Pharyngeal electrical stimulation for early decannulation in tracheotomised patients with neurogenic dysphagia after stroke (PHAST-TRAC): a prospective, single-blinded, randomised trial

Predictors of pharyngeal electrical stimulation treatment success in tracheotomised stroke patients with dysphagia: Secondary analysis from PHADER cohort study

Pharyngeal electrical stimulation (PES) has emerged as a promising intervention for neurogenic dysphagia, with potential benefits in reducing dysphagia severity in stroke patients. PES may facilitate decannulation in tracheotomised stroke patients with dysphagia, yet the predictive factors for treatment success have not been investigated in detail. This study used data from the PHAryngeal electrical stimulation for treatment of neurogenic Dysphagia European Registry (PHADER) study to identify predictive factors for PES treatment success among patients with post stroke dysphagia who required mechanical ventilation and tracheotomy. Multiple linear regression was performed to predict treatment success, as measured in improvement in dysphagia severity rating scale (DSRS), accounting for age, sex, stroke type, lesion location, baseline National Institutes of Health Stroke Scale (NIHSS) score, feeding status, time from stroke onset to PES, PES perceptual threshold and PES stimulation intensity at the first session. Cox regression was conducted to identify the predictors for decannulation for all participants. Ninety-eight participants (mean [SD] age ​= ​66.6 [13.0]; male 73.5%) were included in the analyses. Regression analyses showed that early intervention (p ​= ​0.004) and younger age (p ​= ​0.049) were significant predictors for treatment success. For participants who received PES during tracheotomy (n ​= ​60; mean [SD] age ​= ​66.6 [11.2]; male 73.3%), supratentorial stroke (p ​= ​0.033) and feeding status at baseline (p ​= ​0.025) were predictors of treatment success. Among all participants, early intervention was associated with higher likelihood of decannulation (p ​= ​0.026). These results highlight the importance of timely intervention, age and stroke location in PES treatment success for stroke patients with mechanical ventilation and tracheotomy.

Pharyngeal Electrical Stimulation prior to extubation - Reduction of extubation failure rate in acute stroke patients?

PURPOSE

The aim of our study was to assess if PES before extubation can minimize the extubation failure risk in orally intubated, mechanically ventilated stroke patients at high risk of severe dysphagia.

MATERIALS AND METHODS

Thirty-two ICU patients were prospectively enrolled in this study presenting with a high risk for dysphagia as defined by a DEFISS (Determine Extubation Failure In Severe Stroke) risk score and compared 1:1 to a retrospective matched patient control group. The prospective patient group received PES prior to extubation. Endpoints were need for reintubation, swallowing function as assessed with FEES, pneumonia incidence and length of stay after extubation.

RESULTS

Post-extubation, the Fiberoptic Endoscopic Dysphagia Severity Score (FEDSS, 4.31 ± 1.53vs.5.03 ± 1.28;p = 0.047) and reintubation rate within 72 h (9.4vs.34.4%;p = 0.032) were significantly lower in the PES group than in the historical control group. Pulmonary infections after extubation were less common in PES-treated patients although this difference was not significant (37.5vs.59.4%;p = 0.133). Time from extubation to discharge was significantly shorter after PES compared with the control group (14.09 ± 11.58vs.26.59 ± 20.49 days;p = 0.003).

CONCLUSIONS

In orally intubated and mechanically ventilated stroke patients at high risk of severe dysphagia, PES may improve swallowing function, reduce extubation failure risk and decrease time from extubation to discharge. Further research is required.

Pharyngeal Cavity Electrical Stimulation-Assisted Swallowing for Post-stroke Dysphagia: A Systematic Review and Meta-analysis of Randomized Controlled Studies

Stroke is the leading cause of death and disability among adults. The incidence of stroke per 100, 000 patient-years was 2875. As many as 37% to 78% of patients with acute strokes suffer dysphagia. Dysphagia can easily lead to inhalation pneumonia, dehydration, malnutrition, and other serious complications, affecting the quality of life of stroke patients and increasing their mortality. Effective prevention and treatment of post-stroke dysphagia are of great significance to improving the prognosis and quality of life of patients. Some studies have shown that Pharyngeal cavity electrical stimulation-assisted swallowing (PCES-assisted swallowing) has a positive effect on patients with post-stroke dysphagia. This study will evaluate the effects of PCES-assisted swallowing on post-stroke dysphagia, including swallowing function, withdrawal rate of nasal feeding tubes, duration of hospitalization, and so on. Randomized controlled trials (RCTs) of PCES-assisted swallowing in the treatment of post-stroke dysphagia were searched in eight databases, including Cochrane Library, Embase, PubMed, Web of Science, Chinese Biomedical Literature Database, VIP Information Resource System, CNKI, and Wanfang Medical Science. The retrieval time was from the database establishment to June 2022. Rayyan was used to screen the retrieved literature risk of bias for included studies and was calculated using ROB2.0. The RevMan 5.3 software was used for the meta-analysis with the standard mean difference (SMD) and 95% confidence interval (CI). The model type was a random effect model, The risk ratio (RR) was used as the effect size for the two categorical variables. The swallowing function scores, withdrawal rate of nasal feeding tubes, and Length of stay (LOS) of the intervention and control groups were extracted, and the results of the meta-analysis were presented using a forest plot. Six studies from 2010 to 2018 with a total of 341 people were included in the meta-analysis. All studies reported quantitative outcome measures for the severity of dysphagia, and some reported the withdrawal rate of nasal feeding tubes, LOS, and penetration-aspiration-scale (PAS). The overall swallowing function of the PCES group was better than that of the control group (SMD = - 0.20, 95%CI - 0.38 to - 0.03, P = 0.02). In terms of the severity of dysphagia, there was a statistically significant difference in the Dysphagia Severity Rating scale (DSRS) between the Pharyngeal cavity electrical stimulation (PCES) group and the control group (SMD = - 0.24, 95%CI - 0.48 to 0, P = 0.05). The PCES group nasal feeding withdrawal rate of nasal feeding tubes was higher than the control group (RR = 2.88, 95% CI 1.15 to 7.26, P = 0.02). There was no significant difference in the LOS between the PCES group and the control group (SMD = - 0.19, 95%CI - 0.44 to 0.07, P = 0.15). This systematic review and meta-analysis provide reasonably reliable evidence that PCES-assisted swallowing can improve nasogastric feeding swallowing function and the withdrawal rate of nasal feeding tubes in patients with post-stroke dysphagia. However, the evidence for reducing oral feeding, aspiration, and length of hospitalization stay is lacking, and further studies are needed.

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.

Rehabilitative intervention for successful decannulation in adult patients with acquired brain injury and tracheostomy: a systematic review

PURPOSE

Tracheostomy and dysphagia are independently associated with increased complications and poorer functional outcome after acquired brain injury (ABI). The aim of this study was to identify and evaluate rehabilitation to restore functional swallowing ability and respiratory capacity during tracheal tube weaning.

MATERIALS AND METHODS

The review was conducted according to PRISMA guidelines. Any study design with adult patients with ABI and tracheostomy was eligible. The primary outcome was decannulation.

