Post-stroke Dysphagia: Recent Insights and Unanswered Questions

Neurogenic Dysphagia

This article provides an overview of neurogenic dysphagia, describing the evaluation and management of swallowing dysfunction in various neurologic diseases. The article will focus on stroke, Parkinson's disease, amyotrophic lateral sclerosis, and multiple sclerosis.

Predictors of Complete Oral Intake in Patients With Stroke After Tracheostomy

BACKGROUND

Tracheostomy procedures inhibit swallowing, although details of subsequent recovery of oral intake remain unknown. This retrospective cohort study aimed to investigate factors influencing dysphagia improvement in patients with subacute stroke after tracheostomy.

METHODS AND RESULTS

The study included 117 patients who underwent tracheostomy after subacute stroke, cerebral hemorrhage, or endogenous subarachnoid hemorrhage and received care at 2 convalescent rehabilitation wards in urban and suburban Japan between 2015 and 2022. The primary outcome measure was the achievement of complete oral intake. Patient demographics, Functional Independence Measure scores, body mass index, food intake level scale scores, and the presence of severe white matter hyperintensities on imaging were retrospectively collected from medical records. Statistical analysis involved univariate logistic regression to identify potential predictors and multivariate logistic regression to refine the model while accounting for multicollinearity. In total, 47% of patients achieved complete oral intake on discharge. Sex, days from onset to admission, Functional Independence Measure motor and cognitive scores, body mass index, food intake level scale scores, and severe white matter hyperintensities were identified as potential predictors in the univariate analysis. However, multivariate logistic regression identified only food intake level scale scores (odds ratio [OR], 3.687 [95% CI, 1.519-8.949]; P=0.004) and severe white matter hyperintensities (OR, 0.302 [95% CI, 0.096-0.956]; P=0.042) as significant predictors of complete oral intake.

CONCLUSIONS

In patients with subacute stroke undergoing tracheostomy, the level of oral intake on admission and severe white matter hyperintensities on imaging may be better predictors of complete oral intake. However, prospective studies with larger sample sizes and more comprehensive data are warranted to confirm these findings.

Using status of secondary prevention medications in post-stroke dysphagia patients: time to raise awareness and develop special formulations

Post-stroke dysphagia (PSD) is an increasingly common complication of stroke. Despite its intuitively unfavorable impact on secondary prevention medication use, limited awareness is available regarding this issue. Herein, a cross-sectional survey was conducted to determine the current use, patient-perceived needs and preferences for secondary prevention medications among PSD patients. To emphasize the unique context related to dysphagia, we recruited Chinese stroke patients with a duration of less than 5 years. These patients were initially categorized into PSD respondents with and without dysphagia. Among the 3490 eligible respondents, 42.7% reported experiencing dysphagia after stroke. Those PSD respondents were more likely to consume multiple medications and suffer from anticoagulants-associated gastrointestinal bleeding as compared to non-PSD ones (p < 0.001). More crucially, 40.2% of them had frequent difficulty in swallowing pills, 37.1% routinely crushed solid oral dosage forms (SODFs), and 23.5% coughed frequently when taking SODFs. In consequence, 87.4% responded a need for PSD-specific formulations where safe swallowing, easy swallowing, and reduced medication frequency were preferred pharmaceutical factors. These findings demonstrate an unsatisfactory situation and definite needs for PSD patients in using secondary prevention medications. Awareness should be increased to develop PSD-specific formulations for safe and effective secondary prevention.

Mapping Dysphagia Research Trends in Community Dwelling Older Adults: A Bibliometric Analysis

Background

In recent years, research on dysphagia has gained significant traction as one of the key topics of oral health research pertaining to the aged. Numerous academics have studied dysphagia in great detail and have produced numerous excellent scientific research findings.

Objective

To review the literature regarding dysphagia in community-dwelling older adults and identify the knowledge and trends using bibliometric methods.

Methods

The literature on dysphagia in older adults in the community was gathered from the Web of Science Core Collection (WoSCC), with inclusion criteria specifying English-language publications. The retrieval deadline was November 28, 2022. We extracted the following data: title, year, abstract, author, keywords, institution, and cited literature, and used CiteSpace (version 6.1.R3) to visualize the data through the knowledge map, burst keyword analysis, cluster analysis, and collaborative network analysis.

Results

A total of 979 articles and reviews were retrieved. Regarding productivity, the top 2 countries were the United States (n =239) and Japan (n =236). Hidetaka Wakabayashi (n =26) was one of the most prolific writers. The first paper in the frequency ranking of references cited was a white paper: European Society for Swallowing Disorders and European Union Geriatric Medicine Society white paper: oropharyngeal dysphagia as a geriatric syndrome (n =53). "Prevalence" (n =173), "risk factor" (n =119), and "aspiration pneumonia" (n =108) were the most frequently occurring keywords (excluding defining nouns). The study identified reliability, tongue pressure, home discharge, and swallowing function as research hotspots from 2020 to 2022.

Conclusion

Prevalence, risk factors, and pneumonia are significant areas of study. Tongue pressure and sarcopenia are research hotspots and potential targets. In the future, research on dysphagia needs to refine strategies for prevention and control, as well as provide tertiary preventative services.

Effect of acupuncture on post-stroke dysphagia: a randomized controlled trial

Introduction

Post-stroke dysphagia (PSD) is associated with various complications that increase morbidity and mortality rates. Acupuncture has been used extensively in China to treat these complications; however, its therapeutic efficacy remains uncertain. We therefore aimed to study the clinical effects of acupuncture on PSD.

Methods

Patients (n = 101) were randomly divided into acupuncture (n = 50) and rehabilitation training control (n = 51) groups based on the treatment used. Both groups were treated once daily, 6 days a week, for a total of 4 weeks. Pulse oxygen saturation (SpO2) and standardized swallowing assessment (SSA) were performed before the intervention, 2 weeks into treatment, after the intervention (4 weeks post-intervention), and at a 6-month follow-up (28 weeks). The levels of hemoglobin (Hb) and albumin (ALB), and 5-hydroxytryptamine (5-HT) and dopamine (DA) were measured before the intervention, 2 weeks into treatment, and after the intervention (4 weeks), as nutrition and swallowing function indices, respectively.

Results

Following the intervention, significant differences were observed between the acupuncture and control groups. The acupuncture group exhibited considerably superior enhancements in SpO2 and SSA scores at 4 weeks (p < 0.001). Moreover, this group demonstrated significantly greater improvements in Hb, ALB, 5-HT, and DA values 4 weeks post-treatment (p < 0.001). However, sex-based differences were not observed (P > 0.005).

Conclusion

Acupuncture treatment can improve the swallowing function and nutritional status of patients with PSD, and increase the levels of 5-HT and DA. These findings strongly support the efficacy of acupuncture as a therapeutic intervention in patients with PSD.Clinical trial registration: identifier, ChiCTR2100052201. (https://www.chictr.org.cn/).

Applications of Functional Near-Infrared Spectroscopy (fNIRS) Neuroimaging During Rehabilitation Following Stroke: A Review

Stroke is a cerebrovascular disease that impairs blood supply to localized brain tissue regions due to various causes. This leads to ischemic and hypoxic lesions, necrosis of the brain tissue, and a variety of functional disorders. Abnormal cortical activation and functional connectivity occur in the brain after a stroke, but the activation patterns and functional reorganization are not well understood. Rehabilitation interventions can enhance functional recovery in stroke patients. However, clinicians require objective measures to support their practice, as outcome measures for functional recovery are based on scale scores. Furthermore, the most effective rehabilitation measures for treating patients are yet to be investigated. Functional near-infrared spectroscopy (fNIRS) is a non-invasive neuroimaging method that detects changes in cerebral hemodynamics during task performance. It is widely used in neurological research and clinical practice due to its safety, portability, high motion tolerance, and low cost. This paper briefly introduces the imaging principle and the advantages and disadvantages of fNIRS to summarize the application of fNIRS in post-stroke rehabilitation.

A systematic review and meta-analysis of acupuncture in aspiration caused by post-stroke dysphagia

Objective

This systematic review and meta-analysis aims to systematically evaluate the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia.

Methods

A computer search was conducted in nine databases, including the China National Knowledge Infrastructure (CNKI), China Science and Technology Journal (VIP), Wan-fang Database, China Biomedical Literature Database (CBM), PubMed, Web of Science, Cochrane Library, Embase, and Chinese Clinical Trial Registry (ChiCTR), from their inception until April 2024. Clinical randomized controlled trials comparing acupuncture combined therapy or single therapy with control interventions for the treatment of aspiration caused by post-stroke dysphagia were included. The primary outcome measure was the Penetration Aspiration Scale (PAS), and secondary outcome measures included the overall effective rate, video fluoroscopic swallowing study (VFSS), and hyoid bone displacement. The statistical analysis was performed using RevMan 5.3 and Stata 16.0.

