Oropharyngeal dysphagia management in cervical spinal cord injury patients: an exploratory survey of variations to care across specialised and non-specialised units

Grb2 Expression in Acute Spinal Cord Injury After Methylprednisolone Intrathecal Injection in Rats

OBJECTIVE

This study aims to investigate the effect of methylprednisolone (MP) intrathecal injection on a rat model of acute spinal cord injury (ASCI).

METHODS

Allen's frame was used to establish a rat model of ASCI. MP and normal saline were intrathecally injected to Sprague-Dawley rats at 0, 3, 6, 8, 12, and 24 hours after ASCI, and injured spinal cord tissues were sterilely extracted after 24 hours of treatment. Isobaric tags for relative and absolute quantitation (iTRAQ) were coupled with 2-dimensional liquid chromatography tandem mass spectrometry to separate and identify differentially expressed proteins.

RESULTS

The expression of growth factor receptor-bound protein 2 (Grb2) was downregulated in the MP groups at 0 hours (iTRAQ ratio = 0.996), 3 hours (iTRAQ ratio = 0.737), 8 hours (iTRAQ ratio = 0.763), and 24 hours (iTRAQ ratio = 0.908) after injury compared with that in the control groups. No significant difference in Grb2 expression was observed between the control groups at 6 and 12 hours after ASCI.

CONCLUSIONS

Standardized MP intrathecal injection after ASCI treatment reduces Grb2 activation in a rat ASCI model. Further studies should determine whether or not the same effect can be observed in human ASCIs.

Rehabilitation interventions for weaning from mechanical ventilation in patients with spinal cord injury: A systematic review

BACKGROUND

Despite the fact that weaning from mechanical ventilation (MV) is one of the main rehabilitation goals in patients with spinal cord injury (SCI), controversies are still open about the optimal rehabilitation approach.

OBJECTIVE

This systematic review aimed at characterizing the rehabilitation interventions currently available to optimize weaning from MV in SCI patients.

METHODS

On April 12nd, 2022, a systematic literature search was performed in PubMed, Scopus, Web of Science, Cochrane, and PEDro, identifying studies assessing MV patients with SCI undergoing pulmonary rehabilitation. The primary outcomes were weaning duration, MV duration, and weaning success rate. Secondary outcomes were pulmonary function, extubation or decannulation time, length of stay, and safety.

RESULTS

Out of 413 records, 14 studies were included (2 randomized controlled trials, 7 observational studies, and 5 case reports). Most of the studies assessed a comprehensive rehabilitation approach, including high tidal volume ventilation, positioning, mechanical lung recruitment maneuvers, secretion management strategies, respiratory muscle training, and electrical stimulation.

CONCLUSION

Our findings suggested that a comprehensive rehabilitation intervention might have a role in reducing MV duration in patients with SCI. Further studies are needed to better characterize the optimal rehabilitation strategies for enhancing functional recovery of patients with SCI.

Deglutition and the Regulation of the Swallow Motor Pattern

Despite centuries of investigation, questions and controversies remain regarding the fundamental genesis and motor pattern of swallow. Two significant topics include inspiratory muscle activity during swallow (Schluckatmung, i.e., "swallow-breath") and anatomical boundaries of the swallow pattern generator. We discuss the long history of reports regarding the presence or absence of Schluckatmung and the possible advantages of and neural basis for such activity, leading to current theories and novel experimental directions.

Videofluoroscopic Profiles of Swallowing and Airway Protection Post-traumatic Cervical Spinal Cord Injury

Videofluoroscopic analyses of swallowing in survivors of traumatic cervical spinal cord injury (tCSCI) have been largely limited to case reports/series and qualitative observations. To elucidate the disrupted physiology specifically underlying dysphagia post-tCSCI, this prospective observational study analyzed videofluoroscopic swallow studies (recorded at 30 frames per second) across 20 tCSCI survivors. Norm-referenced measures of swallow timing or displacement, and calibrated area measures of laryngeal vestibule closure (LVC) were explored in relation to the severity of aspiration or pharyngeal residue. Videofluoroscopic performance was compared by injury level, surgical intervention, tracheostomy status, and in relation to clinical bedside assessments. Reduced pharyngeal constriction, delayed hyoid elevation, and impaired LVC characterized post-tCSCI dysphagia. Reduced extent of hyoid excursion and of pharyngoesophageal segment (PES) opening were not as prominent, only present in approximately half or less of the sample. Ten participants aspirated and 94% of aspiration events were silent. Severity of aspiration significantly correlated with pharyngeal constriction and prolonged pharyngeal transit times. Post-swallow residue correlated with delayed PES distention/closure and prolonged pharyngeal transit. Clinical inference regarding the integrity of the pharyngeal phase at bedside was limited; however, EAT-10 scores demonstrated promise as an adjuvant clinical marker of post-tCSCI dysphagia. This exploratory study further describes the pathophysiology underlying post-tCSCI dysphagia to promote deficit-specific rehabilitation and functional recovery.