RESULTS

A total of 2647 records were identified and eight papers included. Four studies investigated pharyngeal electrical stimulation (PES), two explored Facial Oral Tract Therapy (F.O.T.T.), one respiratory physiotherapy (RPT), and one study investigated external subglottic air flow (ESAF). Two RCTs found a significant difference between intervention and control on successful decannulation and readiness for decannulation in favour of PES. Time from rehabilitation admission and tracheostomy to decannulation was significantly reduced after implementing an F.O.T.T.-based protocol.

CONCLUSION

Four interventions were identified, PES, F.O.T.T., RPT, and ESAF, all aimed at increasing oropharyngeal sensory input through stimulation. Due to heterogeneity of interventions, designs and outcome measures, effect could not be estimated. This review highlights the limited research on rehabilitative interventions and thus the limited evidence to guide clinical rehabilitation.

Neurostimulation for treatment of post-stroke impairments

Neurostimulation, the use of electrical stimulation to modulate the activity of the nervous system, is now commonly used for the treatment of chronic pain, movement disorders and epilepsy. Many neurostimulation techniques have now shown promise for the treatment of physical impairments in people with stroke. In 2021, vagus nerve stimulation was approved by the FDA as an adjunct to intensive rehabilitation therapy for the treatment of chronic upper extremity deficits after ischaemic stroke. In 2024, pharyngeal electrical stimulation was conditionally approved by the UK National Institute for Health and Care Excellence for neurogenic dysphagia in people with stroke who have a tracheostomy. Many other approaches have also been tested in pivotal device trials and a number of approaches are in early-phase study. Typically, neurostimulation techniques aim to increase neuroplasticity in response to training and rehabilitation, although the putative mechanisms of action differ and are not fully understood. Neurostimulation techniques offer a number of practical advantages for use after stroke, such as precise dosing and timing, but can be invasive and costly to implement. This Review focuses on neurostimulation techniques that are now in clinical use or that have reached the stage of pivotal trials and show considerable promise for the treatment of post-stroke impairments.

Dysphagia Rehabilitation in Dysphagic Patients with Acute or Critical Illness: A Systematic Review and Meta-Analysis

Dysphagia or swallowing dysfunction is common in patients with acute or critical illness, and diverse methods of dysphagia rehabilitation are provided worldwide. We aimed to examine the efficacy of rehabilitation to treat dysphagia in patients with acute or critical illness. We searched PubMed, ICHUSHI, and Cochrane Central Register of Controlled Trials databases from inception to November 22, 2023 for relevant randomized controlled trials. We focused on dysphagic patients with acute or critical illness who were not orotracheally intubated. Our target intervention included conventional rehabilitation and nerve stimulation/neuromodulation techniques as dysphagia rehabilitation. Comparators were conventional or standard care or no dysphagia interventions. Primary outcomes included mortality, incidence of pneumonia during the study period, and health-related quality of life (HRQoL) scores within 90 days of hospital discharge. We pooled the data using a random-effects model, and classified the certainty of evidence based on the Grading of Recommendations, Assessment, Development, and Evaluation system. Nineteen randomized controlled trials involving 1,096 participants were included. Dysphagia rehabilitation was associated with a reduced incidence of pneumonia (risk ratio [RR], 0.66; 95% confidence interval [CI], 0.54-0.81; moderate certainty), but not with reduced mortality (RR, 0.92; 95% CI, 0.61-1.39; very low certainty) or improved HRQoL scores (mean difference, -0.20; 95% CI, -20.34 to 19.94; very low certainty). Based on the available moderate- or very low- quality evidence, while dysphagia rehabilitation had no impact on mortality or HRQoL, they might reduce the incidence of pneumonia in dysphagic patients with acute or critical illness.

Dysphagia after stroke: research advances in treatment interventions

After a stroke, most patients have dysphagia, which can lead to aspiration pneumonia, malnutrition, and adverse functional outcomes. Protective interventions aimed at reducing these complications remain the cornerstone of treatment. Dietary adjustments and oral hygiene help mitigate the risk of aspiration pneumonia, and nutritional supplementation, including tube feeding, might be needed to prevent malnutrition. Rehabilitative interventions aim to enhance swallowing function, with different behavioural strategies showing promise in small studies. Investigations have explored the use of pharmaceutical agents such as capsaicin and other Transient-Receptor-Potential-Vanilloid-1 (TRPV-1) sensory receptor agonists, which alter sensory perception in the pharynx. Neurostimulation techniques, such as transcranial direct current stimulation, repetitive transcranial magnetic stimulation, and pharyngeal electrical stimulation, might promote neuroplasticity within the sensorimotor swallowing network. Further advancements in the understanding of central and peripheral sensorimotor mechanisms in patients with dysphagia after a stroke, and during their recovery, will contribute to optimising treatment protocols.

Swallowing Rehabilitation: Tracing the Evolution of Assessment and Intervention Approaches for Dysphagia over 30 Years

Dysphagia or difficulty in swallowing is a common condition affecting millions worldwide. It can occur due to structural problems, neurological disorders, cancer treatment, aging, etc. Swallowing rehabilitation aims to help patients regain safe and efficient swallowing function through compensatory strategies and exercises. This literature review examines the recent advancements in swallowing rehabilitation techniques over the past three decades, with a focus on innovations in diagnostics, personalized medicine, and patient care.

Dysphagia therapy in adults with a tracheostomy: A scoping review protocol

BACKGROUND

Swallowing impairment (dysphagia) and tracheostomy coexist. Research in this area has often provided an overview of dysphagia management as a whole, but there is limited information pertaining to specific dysphagia therapy in the tracheostomy population. The aim of this scoping review is to provide a detailed exploration of the literature with regard to dysphagia therapeutic interventions in adults with a tracheostomy. The scoping review will describe current evidence and thus facilitate future discussions to guide clinical practice.

METHODS

A scoping review using the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews guideline will be used. Ten electronic databases from inception to December 2023 and grey literature will be searched. From identified texts forward and backward citation chasing will be completed. Data extraction will compose of population demographics, aetiology and dysphagia therapy (type, design, dose and intensity). A number of citations and papers included in the scoping review will be presented visually.

DISCUSSION

The scoping review aims to expand upon the existing literature in this field. A detailed description of the evidence is required to facilitate clinical discussions and develop therapeutic protocols in a tracheostomised population. The results of this scoping review will support future research in dysphagia therapy and provide the basis for the development of best practice guidelines.