Results

A total of 16 articles involving 1,284 patients were included. The meta-analysis results showed that acupuncture combined therapy or single therapy was more effective in improving PAS scores compared to conventional rehabilitation therapy or balloon dilation of the catheter [WMD = -1.05, 95% CI (-1.30, -0.80), Z = 0.82, p = 0.00 < 0.05]. It was also more effective in improving VFSS scores [WMD = 1.32, 95% CI (0.08, 2.55), Z = 2.09, p = 0.04 < 0.05] and hyoid bone displacement [WMD = 2.02, 95% CI (0.86, 3.18), Z = 3.41, p = 0.00 < 0.05]. Additionally, acupuncture had a higher overall effective rate [WMD = 1.21, 95% CI (1.14, 1.29), Z = 5.76, p = 0.00 < 0.05] and a lower incidence of adverse events. Sensitivity analysis indicated that the literature had minimal impact on the results, and bias tests showed no publication bias.

Conclusion

Acupuncture combined therapy and acupuncture single therapy can effectively improve aspiration caused by post-stroke dysphagia with a low incidence of adverse events. However, due to the low quality of the included literature, more high-quality randomized controlled trials are still needed to confirm the effectiveness and safety of acupuncture in the treatment of aspiration caused by post-stroke dysphagia.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023462707, identifier CRD42023462707.

Efficacy of transcranial direct current stimulation in patients with dysphagia after stroke: a systematic review

BACKGROUND

Swallowing is a complex function that can be disrupted after stroke. Transcranial Direct Current Stimulation (tDCS) is a non-invasive brain stimulation therapy that recently has been tested to treat stroke-related dysphagia.

METHODS

The authors performed a search in the literature to review the described evidence of the use of tDCS in dysphagia after stroke. Three electronic databases were searched. The risk of bias evaluation was carried out through the RoB-2 tool. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was also implemented.

RESULTS

Of 265 articles, only nine studies were included in this review. The most common location of the tDCS stimulation was the unaffected hemisphere (44%). Regarding the outcome measure, the Dysphagia Outcome and Severity Scale (DOSS) was the most commonly used (55%). However, due to the high heterogeneity of the protocols, and considering the differences between the types of stroke, the authors opted not to perform a metanalysis. Instead, a systematic review with a thorough analysis of each individual study and the impact of the differences to the outcomes was preferred.

CONCLUSIONS

The final considerations are that even though the majority of studies described benefits from tDCS in post-stroke dysphagia, as they present too many methodological differences, it is not possible to compare them. In addition, many articles included patients with less than 6 months after stroke, which is an important bias as the swallowing function can be recovered spontaneously within this period, turning the certainty of the evidence really low.

Association between dysphagia and symptoms of depression and anxiety after ischemic stroke

BACKGROUND AND PURPOSE

Dysphagia is associated with poor outcome, higher mortality, reduced quality of life, and social isolation. We investigate the relationship between swallowing impairment and symptoms of anxiety and depression after ischemic stroke.

METHODS

Consecutive patients with ischemic stroke participating in the prospective STROKE-CARD Registry study from 2020 to 2022 were assessed for dysphagia on hospital admission (clinical swallowing assessment) and for persistence until discharge and 3-month follow-up (SINGER Independency Index). Anxiety and depression symptoms were recorded using Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS) at 3-month follow-up.

RESULTS

Of 648 patients, 19.3% had dysphagia on admission, persisting in 14.8% at discharge and 6.8% at 3-month follow-up. With the presence or duration of dysphagia (no dysphagia, dysphagia at baseline, at discharge, at 3 months), score (mean ± SD) increased on the BDI (7.9 ± 6.7, 12.5 ± 8.7, 13.5 ± 9.0, 16.5 ± 10.2), HADS-D (4.4 ± 3.7, 7.1 ± 4.2, 7.7 ± 4.4, 9.8 ± 4.3), and HADS-A (4.4 ± 3.5, 5.4 ± 3.6, 6.0 ± 3.6, 7.0 ± 3.6). In linear regression analysis adjusting for age, sex, diabetes, dementia, and either functional disability or stroke severity, BDI and HADS-D scores were significantly higher in patients with dysphagia across all points in time (admission, discharge, 3-month follow-up). An independent association with HADS-A scores was only evident in patients with persisting dysphagia after 3 months. Patients with dysphagia were more likely to receive antidepressants, antipsychotics, or benzodiazepines at discharge and 3-month follow-up.

CONCLUSIONS

Dysphagia after stroke is common and severely affects psychosocial functioning of individuals. Our results highlight swallowing impairment as an independent predictor for poststroke depressive and, to a lesser extent, anxiety symptoms.

Clinical study on the efficacy of postural control combined with electroacupuncture in treating dysphagia after stroke

Objective

To evaluate the clinical effectiveness of combining postural control with electroacupuncture in the treatment of dysphagia following stroke, with the goal of establishing a solid clinical foundation for this therapeutic approach and investigating potential mechanisms to stimulate additional research and progress in post-stroke dysphagia management.

Methods

138 patients who met the diagnostic and inclusion criteria were enrolled and divided into control group and observation group. Both groups received conventional rehabilitation training. Additionally, the control group received swallowing training and diet optimize, while the observation group received swallowing training, diet optimize, posture control as well as electroacupuncture therapy. After four weeks, swallowing function was assessed and compared between the two groups using the Standardized Swallowing Assessment (SSA) score and water swallowing test (WST).

Results

Patients who underwent postural control therapy in combination with electroacupuncture demonstrated significantly higher treatment efficacy compared to the control group. Notably, The SSA score and WST score in both groups decreased significantly, and the observation group showed more improvements in aspiration compared to the control group.

Conclusion

The integration of posture control, electroacupuncture, and conventional rehabilitation training can effectively lower the degree of post-stroke swallowing disorders, restore swallowing function, and significantly reduce the occurrence of complications such as aspiration, fever, and nutritional disorders. Moreover, this approach significantly improves the quality of life of patients and is more effective than conventional rehabilitation training in treating post-stroke swallowing disorders.

Clinical trial registration

https://www.chictr.org.cn/, Identifier ChiCTR2300075870.

Effect of respiratory training on swallowing function in swallowing disorders: a systematic review and meta-analysis

PURPOSE

To determine the clinical efficacy of different respiratory training interventions on swallowing function in patients with swallowing disorders through the systematic review.

METHODS

We reviewed the literature regarding the application of respiratory training therapy in patients with swallowing disorders, followed by a PRISMA search of published literature in five databases (PubMed, Web of Science, The Cochrane Library, CINAHL and EMBASE) in December 2022. Two reviewers performed study selection, quality evaluation, and risk of bias, followed by data extraction and detailed analysis.

RESULTS

A total of six randomized controlled studies with a total sample size of 193 cases were included. Respiratory training improved swallowing safety (PAS (n = 151, SMD = 0.69, 95% CI - 1.11 to - 0.26, I2 = 36, p < 0.001)) and swallowing efficiency [residual (n = 63, SMD = 1.67, 95% CI - 2.26 to - 1.09, I2 = 23%, p < 0.001)] compared to control groups. The results of the qualitative analysis conducted in this study revealed that respiratory training enhanced hyoid bone movement but had no effect on swallowing quality of life.

CONCLUSIONS

Respiratory training interventions may improve swallowing safety and efficiency in patients with dysphagia. However, the level of evidence is low, and there is a limited amount of research on the effectiveness and physiology of this intervention to improve swallowing function. In the future, there is a need to expand clinical studies, standardize measurement tools, and improve study protocols.

Role of TRPV1 in electroacupuncture-mediated signal to the primary sensory cortex during regulation of the swallowing function

AIMS

Electroacupuncture (EA) at the Lianquan (CV23) could alleviate swallowing dysfunction. However, current knowledge of its neural modulation focused on the brain, with little evidence from the periphery. Transient receptor potential channel vanilloid subfamily 1 (TRPV1) is an ion channel predominantly expressed in sensory neurons, and acupuncture can trigger calcium ion (Ca2+ ) wave propagation through active TRPV1 to deliver signals. The present study aimed to investigate whether TRPV1 mediated the signal of EA to the primary sensory cortex (S1) during regulation of swallowing function.

