with three facets: nominal, functional and perceived challenge. Functional and perceived challenge were integral to optimal challenge. Optimal challenge was central to enhancing the outcomes and experiences of people with stroke, in rehabilitation and everyday life.

CONCLUSIONS

Challenge is a key concept which, when carefully optimised to the person's ability and experience, may positively influence their learning, recovery and engagement after stroke. This review lays a conceptual foundation for better understanding, operationalisation and advancement of challenge, offering important implications for addressing the growing burden of stroke disability, through rehabilitation.

Nursing assessment and care for a patient with a neurological disorder

The previous article discussed the pathophysiology involved in disorders of the nervous system. Having considered some of the most prevalent disorders, this second part uses a case study to explore effective patient assessment and emphasise the importance of facilitating patient self-management for improved outcomes. By addressing these key aspects, nursing professionals can enhance the quality of care and the support provided to individuals experiencing neurological disorders.

Dry needling combined with exercise therapy: Effects on wrist flexors spasticity in post-stroke patients - A randomized controlled trial

BACKGROUND

The positive contribution of dry needling (DN) in conjunction with exercise therapy for patients with stroke and spasticity remains uncertain.

OBJECTIVE

To examine the effects of DN combined with exercise therapy on wrist flexor spasticity and motor function in patients with stroke.

METHODS

Twenty-four participants with stroke were randomly assigned to either the DN and exercise therapy group or the DN alone group. Assessments were conducted at baseline, after the 4th treatment session, and 3 weeks post-treatment.

RESULTS

A significant Group×Time interaction was observed for wrist active range of motion (ROM) (P = 0.046), favoring the DN with exercise therapy group (∼10° at baseline, ∼15° immediately after the 4th session, and 15.4° at follow-up). The improvements in spasticity, passive ROM, and H-reflex latency were sustained during follow-up. However, there were no significant between-group differences in any outcome at any measurement time point.

CONCLUSION

The combined DN and exercise therapy did not exhibit superiority over DN alone concerning spasticity severity and motor function. However, it demonstrated additional advantages, particularly in improving motor neuron excitability and wrist passive extension.

Prehabilitation of dysphagia in the therapy of head and neck cancer- a systematic review of the literature and evidence evaluation

Background

Prehabilitation is becoming increasingly important in oncology because of the significant survival benefits that the reduction of malnutrition provide. Specifically, tumor- and therapy-related dysphagia leads to malnutrition in more than half of head and neck tumor patients. Studies describe the positive effects of an early onset of swallow-specific prehabilitation on the protection of the swallowing function. This paper intents to evaluate the existing evidence on the efficacy of preventive forms of swallowing therapy.

Methods

A systematic literature search was performed in February 2022 in the Cochrane Library, MEDLINE via PubMed, and ClinicalTrials.gov databases for randomized controlled trials investigating preventive swallowing therapy in head and neck tumor patients. This Procedure complies with the PRISMA statement. The RCTs were evaluated by using the PEDro Scale and the Cochrane Risk of Bias tool RoB2.

Results

Five randomized-controlled trials with 423 participants were identified. Four Studies showed moderate to high quality in the PEDro analysis, one showed less. The risk of bias was high in all studies because there was no possibility for blinding and there were high dropout rates. Heterogeneity in interventions, measurement instruments, measurement time points, and outcomes limits a general statement about which swallowing exercises are suitable for the prevention of dysphagia in head and neck tumor patients. Evidence is provided for short-term effects (≤24 months) on functional aspects of swallowing and quality of life. Overall, a decreasing adherence over time was observed in the intervention groups.

Discussion

Initial studies describe swallowing-specific prehabilitation programs in head and neck tumor patients as effective, at least in the short term, whereas long-term effects need to be further investigated. At the current time the evidence base for clear recommendations does not appear to be sufficiently high and studies share a high risk of bias. Further well-designed research, especially considering the conditions in the national health care system, is needed.

Other

There was no funding and no registration.

Research hotspots and trends in post-stroke dysphagia: a bibliometric analysis

Background

Dysphagia represents one of the common complications following a stroke, and post-stroke dysphagia (PSD) can lead to aspiration, pneumonia, and malnutrition, thus prolonging hospital stay, escalating medical expenditures, and imposing a substantial economic strain on both patients and society. The utilization of bibliometric analysis offers a quantitative approach for investigating the existing literature and recognizes the current status of the research. However, bibliometric analysis on the subject of PSD remains absent. Consequently, we carried out this study to provide researchers with insights, facilitating their further exploration of PSD.

Methods

Conducting a bibliometric analysis of articles pertaining to PSD retrieved over the past two decades enables us to acquire the research hotspots and trends in this area. The publications concerning PSD were searched from the Core Collection of Web of Science, spanning the period ranging from 2003 to 2023. Articles or reviews published in English were included in this study. Subsequently, we employed CiteSpace and VOSviewer software to visualize the retrieved articles, thereby identifying the cooperative relationships of authors, institutions, and countries, as well as relevant information about journals and references.

Results

This study comprised 866 papers in total, and the number of articles published each year shows an overall growth trend. As for the analysis of the authors, Dziewas R. was the most prolific author with 21 articles. The most frequently published institutions, countries, and journals were the University of Manchester, China, and Dysphagia, with 28, 254, and 75 publications, respectively. And the co-cited authors and journals with the highest counts were Martino R and Stroke. According to the analysis of keywords and references, dysphagia screening and assessment, prevention of pneumonia, rehabilitation approaches, and nutritional management of PSD are considered research hotpots. Additionally, future research may focus on the topics of systematic review and meta-analysis, noninvasive brain stimulation, and lesion location.

Conclusion

Through the bibliometrics analysis of PSD, we can capture the research hotspots and frontiers of PSD, thereby providing inspiration and reference for subsequent studies in this field.

Enhancing Spiritual Well-Being, Physical Activity, and Happiness in Hospitalized Older Adult Patients with Swallowing Difficulties: A Comparative Study of Thickeners and Swallowing Exercises

Swallowing difficulties often occur in older adult patients during acute hospitalization, leading to reduced nutritional intake, increased frailty, and various psychosocial challenges. This randomized controlled study aimed to assess the effects of two interventions, thickeners and swallowing exercises, on the spiritual well-being, physical activity, and happiness of older adult patients with swallowing difficulties during acute hospitalization from October 2019 to August 2020. Sample size calculation was performed using a conservative estimate approach, resulting in an estimate-required sample size of 42 participants. The sampling method was a random cluster sampling approach, with three ward rooms assigned to the thickeners group, swallowing exercises group and control group, respectively. Seventy-two participants were assigned to the intervention groups (thickeners or swallowing exercises) or the control group using a 1:1:1 stratified random assignment. Data were collected before and after the intervention, and matched samples were analyzed using t-tests, ANOVA, and generalized estimating equations for statistical analysis. Both intervention groups showed significant improvements in spiritual well-being (p < 0.001), physical activity (p < 0.001), and happiness (p < 0.001) compared to the control group. However, there were no significant differences between the intervention groups. Our findings suggest that interventions involving thickeners and swallowing exercises have positive effects on the spiritual well-being, physical activity, and happiness of older adult patients with swallowing difficulties during acute hospitalization and emphasize the importance of implementing these interventions to enhance the overall well-being and quality of life of this vulnerable patient population.