WHAT THIS PAPER ADDS

What is already known on this subject There is an abundance of evidence available regarding dysphagia therapy targeting impairments of the swallowing sequence in a variety of populations including stroke, head and neck cancer, progressive neurological conditions and critical illness. However, there is a paucity in the literature with regard to identifying dysphagia therapy for adults with a tracheostomy. What this study adds The study protocol aims to describe the methodological features that need to be extracted from existing studies to outline dysphagia therapy for adults with a tracheostomy. To the researchers' knowledge, this is the first study protocol to describe the methodological features of dysphagia therapy for people with a tracheostomy from the literature using a standardised approach (Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guideline). This will ensure that the protocol is replicable for other researchers to use and demonstrates transparency in research methods. What are the clinical implications of this work? The development of a robust protocol is necessary in order to facilitate the scoping review to describe the current evidence and thus facilitate future discussions to guide clinical practice for speech and language therapists working with adults who have a tracheostomy and dysphagia. The publication of the scoping review protocol allows future clinical researchers in the area of tracheostomy and dysphagia management a blueprint with which to narrow their own research questions and it also enables replicability as the principles of good research practice dictate.

Continuous electrical stimulation of superior laryngeal nerve inhibits initiation of swallowing in anesthetized rats

Pharyngeal electrical stimulation (PES) applies electrical stimulation to pharyngeal mucosa (PhM) and represents a useful approach to improve swallowing function in patients with dysphagia. To determine the optimal PES modality to treat dysphagia, the mechanism underlying the effects of PES on swallowing function must be elucidated. In this study, we evaluated how PES and electrical stimulation of the superior laryngeal nerve (SLN) modulate the initiation of swallowing in anesthetized rats. A swallow was evoked by electrical stimulation of the PhM, SLN, and nucleus of the solitary tract (nTS) and pharyngeal mechanical stimulation using a von Frey filament. A swallow was identified by electromyographic bursts in mylohyoid and thyrohyoid muscles. Bilateral SLN transection abolished the swallows evoked by PhM electrical stimulation. PhM and SLN electrical stimulation decreased swallowing frequency in a similar time-dependent manner. Intravenous administration of the GABAA receptor antagonist bicuculine did not affect the time-dependent change in swallowing frequency during SLN electrical stimulation. Continuous SLN electrical stimulation significantly inhibited pharyngeal mechanically and nTS-electrically evoked swallows compared with before and 5 min after stimulation. The present findings suggest that the SLN plays a primary role in PES-evoked swallows. Additionally, continuous SLN electrical stimulation inhibits the initiation of swallowing, and the modulation of central network associated with swallowing might be partially involved in this inhibition.

Management of swallowing disorders in ICU patients - A multinational expert opinion

BACKGROUND

Dysphagia is common in intensive care unit (ICU) patients, yet it remains underrecognized and often unmanaged despite being associated with life-threatening complications, prolonged ICU stays and hospitalization.

PURPOSE

To propose an expert opinion for the diagnosis and management of dysphagia developed from evidence-based clinical recommendations and practitioner insights.

METHODS

A multinational group of dysphagia and critical care experts conducted a literature review using a modified ACCORD methodology. Based on a fusion of the available evidence and the panel's clinical experience, an expert opinion on best practice management was developed.

RESULTS

The panel recommends adopting clinical algorithms intended to promote standardized, high-quality care that triggers timely systematic dysphagia screening, assessment, and treatment of extubated and tracheostomized patients in the ICU.

CONCLUSIONS

Given the lack of robust scientific evidence, two clinical management algorithms are proposed for use by multidisciplinary teams to improve early systematic detection and effective management of dysphagia in ICU patients. Additionally, emerging therapeutic options such as neurostimulation have the potential to improve the quality of ICU dysphagia care.

Biomechanical and Cortical Control of Tongue Movements During Chewing and Swallowing

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

Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023 (J-ReCIP 2023)

Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the "Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit" to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.

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.

Efficacy and safety of oropharyngeal muscle strength training on poststroke oropharyngeal dysphagia: a systematic review and meta-analysis

OBJECTIVES

To investigate how oropharyngeal muscle strength training affected the safety and performance of swallowing in patients with poststroke oropharyngeal dysphagia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Central Register of Controlled of Trials, Web of Science, PubMed, Embase databases and ClinicalTrials.gov were systematically searched, for publications in English, from database inception to December 2022.

ELIGIBILITY CRITERIA

Studies comparing the effect of oropharyngeal muscle strength training with conventional dysphagia therapy in patients with poststroke. Penetration-Aspiration Scale (PAS) and Functional Oral Intake Scale (FOIS) were assessed as the main outcomes.

DATA EXTRACTION AND SYNTHESIS

Two researchers independently screened the literature, extracted data and evaluated the quality of the included studies, with disagreements resolved by another researcher. The Cochrane risk-of-bias tool was used to assess the risk of bias. Review Manager V.5.3 was employed for the meta-analysis. Random effect models were used for meta-analysis.

RESULTS

Seven studies with 259 participants were included in this meta-analysis. The results showed that oropharyngeal muscle strength training could reduce PAS score compared with conventional dysphagia therapy (mean difference=-0.98, 95% CI -1.34 to -0.62, p<0.0001, I2=28%). The results also showed that oropharyngeal muscle strength training could increase FOIS score (mean difference=1.04, 95% CI 0.55 to 1.54, p<0.0001, I2=0%) and the vertical displacement of the hyoid bone (mean difference=0.20, 95% CI 0.01 to 0.38, p=0.04, I2=0%) compared with conventional dysphagia therapy.

CONCLUSION

In patients with poststroke oropharyngeal dysphagia, oropharyngeal muscle strength training can improve swallowing safety and performance.

PROSPERO REGISTRATION NUMBER

CRD42022302471.

Development and validation of a machine learning-based prognostic risk stratification model for acute ischemic stroke

Acute ischemic stroke (AIS) is a most prevalent cause of serious long-term disability worldwide. Accurate prediction of stroke prognosis is highly valuable for effective intervention and treatment. As such, the present retrospective study aims to provide a reliable machine learning-based model for prognosis prediction in AIS patients. Data from AIS patients were collected retrospectively from the Second Affiliated Hospital of Xuzhou Medical University between August 2017 and July 2019. Independent prognostic factors were identified by univariate and multivariate logistic analysis and used to develop machine learning (ML) models. The ML model performance was assessed by area under the receiver operating characteristic curve (AUC) and radar plot. Shapley Additive explanations (SHAP) values were used to interpret the importance of all features included in the predictive model. A total of 677 AIS patients were included in the present study. Poor prognosis was observed in 209 patients (30.9%). Six variables, including neuron specific enolase (NSE), homocysteine (HCY), S-100β, dysphagia, C-reactive protein (CRP), and anticoagulation were included to establish ML models. Six different ML algorithms were tested, and Random Forest model was selected as the final predictive model with the greatest AUC of 0.908. Moreover, according to SHAP results, NSE impacted the predictive model the most, followed by HCY, S-100β, dysphagia, CRP and anticoagulation. Based on the RF model, an online tool was constructed to predict the prognosis of AIS patients and assist clinicians in optimizing patient treatment. The present study revealed that NSE, HCY, CRP, S-100β, anticoagulation, and dysphagia were important factors for poor prognosis in AIS patients. ML algorithms were used to develop predictive models for predicting the prognosis of AIS patients, with the RF model presenting the optimal performance.