METHODS

Blood perfusion was evaluated by laser speckle contrast imaging (LSCI), and neuronal activity was evaluated by fiber calcium recording and c-Fos staining. The expression of TRPV1 was detected by RNA-seq analysis, immunofluorescence, and ELISA. In addition, the swallowing function was assessed by in vivo EMG recording and water consumption test.

RESULTS

EA treatment potentiated blood perfusion and neuronal activity in the S1, and this potentiation was absent after injecting lidocaine near CV23. TRPV1 near CV23 was upregulated by EA-CV23. The blood perfusion at CV23 was decreased in the TRPV1 hypofunction mice, while the blood perfusion and the neuronal activity of the S1 showed no obvious change. These findings were also present in post-stroke dysphagia (PSD) mice.

CONCLUSION

The TRPV1 at CV23 after EA treatment might play a key role in mediating local blood perfusion but was not involved in transferring EA signals to the central nervous system (CNS). These findings collectively suggested that TRPV1 may be one of the important regulators involved in the mechanism of EA treatment for improving swallowing function in PSD.

Efficacy of non-invasive brain stimulation for post-stroke dysphagia: a meta-analysis

BACKGROUND

Given the potential harms of dysphagia after stroke, we noticed the possibility of non-invasive brain stimulation treatments in the management process.

METHODS

The meta-analysis search for articles published before May 2023 in databases. We used STATA 12.0 software to compute the standard mean difference (SMD) and 95% confidence intervals (CI).

RESULTS

The study showed a greater improvement in swallowing function in post-stroke dysphagia given transcranial direct current stimulation (tDCS) immediately after treatment, compared to those given sham tDCS (SMD = 2.99, 95% CI = 1.86-4.11). The study showed a greater improvement in swallowing function in post-stroke dysphagia given tDCS some days after treatment, compared to those given sham tDCS (SMD = 2.01, 95% CI = 0.87-3.16). The study showed a greater improvement in swallowing function in post-stroke dysphagia given repetitive transcranial magnetic stimulation (rTMS) immediately after treatment, compared to those given sham rTMS (SMD = 4.17, 95% CI = 3.11-5.23). The study showed a greater improvement in swallowing function in post-stroke dysphagia given rTMS some days after treatment, compared to those given sham rTMS (SMD = 1.77, 95% CI = 0.94-2.60).

CONCLUSIONS

In conclusion, our study showed the beneficial effects of non-invasive brain stimulation on difficulty swallowing for stroke patients and speculated about the potential application of non-invasive brain stimulation on post-stroke dysphagia improvement.

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

Background

Dysphagia is a common complication of stroke that can result in serious consequences. In recent years, more and more papers on post-stroke dysphagia have been published in various journals. However, there is still a lack of bibliometric analysis of post-stroke dysphagia. This study visually analyzes the global research situation of post-stroke dysphagia from 2013 to 2022, aiming to explore the current research status, frontier trends, and research hotspots in this field.

Methods

Articles and reviews relevant to post-stroke dysphagia were obtained and retrieved from the Web of Science core collection database in the last 10 years (from 2013 to 2022). CiteSpace and Microsoft Excel 2019 were used for bibliographic analysis.

Results

A total of 1,447 articles were included in the analysis. The number of publications showed an overall upward trend, from 72 in 2013 to 262 in 2022. The most influential authors, institutions, journals, and countries were Hamdy S, University of London, Dysphagia, and the People's Republic of China. An analysis of keywords and the literature indicated that current studies in the field of post-stroke dysphagia focused on dysphagia and aspiration, dysphagia classification, dysphagia rehabilitation, and daily living.

Conclusion

This bibliometric analysis reveals the latest advancements and emerging trends in the field of post-stroke dysphagia, spanning the years 2013 to 2022. It highlights the paramount importance of conducting large-scale randomized controlled trials examining the efficacy of dysphagia screening protocols and non-invasive intervention techniques in improving the quality of life for these patients. Such research efforts hold significant academic implications for the development of evidence-based treatment strategies in this field.

Does ICU admission dysphagia independently contribute to delirium risk in ischemic stroke patients? Results from a cohort study

BACKGROUND

Delirium is prevalent in ischemic stroke patients, particularly those in the intensive care unit (ICU), and it poses a significant burden on patients and caregivers, leading to increased mortality rates, prolonged hospital stays, and impaired cognitive function. Dysphagia, a common symptom in critically ill patients with ischemic stroke, further complicates their condition. However, the association between dysphagia and delirium in this context remains unclear. The objective of this study was to investigate the correlation between dysphagia and delirium in ICU patients with ischemic stroke.

METHODS

A retrospective analysis was conducted on adult patients diagnosed with ischemic stroke at a medical center in Boston. Ischemic stroke cases were identified using the ninth and tenth revisions of the International Classification of Diseases. Dysphagia was defined as a positive bedside swallowing screen performed by medical staff on the day of ICU admission, while delirium was assessed using the ICU Confusion Assessment Method and review of nursing notes. Logistic regression models were used to explore the association between dysphagia and delirium. Causal mediation analysis was employed to identify potential mediating variables.

RESULTS

The study comprised 1838 participants, with a median age of approximately 70 years, and 50.5% were female. Among the total study population, the prevalence of delirium was 43.4%, with a higher prevalence observed in the dysphagia group (60.7% vs. 40.8%, p < 0.001) compared to the non-dysphagia group. After adjusting for confounding factors including age, sex, race, dementia, depression, sedative medications, history of falls, visual or hearing deficit, sequential organ failure score, and Glasgow coma score, multifactorial logistic regression analysis demonstrated a significant association between dysphagia and an increased likelihood of delirium (odds ratio [OR]: 1.48; 95% confidence interval [CI]: 1.07-2.05; p = 0.018; E-value = 1.73). Causal mediation analysis revealed that serum albumin levels partially mediated the association between dysphagia and delirium in critically ill patients with ischemic stroke (average causal mediated effect [ACME]: 0.02, 95% CI: 0.01 to 0.03; p < 0.001).

CONCLUSION

ICU admission dysphagia may independently contribute to the risk of delirium in patients with ischemic stroke. Early identification and intervention in ischemic stroke patients with dysphagia may help mitigate the risk of delirium and improve patient prognosis.

Efficacy of game training combined with surface electromyography biofeedback on post-stroke dysphagia

OBJECTIVE

To explore the efficacy of game training combined with surface electromyography biofeedback (sEMG-BF) in the treatment of dysphagia after early stroke.

METHODS

Ninety patients with early post-stroke dysphagia (PSD), who were diagnosed and treated from March 2021 to December 2022, were divided randomly into a control group (30 cases), experimental group 1 (30 cases) and experimental group 2 (30 cases). The control group received routine swallowing rehabilitation and transcranial direct current stimulation. Experimental group 1 received sEMG-BF in conjunction with the care provided to the control group. Experimental group 2 received sEMG-BF and game training in addition to the care provided to the control group. Before and after treatment, all three patient groups were evaluated using the WADA water swallowing test, the Functional Oral Intake Scale (FOIS), sEMG and a tongue manometer test.

RESULTS

Before treatment, there was no significant difference (P > 0.05) among the three groups of patients in terms of WADA water swallowing rating, FOIS score, submandibular muscle sEMG peak, swallowing time limit and maximum tongue pressure. After treatment, all three groups exhibited improvements in these indices compared with those before treatment (P < 0.05). Experimental group 1 showed greater improvement than the control group (P < 0.05), and experimental group 2 exhibited greater improvement than experimental group 1 and the control group (P < 0.05).

CONCLUSION

Game training combined with sEMG-BF can significantly improve the swallowing function of patients with PSD.

Association between the Composite Dietary Antioxidant Index and Stroke: A cross-sectional Study

The composite dietary antioxidant index (CDAI) is indeed a valuable nutritional tool used to evaluate the overall antioxidant capacity of an individual's daily food consumption. The CDAI was calculated from the intake of six antioxidant components in the diet, including vitamin A, vitamin C and vitamin E, carotenoids, selenium, and zinc. This study aimed to determine the association between CDAI and stroke. Utilizing data from the 2003-2018 NHANES dataset, CDAI was computed by summarizing the intake of six dietary antioxidants based on 24-hour dietary recall interviews. The relationship between CDAI and stroke was examined using multivariate logistic regression and restricted cubic spline analysis. This study ultimately included 39,432 participants, of whom 1,527 (3.87%) had a stroke. The multivariate logistic regression model 3 that fully adjusted all confounding variables showed a negative association between CDAI and stroke (OR = 0.97; 95% CI:0.95, 0.99). The highest tertile of CDAI saw a 23% drop in the prevalence of stroke compared to the lowest tertile (OR = 0.77; 95%CI: 0.64,0.92). Restricted cubic spline suggested that this negative correlation was nonlinear with an inflection point of -2.99. Subgroup analyses and interaction tests showed that this negative correlation was more applicable in patients with prediabetes (P < 0.05). There was a non-linear negative correlation between CDAI level and stroke prevalence, and this correlation was more significant in people with pre-diabetes. Appropriate CDAI levels may contribute to the management of stroke risk.

Quantitative Analysis of Temporal Parameters Correlated with Aspiration and Lesion Location in Stroke Patients

The purpose of this study was to identify differences in temporal parameters correlating to the presence of aspiration and the severity of penetration-aspiration scale (PAS) in patients with dysphagia after stroke. We also investigated whether there was a significant difference in temporal parameters based on the location of the stroke lesion. A total of 91 patient videofluoroscopic swallowing study (VFSS) videos of stroke patients with dysphagia were retrospectively analyzed. Various temporal parameters including oral phase duration, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, laryngeal vestibule closure reaction time, laryngeal vestibule closure duration, upper esophageal sphincter opening duration and upper esophageal sphincter reaction time were measured. Subjects were grouped by the presence of aspiration, PAS score, and location of the stroke lesion. Pharyngeal response time, laryngeal vestibule closure duration, and upper esophageal sphincter opening duration were significantly prolonged in the aspiration group. These three factors showed positive correlation with PAS. In terms of stroke lesion, oral phase duration was significantly prolonged in the supratentorial lesion group, while upper esophageal sphincter opening duration was significantly prolonged in the infratentorial lesion group. We have demonstrated that quantitative temporal analysis of VFSS can be a clinically valuable tool identifying dysphagia pattern associated with stroke lesion or aspiration risk.

The Role of Perineuronal Nets in the Contralateral Hemisphere in the Electroacupuncture-Mediated Rehabilitation of Poststroke Dysphagia Mice

Acupuncture at Lianquan (CV23) acupoint has been shown to improve swallowing function in poststroke dysphagia (PSD). This improvement is supposed to be associated with the regulation of neuronal activity in the contralateral primary motor cortex (M1), while the underlying mechanism still needs to be elucidated. Perineuronal nets (PNNs) are well-known to be involved in the regulation of neuronal activity. Thus, we here aimed to detect the role of PNNs in the contralateral M1 hemisphere in the electroacupuncture (EA)-mediated effect in male mice. The results were obtained from a combination of methods, including in vitro slice electrophysiological recording, in vivo electrophysiological recording, and immunofluorescent staining in male mice. These results showed a decrease of the excitatory postsynaptic currents (sEPSCs) and no alteration of the inhibitory postsynaptic currents (sIPSCs) in the GABAergic neurons and the tonic inhibition in the excitatory neurons in the contralateral M1 after stroke induction, and EA recovered the impaired sEPSCs in the GABAergic neurons. We further found that the effect of EA-induced increase of c-Fos expression, enhancement of spike firing, potentiation of sEPSCs in the excitatory neurons, and improvement of swallowing function were all blocked by the removal of PNNs in the contralateral M1. In conclusion, the PNNs in the contralateral M1 was suggested to be participated in stroke pathogenesis and might be associated with the EA-mediated swallowing function rehabilitation of PSD in male mice. Our study provides insight into how PNNs might be involved in the mechanism of EA treatment for stroke rehabilitation.

A clinical prediction model based on interpretable machine learning algorithms for prolonged hospital stay in acute ischemic stroke patients: a real-world study

Objective

Acute ischemic stroke (AIS) brings an increasingly heavier economic burden nowadays. Prolonged length of stay (LOS) is a vital factor in healthcare expenditures. The aim of this study was to predict prolonged LOS in AIS patients based on an interpretable machine learning algorithm.

Methods

We enrolled AIS patients in our hospital from August 2017 to July 2019, and divided them into the "prolonged LOS" group and the "no prolonged LOS" group. Prolonged LOS was defined as hospitalization for more than 7 days. The least absolute shrinkage and selection operator (LASSO) regression was applied to reduce the dimensionality of the data. We compared the predictive capacity of extended LOS in eight different machine learning algorithms. SHapley Additive exPlanations (SHAP) values were used to interpret the outcome, and the most optimal model was assessed by discrimination, calibration, and clinical utility.

Results

Prolonged LOS developed in 149 (22.0%) of the 677 eligible patients. In eight machine learning algorithms, prolonged LOS was best predicted by the Gaussian naive Bayes (GNB) model, which had a striking area under the curve (AUC) of 0.878 ± 0.007 in the training set and 0.857 ± 0.039 in the validation set. The variables sorted by the gap values showed that the strongest predictors were pneumonia, dysphagia, thrombectomy, and stroke severity. High net benefits were observed at 0%-76% threshold probabilities, while good agreement was found between the observed and predicted probabilities.

Conclusions

The model using the GNB algorithm proved excellent for predicting prolonged LOS in AIS patients. This simple model of prolonged hospitalization could help adjust policies and better utilize resources.

Evaluating the effectiveness of video-game based swallowing function training in patients with dysphagia: study protocol for a randomized controlled trial

BACKGROUND

Dysphagia can lead to serious complications such as aspiration and aspiration pneumonia, timely and effective rehabilitation training can improve the swallowing function of patients. However, the conventional rehabilitation training methods used in clinical settings have shortcomings such as poor adherence of patients. We present the study design of a randomized controlled trial that evaluated whether video-game based swallowing rehabilitation training can effectively improve swallowing in patients with dysphagia and whether it has additional benefits compared with conventional training methods to improve swallowing function and training compliance among patients with dysphagia.

METHODS

A randomized controlled trial with 4 weeks of intervention and 4 weeks of follow-up will be conducted in a rehabilitation center in Beijing, China. We will enroll 78 patients aged 18-80 years with dysphagia. Participants will be randomly assigned to the experimental group (video-game based swallowing function training) and the control group (conventional swallowing function training). All participants will receive 30 min of training per day, 5 times per week, for a total of 4 weeks. The primary outcome is swallowing function. Secondary outcomes include patients' quality of life, training compliance, and training satisfaction. Outcomes are assessed at baseline (pre-treatment), 4 weeks of treatment (post-treatment), and 8 weeks (follow-up), and the assessor is not aware of the participants' grouping.

DISCUSSION

The protocol describes a new rehabilitation training method for dysphagia, which involves participant eligibility recruitment, recruitment strategies, and data analysis plan. The results of the study will inform the rehabilitation training and clinical care management of swallowing function in patients with dysphagia.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05978700. Registered on 28 July 2023.

Post-stroke Everything

PURPOSE OF REVIEW

This review aims at providing updates on selected post-stroke complications. We examined recent advances in diagnosing and treating the following post-stroke complications: cognitive impairment, epilepsy, depression, fatigue, tremors, dysphagia, and pain.

RECENT FINDINGS

Advances in understanding the mechanisms of post-stroke complications, in general, are needed despite advances made in understanding, treating, and preventing these complications. There are growing progresses in integrating new tools to diagnose post-stroke cognitive impairment. The potential role of acute stroke reperfusion treatment in post-stroke epilepsy and its impact on other stroke complications is getting more transparent. Post-stroke depression remains underestimated and new tools to diagnose depression after stroke are being developed. New promising pharmacological approaches to treating post-stroke pain are emerging. Tremors related to stroke are poorly understood and under-evaluated, while treatment towards post-stroke dysphagia has benefited from new non-pharmacological to pharmacological approaches.

CONCLUSIONS

An integrative approach to stroke complications and collaborations between providers across specialties are more likely to improve stroke outcomes.

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.

Application of deep learning technology for temporal analysis of videofluoroscopic swallowing studies

Temporal parameters during swallowing are analyzed for objective and quantitative evaluation of videofluoroscopic swallowing studies (VFSS). Manual analysis by clinicians is time-consuming, complicated and prone to human error during interpretation; therefore, automated analysis using deep learning has been attempted. We aimed to develop a model for the automatic measurement of various temporal parameters of swallowing using deep learning. Overall, 547 VFSS video clips were included. Seven temporal parameters were manually measured by two physiatrists as ground-truth data: oral phase duration, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, laryngeal vestibule closure reaction time, laryngeal vestibule closure duration, and upper esophageal sphincter opening duration. ResNet3D was selected as the base model for the deep learning of temporal parameters. The performances of ResNet3D variants were compared with those of the VGG and I3D models used previously. The average accuracy of the proposed ResNet3D variants was from 0.901 to 0.981. The F1 scores and average precision were 0.794 to 0.941 and 0.714 to 0.899, respectively. Compared to the VGG and I3D models, our model achieved the best results in terms of accuracy, F1 score, and average precision values. Through the clinical application of this automatic model, temporal analysis of VFSS will be easier and more accurate.