[Diagnostics and treatment of post-stroke dysphagia]

BACKGROUND

Post-stroke dysphagia is highly prevalent and leads to severe complications, such as aspiration pneumonia and malnutrition. Despite the high clinical relevance dysphagia management is heterogeneous and often inadequate.

OBJECTIVE

The aim of this review article is to provide an overview of the diagnostic and treatment strategies for post-stroke dysphagia based on recent studies.

MATERIAL AND METHODS

Narrative literature review.

RESULTS

Dysphagia screening should be performed as early as possible in every stroke patient, e.g., with a simple water swallowing test or a multiconsistency protocol. Subsequently, flexible endoscopic evaluation of swallowing (FEES) is indicated in patients with abnormal screening results or existing risk factors for dysphagia. Dietary modifications, oral hygiene measures, and nutritional therapy can help reduce complications. Behavioral swallowing therapy or experimental therapies, such as neurostimulation procedures and pharmacological approaches aim to improve swallowing function and have shown promising results in studies.

CONCLUSION

Timely management of dysphagia is necessary to reduce complications.

Evaluating the Therapeutic Application of Neuromodulation in the Human Swallowing System

In the last two decades, the focus of neurogenic dysphagia management has moved from passive compensatory strategies to evidence-based rehabilitative approaches. Advances in technology have enabled the development of novel treatment approaches such as neuromodulation techniques, which target the promotion of neurological reorganization for functional recovery of swallowing. Given the rapid pace of development in the field, this review aims to summarize the current findings on the effects of neuromodulation techniques on the human swallowing system and evaluate their therapeutic potential for neurogenic dysphagia. Implications for future clinical research and practical considerations for using neuromodulation in clinical practice will also be discussed.

[Flexible endoscopic evaluation of swallowing in neurology]

BACKGROUND

Neurogenic dysphagia is a frequent symptom in a variety of neurological diseases. The establishment of the flexible endoscopic evaluation of swallowing (FEES) in the field of neurology has led to improvements in the diagnostics and treatment of patients with dysphagia.

OBJECTIVE

The aim of this review is to present the development of the FEES examination in the field of neurology. Furthermore, the additive value in the diagnostic classification of neurogenic dysphagia is elucidated and the impact on treatment management in patients with dysphagia is highlighted.

MATERIAL AND METHODS

Narrative literature review.

RESULTS

The FEES examination is a safe and well-tolerated method for the diagnostics of neurogenic dysphagia. It enables the valid investigation of the swallowing function within the very heterogeneous neurological patient population. It has become an important diagnostic tool, not only in the assessment of the severity of dysphagia and the risk of aspiration but also as a reliable method for the etiological classification of symptoms of deglutition disorders. As FEES can be performed at the bedside and does not require radiation exposure, it can be used not only to examine critically ill patients (point of care diagnostics) but also to monitor treatment.

CONCLUSION

The systematic endoscopic evaluation of swallowing is established as an important functional diagnostic tool in the field of neurology. Further developments to increase the use of FEES in clinically related disciplines such as neurosurgery, neuro-oncology or psychiatry are pending.

Gastrointestinal Dysfunction in Stroke

Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.

Clinical Practice Guidelines for Oropharyngeal Dysphagia

OBJECTIVE

Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one's physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia.

METHODS

Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology.

RESULTS

Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended.

CONCLUSION

This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

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.

A Novel Approach to Severe Chronic Neurogenic Dysphagia Using Pharyngeal Sensory Electrical Stimulation

ABSTRACT

The treatment options for severe chronic neurogenic dysphagia are limited. A patient, after resection of medulla oblongata hemangioblastoma, who failed to respond to 7 mos of traditional dysphagia rehabilitation therapy, was treated with prolonged pharyngeal sensory electrical stimulation for 39 sessions over 57 days. For the first time, this case report showed improvement in hypopharyngeal peak pressure (9.1 vs. 90.8 mm Hg) using high-resolution manometry. Reductions in the penetration and aspiration scale, secretion, and residue of the vallecular and pyriform sinus were verified by videofluoroscopic swallowing study and flexible endoscopic evaluation of swallowing. The Functional Oral Intake Scale score increased from 1 to 6. No adverse event was observed. This case report presented a potential therapeutic protocol for severe chronic neurogenic dysphagia, which might be instructive for clinical practice.

Relationship between post-stroke dysphagia and pharyngeal sensory impairment

BACKGROUND

Post-stroke dysphagia (PSD) is common and can lead to serious complications. Pharyngeal sensory impairment is assumed to contribute to PSD. The aim of this study was to investigate the relationship between PSD and pharyngeal hypesthesia and to compare different assessment methods for pharyngeal sensation.

METHODS

In this prospective observational study, fifty-seven stroke patients were examined in the acute stage of the disease using Flexible Endoscopic Evaluation of Swallowing (FEES). The Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS) and impaired secretion management according to the Murray-Secretion Scale were determined, as well as premature bolus spillage, pharyngeal residue and delayed or absent swallowing reflex. A multimodal sensory assessment was performed, including touch-technique and a previously established FEES-based swallowing provocation test with different volumes of liquid to determine the latency of swallowing response (FEES-LSR-Test). Predictors of FEDSS, Murray-Secretion Scale, premature bolus spillage, pharyngeal residue, and delayed or absent swallowing reflex were examined with ordinal logistic regression analyses.

RESULTS

Sensory impairment using the touch-technique and the FEES-LSR-Test were independent predictors of higher FEDSS, Murray-Secretion Scale, and delayed or absent swallowing reflex. Decreased sensitivity according to the touch-technique correlated with the FEES-LSR-Test at 0.3 ml and 0.4 ml, but not at 0.2 ml and 0.5 ml trigger volumes.

CONCLUSIONS

Pharyngeal hypesthesia is a crucial factor in the development of PSD, leading to impaired secretion management and delayed or absent swallowing reflex. It can be investigated using both the touch-technique and the FEES-LSR-Test. In the latter procedure, trigger volumes of 0.4 ml are particularly suitable.

Neuroplasticity Elicited by Modified Pharyngeal Electrical Stimulation: A Pilot Study

Modified pharyngeal electrical stimulation (mPES) is a novel therapeutic method for patients with neurogenic dysphagia and tracheostomy. However, the underlying neural mechanisms are still unclear. This study aims to investigate the impact of mPES on swallowing-related neural networks and involuntary swallowing frequency using functional near-infrared spectroscopy (fNIRS). 20 healthy volunteers participated in this study, including two separate experimental paradigms. Experiment 1: Immediate effect observation, 20 participants (10 female; mean age 47.65 ± 10.48) were delivered with real and sham mPES in random order for 8 repetitions. fNIRS signals were collected during the whole period of Experiments 1. Swallowing frequency was assessed during sham/real mPES. Experiment 2: Prolonged effect observation, 7 out of the 20 participants (4 female; mean age 49.71 ± 6.26) completed real mPES for 5 sessions (1 session/day). 13 of the 20 participants withdrew for personal reasons. Hemodynamic changes were recorded by fNIRS on day 1 and 5. Results show that mPES evoked cortical activation over a distributed network in bilateral primary somatosensory, primary motor, somatosensory association cortex, pre-motor and supplementary motor area, dorsolateral prefrontal cortex, Broca's area, and supramarginal gyrus part of Wernicke's area. Meanwhile, the increased frequency of involuntary swallowing was associated with decreased frontopolar activation (frontopolar cortex: Channel 6, p = 0.024, r = -0.529; Channel 23, p = 0.019, r = -0.545). Furthermore, after five days of mPES, decreased cortical activations were observed in the right dorsolateral prefrontal and supramarginal gyrus part of Wernicke's area, and left frontopolar and M1 areas. Overall, these results might suggest that mPES could elicit changes in neuroplasticity that could reorganize the swallowing-related neural network and increase involuntary swallow frequency.