Strategies of Screening and Treating Post-Extubation Dysphagia: An Overview of the Situation in Greek-Cypriot ICUs

Post-extubation dysphagia (PED) can lead to serious health problems in critically ill patients. Contrasting its high incidence rate of 12.4% reported in a recent observational study, many ICUs lack routine bedside screening, likely due to limited awareness. This study aimed to establish baseline data on the current approaches and the status of perceived best practices in PED screening and treatment, as well as to assess awareness of PED. A nationwide cross-sectional, online survey was conducted in all fourteen adult ICUs in the Republic of Cyprus in June 2018, with a 100% response rate. Over 85% of ICUs lacked a standard screening protocol for PED. The most commonly reported assessment methods were cough reflex testing and the water swallow test. Treatment approaches included muscle strengthening exercises without swallowing and swallowing exercises. Only 28.6% of ICUs acknowledged PED as a common issue. The study identified significant gaps in awareness and knowledge regarding PED screening and treatment in Greek-Cypriot ICUs. Urgent implementation of comprehensive dysphagia education programs within the units is necessary, and interdisciplinary collaboration among nurses, intensivists, and speech and language therapists is crucial to improve the quality of care provided.

Stroke Rehabilitation and Motor Recovery

OBJECTIVE

Up to 50% of the nearly 800,000 patients who experience a new or recurrent stroke each year in the United States fail to achieve full independence afterward. More effective approaches to enhance motor recovery following stroke are needed. This article reviews the rehabilitative principles and strategies that can be used to maximize post-stroke recovery.

LATEST DEVELOPMENTS

Evidence dictates that mobilization should not begin prior to 24 hours following stroke, but detailed guidelines beyond this are lacking. Specific classes of potentially detrimental medications should be avoided in the early days poststroke. Patients with stroke who are unable to return home should be referred for evaluation to an inpatient rehabilitation facility. Research suggests that a substantial increase in both the dose and intensity of upper and lower extremity exercise is beneficial. A clinical trial supports vagus nerve stimulation as an adjunct to occupational therapy for motor recovery in the upper extremity. The data remain somewhat mixed as to whether robotics, transcranial magnetic stimulation, functional electrical stimulation, and transcranial direct current stimulation are better than dose-matched traditional exercise. No current drug therapy has been proven to augment exercise poststroke to enhance motor recovery.

ESSENTIAL POINTS

Neurologists will collaborate with rehabilitation professionals for several months following a patient's stroke. Many questions still remain about the ideal exercise regimen to maximize motor recovery in patients poststroke. The next several years will likely bring a host of new research studies exploring the latest strategies to enhance motor recovery using poststroke exercise.

Exploration of treatment methods for patients with post-stroke dysphagia: a network meta-analysis

To compare the effects of various therapies in patients with post-stroke dysphagia.

DATA SOURCES

We searched databases between January 1980 and 2022.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials (RCTs) on therapy for dysphagia after stroke.

STUDY APPRAISAL AND SYNTHESIS METHODS

The outcomes were improvement in dysphagia, case fatality, and chest infection or pneumonia, reported as OR (odd ratio), 95% CrI (confidence interval), and SUCRA (the surface under the cumulative ranking curve analysis) score. Forty-two randomized controlled trials (2,993 patients, seven therapies, and one control) were included. In the improvement of dysphagia analysis, the following therapies were superior to the control: Acupuncture, behavioral interventions, drug therapy, neuromuscular electrical stimulation (NMES) and pharyngeal electrical stimulation (PES). In the case fatality analysis, OR and 95% CrI indicated none of the therapies were superior to the control. In the chest infection or pneumonia analysis, OR values showed that no therapy was superior to the control. Our Network Meta-analysis suggests that commonly used therapies for dysphagia after stroke have equal efficacies.

Effects of repetitive transcranial magnetic stimulation on post-stroke patients with cognitive impairment: A systematic review and meta-analysis

BACKGROUND

Post-stroke cognitive impairment (PSCI) is one of the common symptoms in stroke survivors, by which their quality of life and rehabilitation progress are severely limited. Repetitive transcranial magnetic stimulation (rTMS) has been proven to regulate cognition in a non-invasive way. However, the inconsistency in its effectiveness on PSCI reported in previous studies cannot be ruled out. A critical and comprehensive systematic review of rTMS on PSCI patients is necessary.

METHODS

Trials published before the end of February 2022 on rTMS and PSCI were systematically retrieved from PubMed, Cochrane Library, EBSCO, Embase and SCOPUS. High-quality literature was selected following the inclusion and exclusion criteria, with their references being screened. Meta-analysis of data was carried out using RevMan 5.4 software.

RESULTS

Ten trials involving 347 participants were included in the current review. Global cognition as measured by MMSE or MoCA (SMD=0.54; 95% CI=0.31, 0.76; P < 0.00001; I² = 38%) and modified Barthel index (MD=9.00; 95% CI=2.93, 15.06; P = 0.004; I² = 0%) were significantly improved by rTMS compared to sham stimulation in PSCI patients. Performance of the digit symbol test, rivermead behavioral memory test and attention in PSCI patients were also significantly improved. Subgroup analyses showed that significant differences were found in both MoCA and MMSE among PSCI patients by rTMS. MoCA was significantly improved by high frequency rTMS, while both MoCA and MMSE were significantly improved targeting on left dorsolateral prefrontal cortex.

CONCLUSION

rTMS provides a non-invasive and effective technique for the treatment of post-stroke patients with cognitive impairment.

Post-stroke dysphagia: Clinical characteristics and evolution in a single-primary stroke center

BACKGROUND

Dysphagia is a common manifestation after stroke and seems to play a major role in clinical and functional outcomes.

OBJECTIVES

To identify clinical predictors of higher degrees of dysphagia, as well as assess its burden in our hospital, in order to understand how to improve the approach to this symptom.

METHODS

We included 311 patients admitted in an acute stroke unit in a year-long period. The relationship of dysphagia with different outcomes, both in acute phase and within the first year after stroke, were investigated.

RESULTS

Using the Pearson Correlation Coefficient, NIHSS score at admission was positively correlated with the degree of dysphagia (r = 0,783; p <  0,001) and total anterior circulation infarcts and age (>  70 years) were also associated with higher risk of dysphagia (p <  0.001). During hospitalization both respiratory infections and mortality occurred at significantly higher rates for dysphagic patients (p <  0.001) and we observed an increasing trend towards a higher mortality rate, the higher the degree of dysphagia. These patients stayed longer in the stroke unit, with less chance to be discharged home and more frequently transferred to inpatient rehabilitation care. One year after admission, dysphagic patients were more frequently readmitted due to pneumonia and we observed a higher mortality rate compared to patients without dysphagia (p <  0.001).

CONCLUSION

The presence of the above-mentioned dysphagia predictive factors should alert us to the need for an early approach, starting in the stroke unit, but also after discharge, taking into account its impact on clinical outcomes, mortality and healthcare costs.

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.

Effectiveness of smart health-based rehabilitation on patients with poststroke dysphagia: A brief research report

Objective

This study aimed to evaluate the effectiveness of smart health-based rehabilitation on patients with poststroke dysphagia (PSD).

Methods

We recruited 60 PSD patients and randomly allocated them to the intervention (n = 30) and control (n = 30) groups. The former received the smart health-based rehabilitation for 12 weeks, whereas the latter received routine rehabilitation. Water swallow test (WST), standardized swallowing assessment (SSA), swallow quality-of-life questionnaire (SWAL-QOL), stroke self-efficacy questionnaire (SSEQ), perceived social support scale (PSSS) and nutritional measurements including body weight, triceps skinfold thickness (TSF), total protein (TP), serum albumin (ALB) and serum prealbumin (PA) in both groups were measured.

Results

When the baseline WST, SSA, SWAL-QOL, SSEQ, PSSS and nutritional measurements were examined, there was no significant difference between the intervention group and the control group (P > 0.05). After rehabilitation interventions, the WST and SSA scores in the intervention group were significantly lower than those in the control group (P < 0.01). The SWAL-QOL, SSEQ and PSSS scores in the intervention group were significantly higher than in the control group (P < 0.01). Compared with the control group, the intervention group showed an increase in the serum levels of PA (P < 0.01). However, no statistically significant difference existed between the intervention group and the control group in terms of body weight, TSF, TP or ALB (P > 0.05).

Conclusions

Overall, our data revealed that smart health-based rehabilitation is significantly beneficial to the swallowing function, quality of life, self-efficacy, and social support for PSD patients when compared with routine rehabilitation. However, nutritional measurements were not significantly improved in such patients under the smart health-based rehabilitation when compared the routine rehabilitation. In the future, it is necessary to extend the intervention time to further evaluate the long-term efficacy of smart health-based rehabilitation on nutritional measurements of PSD patients.

Analysis of the current status of rehabilitation motivation and its influencing factors in older adults with stroke: a cross-sectional study

Objective

Among stroke patients, exercise adherence is an important factor in reducing the rate of physical disability and mortality. Rehabilitation exercise after stroke is a safe and effective measure to restore normal body functions, but the analysis of factors influencing patients' motivation for rehabilitation is not well established. Therefore, this study will explore the influencing factors of rehabilitation motivation in older adults with stroke so as to reduce the disability rate of stroke.

Method

A convenience sampling method was used to study 350 patients in a stroke ward of a tertiary care hospital in Jinzhou, Liaoning Province. Patients' general demographic data, Multidimensional Scale of Perceived Social Support (PSSS), Questionnaire of Exercise Adherence (EAQ), Tampa scale of kinesiophobia (TSK-11), and Motivation in stroke patients for rehabilitation scale (MORE) were assessed. ANOVA or t-test analysis, correlation analysis, and linear regression analysis were used to explore the factors influencing the motivation for rehabilitation in older adults with stroke.

Results

The results showed that stroke patients' motivation for rehabilitation was at a moderate level. Perceived social support, exercise adherence, and stroke motivation were positively correlated (r = 0.619, p < 0.01; r = 0.569, p < 0.01), and kinesiophobia was negatively correlated with stroke motivation (r = -0.677, p < 0.01). Time of stroke, location of the lesion, perceived social support, exercise adherence, and kinesiophobia are influential factors affecting patients' motivation to recover.

Conclusion

In the rehabilitation program for older adult patients with stroke, healthcare providers should specify targeted rehabilitation measures according to the different degrees of the patient's condition, so as to improve the effectiveness of rehabilitation medical implementation.

Study on dysphagia from 2012 to 2021: A bibliometric analysis via CiteSpace

Objectives

This study aims to review the documents on dysphagia, summarize the research direction, analyze the research hot spots and frontiers, report the research trends, and provide new ideas for future development in the field via CiteSpace.

Methods

We retrieved articles on dysphagia published between 2012 and 2021 from the Web of Science Core Collection database. We downloaded the entire data and utilized CiteSpace version 5.8.R3 (64-bit) to analyze the number of publications annually, cited journals, countries, institutions, authors, cited authors, cited references, and keywords. We visualized the data with a knowledge map, collaborative network analysis, cluster analysis, and strongest citation burst analysis.

Results

We obtained 14,007 papers with a continually increasing trend over time. The most productive country and institute in this field were the United States (4,308) and Northwestern University (236), respectively. Dysphagia (5,062) and Laryngoscope (2,812) were the most productive journals, Elizabeth Ward had the highest number of publications (84), and Logeman et al.'s article (centrality: 0.02) was the most referenced. The most common keywords were dysphagia, management, quality of life, deglutition disorder, diagnosis, aspiration, prevalence, children, outcome, and oropharyngeal dysphagia.

Conclusion

This study analyzed the current literature on dysphagia via CiteSpace and identified its research hot spots and frontiers. The prevalent global trends in dysphagia research and the growing public awareness about healthcare and quality of life suggest that research on dysphagia will gain popularity with further breakthroughs.

Effect of Tongue-Pressure Resistance Training in Poststroke Dysphagia Patients With Oral Motor Dysfunction: A Randomized Controlled Trial

OBJECTIVES

The aims of the study were to investigate the effect of tongue-pressure resistance training in poststroke dysphagia patients with oral motor dysfunction and to examine the therapeutic value of tongue-pressure resistance training in the oral and pharyngeal phases.

DESIGN

Patients were divided into an experimental and a control group. Both groups received 30 mins of traditional swallowing rehabilitation treatment every day for 4 wks. In addition, the experimental group received tongue-pressure resistance training for an extra 20 mins/d. Maximum tongue pressure and fiberoptic endoscopic examination of swallowing were assessed before and after treatments.

RESULTS

Compared with the control group, the experimental group showed significant improvement in Functional Communication Measure for swallowing, Oral Motor Function Scale, maximum tongue pressure, Murray Secretion Scale, Rosenbek Penetration-Aspiration Scale, and food residue in pyriform sinuses ( P < 0.05). There was no significant difference in food residue in epiglottic vallecula between both groups ( P > 0.05).

CONCLUSIONS

This study demonstrated that tongue-pressure resistance training is an effective approach to improve the overall swallowing function in patients with oral motor dysfunction. The improvement of oral motor function could facilitate the recovery of pharyngeal motor function. Tongue-pressure resistance training seems to have more clearance of residue in piriform sinus than epiglottic vallecula.

Analysis of medical service utilization for post-stroke sequelae in Korea between 2016 and 2018: a cross-sectional study

In this retrospective cross-sectional observational study, the medical service utilization of post-stroke sequelae patients was examined using a national patient sample. The Korean Health Insurance Review and Assessment Service-National Patients Sample database was used to investigate the medical service utilization of 19,562 patients, diagnosed with post-stroke sequelae of cerebrovascular disease (I69) in Korea between January 2016 and December 2018. We compared the demographic characteristics, diagnosis code subtypes, frequency of healthcare utilization, medical costs, and comorbidities of standard care (SC) and Korean medicine (KM) users. Overall, patients aged ≥ 65 years accounted for the highest percentage, and utilization of medical services increased among patients aged ≥ 45 years. Outpatient care was higher among SC (79.23%) and KM (99.38%) users. Sequelae of cerebral infarction accounted for the highest percentage of diagnosis subtypes. Physical therapy and rehabilitation therapy were most frequent in SC, whereas injection/procedure and acupuncture were most frequent in KM. Cerebrovascular circulation/dementia drugs were prescribed most frequently in SC. Circulatory, digestive, endocrine, and metabolic disorders were the most common comorbidities in SC, whereas musculoskeletal and connective tissue disorders were most common in KM. Overall, SC and KM users showed differences in the number of medical service claims, cost of care, and comorbidities. Our findings provide basic research data for clinicians, researchers, and policy makers.

Reversing the Ruin: Rehabilitation, Recovery, and Restoration After Stroke

PURPOSE OF REVIEW

Stroke is a common cause of disability in aging adults. A given individual's needs after stroke vary as a function of the stroke extent and location. The purpose of this review was to discuss recent clinical investigations addressing rehabilitation of an array of overlapping functional domains.

RECENT FINDINGS

Research is ongoing in the domains of movement, cognition, attention, speech, language, swallowing, and mental health. To best assist patients' recovery, innovative research has sought to develop and evaluate behavioral approaches, identify and refine synergistic approaches that augment the response to behavioral therapy, and integrate technology where appropriate, particularly to introduce and titrate real-world complexity and improve the overall experience of therapy. Recent and ongoing trials have increasingly adopted a multidisciplinary nature - augmenting refined behavioral therapy approaches with methods for increasing their potency, such as pharmaceutical or electrical interventions. The integration of virtual reality, robotics, and other technological advancements has generated immense excitement, but has not resulted in consistent improvements over more universally accessible, lower technology therapy.

Functional prognosis in patients with sarcopenic dysphagia: An observational cohort study from the Japanese sarcopenic dysphagia database

AIM

In sarcopenic dysphagia, confirmation of recovery of the swallowing function and activity of daily living is insufficient. The aim of this study was to examine differences in the recovery of the swallowing function and activities of daily living between sarcopenic dysphagia patients and non-sarcopenic dysphagia patients.

METHODS

The registry data of the Japanese Sarcopenic Dysphagia Database were used for the analysis; 440 patients met the eligibility criteria of the study. Dysphagia was evaluated according to the Food Intake Level Scale and a five-step diagnostic algorithm for the disorder. Patients were divided into two groups according to the presence or absence of sarcopenic dysphagia.