The Biomechanical Characteristics of Swallowing in Tracheostomized Patients with Aspiration following Acquired Brain Injury: A Cross-Sectional Study

Objectives: Investigate the biomechanical characteristics in tracheostomized patients with aspiration following acquired brain injury (ABI) and further explore the relationship between the biomechanical characteristics and aspiration. Methods: This is a single-center cross-sectional study. The tracheostomized patients with aspiration following ABI and age-matched healthy controls were recruited. The biomechanical characteristics, including velopharynx (VP) maximal pressure, tongue base (TB) maximal pressure, upper esophageal sphincter (UES) residual pressure, UES relaxation duration, and subglottic pressure, were examined by high-resolution manometry and computational fluid dynamics simulation analysis. The penetration−aspiration scale (PAS) score was evaluated by a videofluoroscopic swallowing study. Results: Fifteen healthy subjects and fifteen tracheostomized patients with aspiration following ABI were included. The decreased VP maximal pressure, increased UES residual pressure, and shortened UES relaxation duration were found in the patient group compared with the control group (p < 0.05). Furthermore, the subglottic pressure significantly decreased in patients (p < 0.05), while no significant difference was found in TB maximal pressure between groups (p > 0.05). In addition, in the patient group, VP maximal pressure (rs = −0.439; p = 0.015), UES relaxation duration (rs = −0.532; p = 0.002), and the subglottic pressure (rs = −0.775; p < 0.001) were negatively correlated with the PAS score, while UES residual pressure (rs = 0.807; p < 0.001) was positively correlated with the PAS score (p < 0.05), the correlation between TB maximal pressure and PAS score (rs = −0.315; p = 0.090) did not reach statistical significance. Conclusions: The biomechanical characteristics in tracheostomized patients with aspiration following ABI might manifest as decreased VP maximal pressure and subglottic pressure, increased UES residual pressure, and shortened UES relaxation duration, in which VP maximal pressure, UES relaxation duration, subglottic pressure, and UES residual pressure were correlated with aspiration.

Long-Term Clinical Trajectory of Patients with Subarachnoid Hemorrhage: Linking Acute Care and Neurorehabilitation

BACKGROUND

Despite improvements in the critical care management of subarachnoid hemorrhage (SAH), a substantial number of patients still suffer from disabilities. In most areas of the world, longitudinal follow-up is not routinely performed, and the patient's trajectory remains unknown.

METHODS

We prospectively collected data of 298 consecutive patients with spontaneous SAH and evaluated clinical trajectories at discharge, 3 months, and 1 year after SAH. In a subgroup of patients transferred to a local neurorehabilitation center (Rehab-Hochzirl), we studied the effects of rehabilitation intensity on clinical trajectories. Any decrease in the modified Rankin Scale (mRS) was defined as an improvement, with mRS ≤ 2 indicating good outcome. We used multivariate generalized linear models to investigate associations with clinical trajectories.

RESULTS

Out of the 250 surviving patients, 35% were transferred directly to Rehab-Hochzirl (n = 87 of 250; mRS at discharge = 4), 11% were transferred to another rehabilitation center (n = 27 of 250; mRS = 1), 1% were transferred to a nursing home (n = 3 of 250; mRS = 5), 21% were transferred to their country of origin (n = 52 of 250; mRS = 4), and 32% (n = 79 of 250; mRS = 1) were discharged home. Functional outcome improved in 57% (n = 122 of 215) of patients during the first 3 months, with an additional 16% (35 of 215) improving between 3 and 12 months, resulting in an overall improvement in 73% (n = 157 of 215) of survivors. After 1 year, 60% (n = 179 of 250) of patients were functionally independent. A lower Hunt and Hess scale score at intensive care unit admission, younger age, a lower mRS at intensive care unit discharge, fewer days on mechanical ventilation, and male sex were independently associated with better functional recovery. Although the subgroup of patients transferred to Rehab-Hochzirl were more severely affected, 60% (52 of 87) improved during inpatient neurorehabilitation.

CONCLUSIONS

Our results indicate ongoing functional improvement in a substantial number of patients with SAH throughout a follow-up period of 12 months. This effect was also observed in patients with severe disability receiving inpatient neurorehabilitation.

Costs of post-stroke dysphagia during acute hospitalization from a health-insurance perspective

Purpose:

Oropharyngeal dysphagia is a common and complication-prone symptom after stroke and is assumed to increase medical expenses. The purpose of this study was therefore to examine acute hospitalization costs associated with post-stroke dysphagia.

Method:

This retrospective study included patients with acute stroke who had been examined by Flexible Endoscopic Evaluation of Swallowing (FEES). Health insurance expenditures were determined for the patient cases according to the 2021 revenue criteria. Multiple linear regression was used to examine predictors of health insurance spending including age, sex, stroke severity, stroke characteristics, comorbidity, therapeutic interventions, duration of artificial ventilation, length of hospital stay, and severity of dysphagia, as assessed by the Fiberoptic Endoscopic Dysphagia Severity Scale (FEDSS), ranging from 1 (best) to 6 (worst).

Findings:

Six hundred seventy four patients (men/women: 367/307; mean age: 71.1 ± 12.8 years; mean National Institute of Health Stroke Scale: 11.2 ± 6.2; FEDSS 1/2/3/4/5/6: 113/73/144/119/124/101; mean health-insurance costs 11,521.5 ± 12,950.5€) were included in the analysis. Advanced age ( p = 0.007; B = 57.6), catheter interventions ( p < 0.001; B = 4105.6), tracheotomy ( p = 0.006; B = 5195.2), duration of artificial ventilation ( p < 0.001; B = 388.6), length of hospital stay ( p < 0.001; B = 441.9), and severe dysphagia with an FEDSS of 6 ( p = 0.004, B = 2554.3) were independent predictors of increased health insurance expenditures ( p < 0.001, R-squared = adjusted-R-squared = 0.83).

Discussion and conclusion:

The results of this study show an association between severe dysphagia and health care costs for acute hospitalization from a health-insurance perspective. Therefore, therapies that target severe dysphagia with impaired secretion management may have the potential to reduce costs.