RESULTS

Sarcopenic dysphagia was found in 268 cases (60.9%). The rate of improvement in the Food Intake Level Scale was 47.4% in sarcopenic dysphagia patients and 62.2% in non-sarcopenic dysphagia patients. The rate of improvement in the Food Intake Level Scale was lower in the sarcopenic dysphagia patients (P = 0.008). A multiple regression analysis showed that the presence of sarcopenic dysphagia had a significant influence on changes in the Food Intake Level Scale and Barthel Index (β = -0.191, 95% confidence interval, -1.484 to -0.530, P < 0.001, β = 0.112, 95% confidence interval, 0.587 to 10.450, P = 0.028).

CONCLUSION

Improvement in the swallowing function was poor in patients with sarcopenic dysphagia. Sarcopenic dysphagia should be examined to improve swallowing function. Geriatr Gerontol Int 2022; 22: 839-845.

Behavioral Interventions Targeting Base of Tongue to Posterior Pharyngeal Wall Approximation: A Scoping Review

Pharyngeal pressure generated by approximation of the base of tongue to the posterior pharyngeal wall (BOT-PPW approximation) is critical for efficient pharyngeal bolus passage and is a frequent goal of dysphagia management. This scoping review evaluated behavioral interventions available to improve BOT-PPW approximation. We searched MEDLINE, CINAHL, Ovid Emcare, Web of Science, SCOPUS, and ProQuest for studies that met the following criteria: (i) behavioral interventions targeting BOT-PPW approximation, which (ii) were assessed using BOT-PPW-specific outcome measures, and (iiia) performed over a period of time (Review Part 1) or (iiib) studied immediate effects (Review Part 2). Study quality was rated using the GRADE framework. Data were extracted and synthesized into dominant themes. Of the 150 studies originally identified, three examined long-term effects (two single cases studies of individuals with dysphagia, and a third study evaluating effortful swallowing in healthy individuals). BOT-PPW approximation only increased in the two single case studies. Twenty-one studies evaluating immediate effects were categorized as follows: (1) effortful swallowing, (2) Mendelsohn maneuver, (3) tongue-hold maneuver, (4) super supraglottic swallowing maneuver, and (5) non-swallowing exercises. Across all studies, varying levels of success in increasing BOT-PPW approximation were reported. Four of 21 immediate effects studies evaluated patients with demonstrated swallowing impairment, whereas 17 studies evaluated healthy adults. Quality assessment revealed low strength of the existing evidence base. The evidence base for rehabilitative interventions targeting BOT-PPW approximation is severely limited and translation is hindered by small sample sizes and methodological limitations. Further clinical research is warranted.

Swallow Safety and Laryngeal Kinematics: A Comparison of Dysphagia Between Parkinson's Disease and Cerebrovascular Accident

BACKGROUND

Cerebrovascular accident (CVA) and Parkinson's disease (PD) are well established etiologies of dysphagia. However, differing physiological mechanisms underlying dysphagia may exist between these two causes. There have been limited investigations specifically comparing dysphagia between these two groups. Comparing dysphagia presentation in two different populations may improve clinical expectations, guide treatment approaches, and inform future research.

OBJECTIVE

This study examined the differences in presentation of dysphagia between PD and CVA. Dysphagia presentation, swallow safety, and laryngeal kinematics were compared between two clinical cohorts. What factors best predicted airway invasion in each group were explored.

METHODS

110 swallow studies of individuals with PD and CVA who were referred for swallowing evaluation were obtained. Each video was analyzed for quantitative dysphagia presentation using the Videofluoroscopic Dysphagia Scale (VDS), swallow safety using the Penetration-Aspiration scale, and kinematic timings of the laryngeal vestibule (time-to-laryngeal vestibule closure [LVC] and closure duration [LVCd]).

RESULTS

Frequencies of penetration or aspiration were similar between groups. The PD group displayed significantly greater pharyngeal stage swallow impairment than CVA, with more frequent reduced laryngeal elevation and increased vallecular residue. The CVA group displayed significantly greater oral stage impairment, with prolonged oral transit times. Time-to-LVC was significantly prolonged and was the strongest predictor of airway invasion in the PD group, but not for CVA.

CONCLUSION

Similar airway invasion rates for PD and CVA indicate the importance of screening for dysphagia in PD. Laryngeal kinematics as significant contributors to airway invasion in PD but not for CVA highlight the need for further research into these mechanisms and for targeted treatment approaches to dysphagia.

Effects of vitamin C stimulation on rehabilitation of dysphagia after stroke: a randomized trial

BACKGROUND

Stroke is a clinical syndrome of localized or global brain dysfunction caused by cerebrovascular disease.

AIM

The aim of this study was to explore the effect of vitamin C acid stimulation on the rehabilitation process, Nourishment State Index and immune function indicators of stroke patients with dysphagia.

DESIGN

This is a prospective cohort study.

SETTING

This study was conducted at our hospital.

POPULATION

We analyzed stroke patients with dysphagia.

METHODS

A total of 120 stroke patients with dysphagia were randomly divided into a routine group and a test group, with 60 cases in each group. Routine swallowing training was performed in the routine group, and the test group was stimulated with vitamin C acid. The water swallow test (WST) and video fluoroscopic swallowing study (VFSS) were used to compare the rehabilitation of dysphagia in the two groups. Nourishment State Index was evaluated by BMI, serum albumin, total serum protein and hemoglobin. Immune Function Index was evaluated by IgA, IgM and IgG.

RESULTS

Compared with the control group, the WST level of patients treated with vitamin C acid stimulation intervention were significantly reduced, and the VFSS score were significantly increased. Serum levels of hemoglobin, albumin, total protein, IgA, IgM and IgG in the vitamin C acid stimulation group were remarkably increased than those in the control group.

CONCLUSIONS

Vitamin C acid stimulation exhibits a good application effect in patients with dysphagia after stroke. Moreover, vitamin C acid stimulation can further improve the nutritional status and immune function after stroke and promote postoperative recovery of patients. Therefore, we believe that vitamin C stimulation therapy can be widely used in stroke rehabilitation management.

CLINICAL REHABILITATION IMPACT

Vitamin C acid stimulation significantly improves rehabilitation of stroke patients with dysphagia and ameliorates the nutritional status and immune function of patients.

Update on Stroke Rehabilitation for Non-Motor Impairment

Various interventions exist to treat non-motor impairments caused by stroke. Adjuvant treatments such as non-invasive brain stimulation, virtual reality, computer-assisted training, neurostimulation, and biofeedback are being investigated and applied in the areas of cognitive dysfunction, language problems, visual disorders, dysphagia, mood disorders, and post-stroke pain. Most of these treatments have shown efficacy and symptom improvement, but further investigation is required to fully clarify their effects.

A comparison of Knowledge, attitude and practice (KAP) of nurses on nursing Post-stroke dysphagia patients between iii-A and ii-A hospitals in China: a propensity score-matched analysis

Background

Whether knowledge, attitude and practice of nurses on nursing post-stroke dysphagia patients varies between different ranking hospitals is still unknown. This study aimed to compare the knowledge, attitude and practice level of nurses on nursing post-stroke dysphagia patients between iii-A and ii-A hospitals in China.

Design

A cross-sectional study design was used.

Methods

Data were collected from eighteen hospitals in Wuhan, Hubei in May–July 2020, and a total of 824 nurses were recruited by convenient sampling. After propensity score matching, 205 participants in iii-A hospitals were matched with 205 participants in ii-A hospitals.

Results

There were no statistically differences in the socio-demographic characteristics between two groups after propensity score matching. Before matching, the regression coefficients between hospital ranking and knowledge, attitude, practice were -0.415, -0.718 and -1.855, respectively. After matching, the coefficients changed to -0.394, -0.824 and -1.278. Nurses from iii-A hospitals had higher knowledge and attitude scores than nurses from ii-A hospitals, but no significant practice scores difference was observed between various rankings of hospitals.

Conclusions

The KAP of nurses on nursing post-stroke dysphagia patients were different in iii-A and ii-A hospitals. Administrators should strengthen management, provide more learning resources and trainings to meet nurses’ needs about methods to deal with and recognize dysphagia, so as to further improve the quality of post-stroke dysphagia management.

Risk factors of dysphagia in patients with ischemic stroke: A meta-analysis and systematic review

Background

Dysphagia is a common yet serious complication in stroke patients. We aimed to conduct a meta-analysis and systematic review to evaluate the risk factors of dysphagia in patients with ischemic stroke, to provide insights to the clinical treatment and nursing care of dysphagia.