Dysphagia in Intensive Care Evaluation (DICE): An International Cross-Sectional Survey

Dysphagia occurs commonly in the intensive care unit (ICU). Despite the clinical relevance, there is little worldwide research on prevention, assessment, evaluation, and/or treatment of dysphagia for ICU patients. We aimed to gain insight into this international knowledge gap. We conducted a multi-center, international online cross-sectional survey of adult ICUs. Local survey distribution champions were recruited through professional and personal networks. The survey was administered from November 2017 to June 2019 with three emails and a final telephone reminder. Responses were received from 746 ICUs (26 countries). In patients intubated > 48 h, 17% expected a > 50% chance that dysphagia would develop. This proportion increased to 43% in patients intubated > 7 days, and to 52% in tracheotomized patients. Speech-language pathologist (SLP) consultation was available in 66% of ICUs, only 4% reported a dedicated SLP. Although 66% considered a routine post-extubation dysphagia protocol important, most (67%) did not have a protocol. Few ICUs routinely assessed for dysphagia after 48 h of intubation (30%) or tracheostomy (41%). A large proportion (46%) used water swallow screening tests to determine aspiration, few (8%) used instrumental assessments (i.e., flexible endoscopic evaluation of swallowing). Swallowing exercises were used for dysphagia management by 30% of ICUs. There seems to be limited awareness among ICU practitioners that patients are at risk of dysphagia, particularly as ventilation persists, protocols, routine assessment, and instrumental assessments are generally not used. We recommend the development of a research agenda to increase the quality of evidence and ameliorate the implementation of evidence-based dysphagia protocols by dedicated SLPs.

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.

Research progress of clinical intervention and nursing for patients with post-stroke dysphagia

Post-stroke dysphagia (PSD) is a common and costly complication of stroke and is associated with increased mortality, morbidity, and hospitalization. Although most patients can spontaneously resume swallowing, there are still many patients who do not recover and even die. Despite multiple advances in the acute treatment and secondary prevention of stroke, the effective treatment of PSD remains a neglected area. Studies have shown that repair mechanisms of neurostimulation techniques and increased cortical activity play an important role in the treatment of PSD. In addition, nutritional interventions are also crucial for the treatment of malnutrition in PSD patients. Therefore, this article reviews the effects of the current main clinical treatment methods and nutritional interventions on the treatment and rehabilitation of PSD patients. It also emphasized the necessity of developing an individualized care plan for PSD patients, which is of great significance to promote the clinical treatment, nutritional status, prognosis, and quality of life of PSD patients.

Gram-negative multidrug-resistant organisms were dominant in neurorehabilitation ward patients in a general hospital in southwest China

This study aimed to investigate the prevalence of and risk factors for multidrug-resistant organism (MDRO) infection in the rehabilitation ward of a general hospital in Southwest China. We analyzed rehabilitation patients with nosocomial infections caused by MDROs from June 2016 to June 2020. MDRO infection pathogens and associated antibiotic resistance were calculated. Possible risk factors for MDRO-related infection in the neurorehabilitation ward were analyzed using chi-square, and logistic regression. A total of 112 strains of MDRO were found positive from 96 patients. The MDRO test-positive rate was 16.70% (96/575). Ninety-five MDRO strains were detected in sputum, of which 84.82% (95/112) were gram-negative bacteria. Acinetobacter baumannii (A. Baumannii), Pseudomonas aeruginosa (P. aeruginosa), and Klebsiella pneumonia (K. pneumonia) were the most frequently isolated MDRO strains. The logistic regression model and multifactorial analysis showed that long-term (≥ 7 days) antibiotic use (OR 6.901), history of tracheotomy (OR 4.458), and a low albumin level (< 40 g/L) (OR 2.749) were independent risk factors for the development of MDRO infection in patients in the rehabilitation ward (all P < 0.05). Gram-negative MRDOs were dominant in rehabilitation ward patients. Low albumin, history of a tracheostomy, and long-term use of antibiotics were independent risk factors for MRDO infection and are worthy of attention.

Peripheral Organ Injury After Stroke

Stroke is a disease with high incidence, mortality and disability rates. It is also the main cause of adult disability in developed countries. Stroke is often caused by small emboli on the inner wall of the blood vessels supplying the brain, which can lead to arterial embolism, and can also be caused by cerebrovascular or thrombotic bleeding. With the exception of recombinant tissue plasminogen activator (rt-PA), which is a thrombolytic drug used to recanalize the occluded artery, most treatments have been demonstrated to be ineffective. Stroke can also induce peripheral organ damage. Most stroke patients have different degrees of injury to one or more organs, including the lung, heart, kidney, spleen, gastrointestinal tract and so on. In the acute phase of stroke, severe inflammation occurs in the brain, but there is strong immunosuppression in the peripheral organs, which greatly increases the risk of peripheral organ infection and aggravates organ damage. Nonneurological complications of stroke can affect treatment and prognosis, may cause serious short-term and long-term consequences and are associated with prolonged hospitalization and increased mortality. Many of these complications are preventable, and their adverse effects can be effectively mitigated by early detection and appropriate treatment with various medical measures. This article reviews the pathophysiological mechanism, clinical manifestations and treatment of peripheral organ injury after stroke.

Safety and performance of oropharyngeal muscle strength training in the treatment of post-stroke dysphagia during oral feeding: protocol for a systematic review and meta-analysis

INTRODUCTION

Dysphagia is a common functional disorder after stroke. Most patients post-stroke are incapable of oral feeding, which often leads to complications such as malnutrition, aspiration pneumonia and dehydration that seriously affect the quality of life of patients. Oropharyngeal muscle strength training is a major method of swallowing training, and recent studies have focused on healthy adults, elderly persons, and patients with head and neck cancer or neurodegenerative diseases; but there have been few studies on such training in patients with post-stroke dysphagia. Our study aims to systematically review the safety and performance of oropharyngeal muscle strength training in the treatment of post-stroke dysphagia during oral feeding.

METHODS AND ANALYSIS

The Cochrane Library, Web of Science, PubMed, Embase and ClinicalTrials.gov databases will be systematically searched, and all relevant articles in English from the establishment of the databases to January 2022 will be reviewed. The study will be conducted in accordance with the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions and will be reported in accordance with Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines. The primary outcome measures include the Penetration-Aspiration Scale and the Functional Oral Intake Scale. Two authors will independently screen the articles, extract the data and assess the study quality. Any disagreements during this process will be resolved by discussion or by consultation with a third author. Next, quantitative or qualitative, subgroup and sensitivity analyses of the included literature data will be performed as appropriate.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review as no primary data collection will be required. The results of the present study will be published in a peer-reviewed journal in the field of deglutition disorders.

PROSPERO REGISTRATION NUMBER

CRD42022302471.

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.

Endpoints in Dysphagia Trials. Comment on Speyer et al. Neurostimulation in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analyses of Randomised Controlled Trials-Part I: Pharyngeal and Neuromuscular Electrical Stimulation. J. Clin. Med. 2022, 11, 776

We read with interest the authors' systematic review and meta-analysis of pharyngeal electrical stimulation (PES) and neuromuscular electrical stimulation (NMES) in patients with oropharyngeal dysphagia (OD) [...].