Methods

We searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI) and Wanfang Database, China Biomedical Literature Database (CBM) for studies on dysphagia in patients with ischemic stroke up to January 31, 2022. The quality of the literature was evaluated using the Newcastle-Ottawa scale. Meta-analysis was performed using RevMan 5.3 software.

Results

A total of 10 studies involving 4637 ischemic stroke patients were included, 1183(25.51%) patients had dysphagia after stroke. The synthesized outcomes showed that elder age (SMD = 0.42, 95%CI:0.34–0.50), hypertension (OR = 1.96, 95%CI:1.48–2.61), diabetes (OR = 1.83, 95%CI:1.47–2.28), brainstem stroke (OR = 2.12, 95%CI:1.45–3.09) were associated with dysphagia in patients with ischemic stroke (all P<0.05). There was no significant difference in the gender between dysphagia and no dysphagia patients (OR = 1.07, 95%CI:0.91–1.27, P = 0.40). Egger regression tests indicated there were no significant publication biases in the synthesized outcomes (all P>0.05).

Conclusions

Elder age, hypertension, diabetes and brainstem stroke are associated with the development of dysphagia in patients with ischemic stroke. Attention should be paid to the assessment and early intervention of those risk factors for dysphagia to improve the prognosis of stroke patients.

Potential Benefits of Music Therapy on Stroke Rehabilitation

Stroke is associated with a high rate of disability and mortality, and survivors are usually accompanied with dysphagia, aphasia, motor dysfunction, cognitive impairment, depression, and other complications. In the past decades, many studies have been conducted to reveal the pathogenesis and pathological mechanisms of stroke. Furthermore, treatment methods have been developed that contribute to the elevated survival rate of stroke patients. Early rehabilitation poststroke is starting to be recognized as important and has been receiving increasing attention in order to further improve the quality of life of the patients. As an emerging method of poststroke rehabilitation, music therapy can help attenuate dysphagia and aphasia, improve cognition and motor function, alleviate negative moods, and accelerate neurological recovery in stroke patients. This review helps summarize the recent progress that has been made using music therapy in stroke rehabilitation and is aimed at providing clinical evidence for the treatment of stroke patients.

Communication, Feeding and Swallowing Disorders in Neurological Diseases

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Inhalation Therapy with Nebulized Capsaicin in a Patient with Oropharyngeal Dysphagia Post Stroke: A Clinical Case Report

Dysphagia and aspiration risk are common sequelae of stroke, leading to increased risk of stroke-associated pneumonia. This is often aggravated by stroke-related impairment of cough, the most immediate mechanical defense mechanism against aspiration. In humans, reflex cough can be repeatedly and safely elicited by inhalation of nebulized capsaicin, a compound contained in chili peppers. Could this cough-eliciting property of capsaicin support the recovery of stroke survivors who present with dysphagia and aspiration risk? We present a clinical case report of a 73-year-old man, admitted to inpatient stroke rehabilitation following a right middle cerebral artery infarct with subsequent dysphagia and hospital-acquired pneumonia. A course of daily inhalation therapy with nebulized capsaicin was initiated, triggering reflex coughs to support secretion clearance and prevent recurrence of pneumonia. Clinical observations in each inhalation therapy session demonstrate good patient response, safety and tolerability of nebulized capsaicin in this mode of application. Repeated Fiberoptic Endoscopic Evaluation of Swallowing (FEES) assessments show concurrent improvement in the patient’s swallowing status. Inhalation therapy with nebulized capsaicin may offer a viable treatment to facilitate coughing and clearing of secretions, and to minimize aspiration and risk of aspiration-related pneumonia post stroke. Further investigation in a randomized controlled trial design is warranted.

Net clinical benefit of anticoagulant therapy from a neurologist's perspective: A review

In this article the concept of "net clinical benefit" (NCB) is considered in the context of stroke, the role of direct oral anticoagulants in secondary prevention of cardioembolic stroke and NCB from their prescription. Practical aspects of NCB evaluation from the neurologist's point of view are presented, taking into account such factors as stroke duration and severity, features of neurological deficit (severity of residual limitations, dysphagia, motor disorders and risk of falls), neuroimaging characteristics of stroke (focal size and hemorrhagic transformation) and concomitant neurological diseases (epilepsy and dementia). In all these situations, the use of oral anticoagulants has a significant clinical benefit, which justifies the inadmissibility of refusal to prescribe them.

Acupuncture Reduces the Risk of Dysphagia in Stroke Patients: A Propensity Score-Matched Cohort Study

Background: Post-stroke dysphagia (PSD) affects the quality of life in stroke patients, impairs their rehabilitation ability, and causes other complications following stroke. Currently, there is currently some understanding of PSD risk factors, but its protective factors remain largely unknown. Objective: To analyze the effects of acupuncture (AP) on dysphagia in stroke patients and explore its potential as a preventive therapy. Methods: Patients with a diagnosis of stroke from 2010 to 2019 were selected and followed until 2020, utilizing factors such as age, gender, stroke location, stroke type, and baseline comorbidity. To compare the incidence of dysphagia, equal numbers of stroke patients treated with and without AP (n = 1,809) were matched by 1:1 propensity scoring. The Cox proportional hazards model and Kaplan-Meier method were used to assess the risk of dysphagia as an outcome measure. Results: The stroke patients treated with AP had a lower risk of dysphagia after adjusting for age, gender, stroke location, stroke type, and baseline comorbidity [adjusted hazard ratio (AHR) = 0.43, 95% confidence interval = 0.37-0.49] compared with those in the non-AP cohort. AP also decreased the risk of PSD among different gender groups. The risk ratios were AHR = 0.45 and AHR = 0.33 for males and females, respectively. AP also reduced the risk for PSD among different age groups. The risk ratios were AHR = 0.20, AHR = 0.37, AHR = 0.41, and AHR = 0.45 for the 18-39, 40-59, 60-79, and >80 years-old groups. Regarding stroke types (ischemic, hemorrhagic, and mixed type), patients treated with AP had a lower risk (AHR = 0.47, 0.28 and 0.17, respectively). With respect to stroke location, the risk of PSD in AP-treated patients was decreased regardless of location: brain stem (AHR = 0.41), diencephalon (AHR = 0.13), or multiple lesions (AHR = 0.40), the risk of PSD in AP-treated patients was decreased. For all baseline comorbidities, AP attenuated the risk of dysphagia. The cumulative incidence of dysphagia was remarkably lower in the AP group than in the non-AP group (log-rank test, P = 0.000). Limitations: First, this was a single-center clinical retrospective study. Second, we did not classify the severity of stroke and dysphagia. Third, all data were extracted manually. Lastly, the sample size was relatively small. Thus, future studies with larger sample sizes are warranted to verify our findings. Conclusion: Acupuncture treatment attenuates the risk of dysphagia in stroke patients. Future research should increase the sample size and elaborate further on the details of the AP protocol.

Compensatory swallowing methods in a patient with dysphagia due to lateral medullary syndrome-vacuum and prolonged swallowing: A case report

INTRODUCTION

The nature of pharyngeal swallowing function during the course of recovery of dysphagia due to lateral medullary syndrome (LMS) is unclear. Vacuum swallowing is a compensatory swallowing method that improves the pharyngeal passage of a bolus by creating negative pressure during swallowing in the esophagus in patients with dysphagia due to LMS. We present a case involving a patient with dysphagia due to LMS who involuntarily acquired a swallowing method with prolonged and increased pharyngeal contraction and vacuum swallowing.

PATIENT CONCERNS

We report a unique case involving a 52-year-old patient with dysphagia due to LMS. His dysphagia was severe but improved gradually with swallowing rehabilitation. The patient involuntarily acquired a swallowing method with prolonged and increased pharyngeal contraction and vacuum swallowing.

DIAGNOSIS

The patient presented with dysphagia due to left LMS. A videofluoroscopic examination of swallowing revealed pharyngeal residue.

INTERVENTIONS

Forty-five days after the onset of the dysphagia, the swallowing pressure along the pharynx and esophagus was measured using high-resolution manometry.

OUTCOMES

Vacuum swallowing was observed in six out of 19 swallows (32.5%). The velopharyngeal contractile integral (CI) and mesohypopharyngeal CI values increased during swallowing, reflecting prolonged and increased pharyngeal contraction. We named this swallowing method "prolonged swallowing."

CONCLUSION

The findings in this case indicate that vacuum and prolonged swallowing may be compensatory swallowing methods observed in individuals recovering from dysphagia due to LMS. Further research is needed to clarify the relationship between these swallowing methods and the pathophysiology, prognosis, and treatment of dysphagia in patients with LMS.