Post-stroke Dysphagia: Prognosis and Treatment-A Systematic Review of RCT on Interventional Treatments for Dysphagia Following Subacute Stroke

Purpose

Post-stroke dysphagia is an underdiagnosed but relevant complication, associated with worse outcome, dependency and quality of life of stroke survivors. Detailed mechanisms of post-stroke dysphagia are not very well understood, but established therapeutic concepts are needed. Different interventional studies have been published dealing with post-stroke dysphagia. This systematic review wants to collect and give an overview over the published evidence.

Methods

PubMed, Embase, Cochrane, CINAHL were searched for relevant interventional studies on post-stroke dysphagia in the (sub-)acute setting (within 3 months of stroke onset). The search has been filtered for randomized trials with an inactive control and the relevant data extracted.

Results

After initially finding 2,863 trials, finally 41 trials have been included. Seven different therapeutic concepts have been evaluated (Acupuncture, behavioral/physical therapy, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, transcranial direct current stimulation and repetitive transcranial magnetic stimulation). Studies of all modalities have shown some effect on post-stroke dysphagia with several studies raising concerns about the potential bias.

Conclusion

The amount and quality of studies are not enough to suggest certain therapies. Some therapeutical concepts (intensive physical therapy, transcranial magnetic stimulation, drug therapy) seem to be good potential therapeutic options, but further research is needed.

Efficacy and Safety of Transcranial Direct Current Stimulation on Post-Stroke Dysphagia: A Systematic Review and Meta-Analysis

Dysphagia is one of the most common symptoms in patients after stroke onset, which has multiple unfavorable effects on quality of life and functional recovery. Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation that is widely used to improve deglutition function. Recently, some studies have confirmed that tDCS enhances deglutition function after stroke. However, the number of evaluation indexes used in those studies was small, and the number of trials included was limited. Most importantly, the optimal stimulation protocol is still uncertain and the safety of tDCS has not been reviewed. Therefore, we conducted a systematic review and meta-analysis to address these shortcomings.

METHODS

Seven databases were searched entirely, including Pubmed, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Service System (SinoMed), Wan-fang database, and the Chinese Scientific Journals Database (VIP) from inception to 31 December 2021. Two reviewers independently evaluated the eligibility of retrieved data according to the selection criteria and assessed the methodological quality of the studies using the Cochrane risk of bias tool. Outcomes, measures, and indicators used in this study included the dysphagia outcome and severity scale (DOSS), modified Mann assessment of swallowing ability (MMASA), functional oral intake scale (FOIS), functional dysphagia scale (FDS), and Kubota's water-drinking test (KWDT). Sensitivity and subgroup analyses were performed to evaluate the intervention effect more specifically.

RESULTS

Fifteen trials with a total of 787 participants (394 subjects in the tDCS groups were treated with true tDCS, and 393 subjects in the control groups were wait-listed or treated with sham tDCS) involving tDCS for dysphagia after stroke and were included in the meta-analysis. Results of this meta-analysis confirmed that tDCS had a positive effect on post-stroke dysphagia. Subgroup analyses revealed that bilateral and high-intensity stimulation with tDCS had a more significant impact on post-stroke dysphagia. Furthermore, no adverse events occurred during the application of tDCS for post-stroke dysphagia.

CONCLUSION

tDCS can promote the recovery of deglutition function in patients with dysphagia after stroke. In addition, bilateral stimulation and high-intensity stimulation may have better effects. However, the safety evidence for tDCS and post-stroke dysphagia is insufficient.

[Update on Intensive Care Unit Management of Stroke]

In this review, we provide an update on the intensive care unit (ICU) management of ischemic stroke. Over the last decade, new evidence has led to rapid changes in the early management of patients admitted with acute ischemic stroke. Nevertheless, stroke remains a leading cause of disability. Consequently, a significant number of patients with acute ischemic stroke require ICU level care. The most frequent reasons for ICU admissions are large infarction with potential swelling, reduced level of consciousness, secondary hemorrhagic transformation, acute symptomatic seizures or respiratory failure and stroke-related disorders of the brain-heart interaction. Moreover, there is an increasing number of patients receiving intravenous thrombolysis or mechanical thrombectomy with a subsequent need of ICU monitoring. Several studies have shown that the implementation of specialized neuro-intensive care teams help to improve functional outcome after acute ischemic stroke. The main goal in the ICU management of stroke patients is to prevent secondary brain injury. To this end, a comprehensive approach to optimize systemic physiological homeostasis, control intracranial pressure, cerebral perfusion, hemodynamic and respiratory parameters is needed. Here, we summarize recent advances in invasive and non-invasive neuro-monitoring, decision making in decompressive neurosurgery for large supratentorial or cerebellar infarction, specific cardiorespiratory management, nutrition, temperature management and mobilization strategies in ischemic stroke.

[Postextubation dysphagia in intensive care patients : Current findings and clinical recommendations]

BACKGROUND

A considerable number of critically ill and mechanically ventilated intensive care patients show pronounced dysphagia after extubation. Many studies have shown that postextubation dysphagia (PED) leads to a significant decline of outcome. The awareness, timely diagnostic procedures and integration of suitable treatment methods in intensive care units are therefore of great importance.

OBJECTIVE

Current basic findings on PED, diagnostic possibilities, therapeutic methods as well as the development of concrete recommendations for clinical practice.

METHODS

A selective literature search was performed in PubMed, Medline and Cochrane using keywords.

RESULTS

In the literature the incidence PED is reported very heterogeneous but is probably at least 10% in intensive care patients after mechanical ventilation. The duration of intubation plays a critical role here. A multifactorial interaction of several factors is assumed to be the cause, whereby the impairment of laryngeal structures is of particular relevance. A PED leads to longer hospital stays, higher mortality, more reintubation and a higher number of patients with tube feeding. With respect to diagnostics, screening by trained nurses, clinical swallowing examinations and, in particular, the use of instrumental examinations by flexible endoscopic evaluation of swallowing (FEES) are recommended. The treatment should include adaptive measures in the sense of an adapted diet but also functional exercises. Innovative approaches, such as electrical stimulation are also conceivable. The aim is primarily to avoid penetration and aspiration in order to counteract respiratory complications.

CONCLUSION

In many intensive care units the clinical picture of PED is still neglected despite clear evidence. A simple algorithm in the treatment of intensive care patients can contribute to early detection and initiation of further steps. These should be integrated into clinical treatment standards.

Pharyngeal electrical stimulation in amyotrophic lateral sclerosis: a pilot study

Background:

Patients with amyotrophic lateral sclerosis (ALS) suffer from dysphagia that increases the risk for aspiration, pneumonia and weight loss. Pharyngeal electrical stimulation (PES) is a therapeutic technique that applies electric stimuli to the patient’s pharynx in order to improve swallowing based on the principle of cortical plasticity and reorganization. Previous studies have demonstrated positive effects in patients with various neurological diseases.

Objective:

This study was initiated to investigate the effect of PES on swallowing function in patients with ALS.

Methods:

In all, 20 ALS patients with severe dysphagia [characterized by a Penetration Aspiration Scale (PAS) of at least 4 in thin liquid] were randomized to receive either PES for 10 min at 3 consecutive days in addition to Standard Logopaedic Therapy (SLT) or SLT alone. Swallowing function was evaluated by Fiberoptic Endoscopic Evaluation of Swallowing (FEES) at five timepoints: at baseline, 1 day, 4 days, 3 weeks and 3 months after treatment. Primary endpoint was the severity of penetrations or aspirations as classified by PAS. Secondary endpoints were adverse events, dysphagia-related quality of life, Swallowing Quality of Life (SWAL-QOL), Dysphagia Severity Rating Scale (DSRS), residues, leaking, ALS Functional Rating Scale Revised (ALSFRS-R), and the performance in Clinical Evaluation of Swallowing (CES). The trial is registered under the name of ‘Pharyngeal Electrical Stimulation in Amyotrophic Lateral Sclerosis’ with ClinialTrials.gov, number NCT03481348 (https://clinicaltrials.gov/ct2/show/NCT03481348).

Results:

Both groups combined showed a significant improvement (p = 0.003) of median Total-PAS from 3.6 [interquartile range (IQR) = 2.9–5.0] at baseline to 2.3 (IQR = 1.8–4.0) 1 day after treatment. During subsequent study visits, PAS increased again but remained below baseline. PES and control group did not differ significantly 1 day after intervention (p = 0.32). Similar effects were found in the majority of secondary endpoints.

Interpretation:

The findings suggest that PES may not provide an additional positive effect on swallowing function in ALS. SLT seems to yield at least short-term positive effects on swallowing function and swallowing-specific life quality in ALS.

Registration: ClinialTrials.gov: NCT03481348

Neurostimulation in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analyses of Randomised Controlled Trials-Part I: Pharyngeal and Neuromuscular Electrical Stimulation

Objective. To assess the effects of neurostimulation (i.e., neuromuscular electrical stimulation (NMES) and pharyngeal electrical stimulation (PES)) in people with oropharyngeal dysphagia (OD). Methods. Systematic literature searches were conducted to retrieve randomised controlled trials in four electronic databases (CINAHL, Embase, PsycINFO, and PubMed). The methodological quality of included studies was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Results. In total, 42 studies reporting on peripheral neurostimulation were included: 30 studies on NMES, eight studies on PES, and four studies on combined neurostimulation interventions. When conducting meta analyses, significant, large and significant, moderate pre-post treatment effects were found for NMES (11 studies) and PES (five studies), respectively. Between-group analyses showed small effect sizes in favour of NMES, but no significant effects for PES. Conclusions. NMES may have more promising effects compared to PES. However, NMES studies showed high heterogeneity in protocols and experimental variables, the presence of potential moderators, and inconsistent reporting of methodology. Therefore, only conservative generalisations and interpretation of meta-analyses could be made. To facilitate comparisons of studies and determine intervention effects, there is a need for more randomised controlled trials with larger population sizes, and greater standardisation of protocols and guidelines for reporting.

Scoping review to identify and map non-pharmacological, non-surgical treatments for dysphagia following moderate-to-severe acquired brain injury

INTRODUCTION

Dysphagia is a common and critical consequence of acquired brain injury (ABI) and can cause severe complications. Dysphagia rehabilitation is transforming from mainly compensatory strategies to the retraining of swallowing function using principles from neuroscience. However, there are no studies that map interventions available to retrain swallowing function in patients with moderate-to-severe ABI.

OBJECTIVE

To systematically map the accessible research literature to answer the research question: Which non-surgical, non-pharmacological interventions are used in the treatment of dysphagia in patients with moderate and severe ABI in the acute and subacute phase? DESIGN: Scoping review based on the methodology of Arksey and O'Malley and methodological advancement by Levac et al. DATA SOURCES: MEDLINE, Embase, Cochrane Library, CINAHL, PsycINFO, Web of Science, OTseeker, speechBITE and PEDro were searched up until 14 March 2021.

ELIGIBILITY CRITERIA

All studies reporting rehabilitative interventions within 6 months of injury for patients with moderate-to-severe ABI and dysphagia were included.

DATA EXTRACTION AND SYNTHESIS

Data was extracted by two independent reviewers and studies were categorised based on treatment modality.

RESULTS

A total of 21 396 records were retrieved, and a final of 26 studies were included. Interventions were categorised into cortical or non-cortical stimulation of the swallowing network. Cortical stimulation interventions were repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation. Non-cortical were complex swallowing interventions, neuromuscular electrical stimulation, pharyngeal electrical stimulation (PES), sensory stimulation, strengthening exercises and respiratory muscle training.

CONCLUSION

This scoping review provides an overview of rehabilitative dysphagia interventions for patients with moderate and severe ABI, predominantly due to stroke, in the acute and subacute phase. Positive tendencies towards beneficial effects were found for rTMS, complex swallowing interventions, PES and cervical strengthening. Future studies could benefit from clear reporting of patient diagnosis and disease severity, the use of more standardised treatment protocols or algorithms and fewer but standardised outcome measures to enable comparison of effects across studies and interventions.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

Risk Factors for Dysphagia and the Impact on Outcome After Spontaneous Subarachnoid Hemorrhage

Background

Despite the tremendous impact of swallowing disorders on outcome following ischemic stroke, little is known about the incidence of dysphagia after subarachnoid hemorrhage (SAH) and its contribution to hospital complications, length of intensive care unit stay, and functional outcome.

Methods

This is a retrospective analysis of an ongoing prospective cohort study. Swallowing ability was assessed in consecutive non-traumatic SAH patients admitted to our neurological intensive care unit using the Bogenhausen Dysphagia Score (BODS). A BODS > 2 points indicated dysphagia. Functional outcome was assessed 3 months after the SAH using the modified Rankin Scale with a score > 2 defined as poor functional outcome.

Results

Two-hundred and fifty consecutive SAH patients comprising all clinical severity grades with a median age of 57 years (interquartile range 47–67) were eligible for analysis. Dysphagia was diagnosed in 86 patients (34.4%). Factors independently associated with the development of dysphagia were poor clinical grade on admission (Hunt & Hess grades 4–5), SAH-associated parenchymal hematoma, hydrocephalus, detection of an aneurysm, and prolonged mechanical ventilation (> 48 h). Dysphagia was independently associated with a higher rate of pneumonia (OR = 4.32, 95% CI = 2.35–7.93), blood stream infection (OR = 4.3, 95% CI = 2.0–9.4), longer ICU stay [14 (8–21) days versus 29.5 (23–45) days, p < 0.001], and poor functional outcome after 3 months (OR = 3.10, 95% CI = 1.49–6.39).

Conclusions

Dysphagia is a frequent complication of non-traumatic SAH and associated with poor functional outcome, infectious complications, and prolonged stay in the intensive care unit. Early identification of high-risk patients is needed to timely stratify individual patients for dysphagia treatment.

Electronic supplementary material

The online version of this article (10.1007/s12028-019-00874-6) contains supplementary material, which is available to authorized users.