Development of a swallowing risk screening tool and best practice recommendations for the management of oropharyngeal dysphagia following acute cervical spinal cord injury: an international multi-professional Delphi consensus

PURPOSE

International multi-professional expert consensus was sought to develop best practice recommendations for clinical management of patients following cervical spinal cord injury with oropharyngeal dysphagia and associated complications. Additionally, risk factors for dysphagia were identified to support the development of a screening tool.

MATERIALS AND METHODS

A two-round Delphi study was undertaken with a 27-member panel of expert professionals in cervical spinal cord injury and complex dysphagia. They rated 85 statements across seven topic areas in round one, using a five-point Likert scale with a consensus set at 70%. Statements not achieving consensus were revised for the second round. Comparative group and individual feedback were provided at the end of each round.

RESULTS

Consensus was achieved for 50 (59%) statements in round one and a further 12 (48%) statements in round two. Recommendations for best practice were agreed for management of swallowing, respiratory function, communication, nutrition and oral care. Twelve risk factors for dysphagia were identified for components of a screening tool.

CONCLUSIONS

Best practice recommendations support wider clinical management to prevent complications and direct specialist care. Screening for risk factors allows early dysphagia identification with the potential to improve clinical outcomes. Further evaluation of the impact of these recommendations is needed.Implications for RehabilitationDysphagia is an added complication following cervical spinal cord injury (cSCI) affecting morbidity, mortality and quality of life.Early identification of dysphagia risk allows focused interventions that reduce associated nutritional and respiratory impairments.Best practice recommendations based on expert consensus provide a baseline of appropriate interventions, in the absence of empirical evidence.A multi-professional approach to rehabilitation encourages a consistent and coordinated approach to care across acute and rehabilitation settings.

Oropharyngeal Dysphagia in Acute Cervical Spinal Cord Injury: A Literature Review

Dysphagia (swallowing impairment) is a frequent complication of cervical spinal cord injury (cSCI). Recently published national guidance in the UK on rehabilitation after traumatic injury confirmed that people with cSCI are at risk for dysphagia and require early evaluation while remaining nil by mouth [National Institute for Health and Care Excellence. Rehabilitation after traumatic injury (NG211), 2022, https://www.nice.org.uk/guidance/ng21]. While the pathogenesis and pathophysiology of dysphagia in cSCI remains unclear, numerous risk factors have been identified in the literature. This review aims to summarize the literature on the risk factors, presentation, assessment, and management of dysphagia in patients with cSCI. A bespoke approach to dysphagia management, that accounts for the multiple system impairment in cSCI, is presented; the overarching aim of which is to support effective management of dysphagia in patients with cSCI to prevent adverse clinical consequences.

Laryngeal and swallow dysregulation following acute cervical spinal cord injury

Laryngeal function is vital to airway protection. While swallow is mediated by the brainstem, mechanisms underlying increased risk of dysphagia after cervical spinal cord injury (SCI) are unknown. We hypothesized that loss of descending phrenic drive affects swallow and breathing differently, and loss of ascending spinal afferent information alters swallow regulation. We recorded electromyograms from upper airway and chest wall muscles in freely breathing pentobarbital-anesthetized cats and rats. Inspiratory laryngeal activity increased ~two-fold following C2 lateral-hemisection. Ipsilateral to the injury, crural diaphragm EMG amplitude was reduced during breathing (62 ± 25% change post-injury), but no animal had complete termination of activity; 75% of animals increased contralateral diaphragm recruitment, but this did not reach significance. During swallow, laryngeal adductor and pharyngeal constrictor muscles increased activity, and diaphragm activity was bilaterally suppressed. This was unexpected because of the ipsilateral-specific response during breathing. Swallow-breathing coordination was also disrupted and more swallows occurred during early expiration. Finally, to determine if the chest wall is a major source of feedback for laryngeal regulation, we performed T1 total transections in rats. As in the C2 lateral-hemisection, inspiratory laryngeal recruitment was the first feature noted. In contrast to the C2 lateral-hemisection, diaphragmatic drive increased after T1 transection. Overall, we found that SCI alters laryngeal drive during swallow and breathing, and reduced swallow-related diaphragm activity. Our results show behavior-specific effects, suggesting SCI affects swallow more than breathing, and emphasizes the need for additional studies on the effects of ascending afferents from the spinal cord on laryngeal function.

Dysphagia in cervical spinal cord injury: How international literature trends can guide South African practice patterns - A scoping review

Background

The limited data regarding dysphagia in high-level spinal cord injuries (SCIs) stem from economically developed countries. Dysphagia is prevalent in patients with cervical SCI; however, in a South African context, speech-language pathologists (SLPs) are not seen as key when managing this population. This may result in patients not being screened or identified early, leading to possible complications. The literature could provide useful insight on how best to address this clinical gap.

Objectives

The aim of my study was to conduct a scoping review on the description of dysphagia, the risk factors for developing dysphagia post-SCI and the practice patterns of team members working with dysphagia in cervical SCIs.

Methods

A five-step scoping review was undertaken. Data were analysed by using descriptive statistics as well as a thematic analysis by using a top-down approach.

Results

Through the process of screening according to the inclusion and exclusion criteria, 25 articles were included. Primarily, the pharyngeal phase was affected, which can lead to an aspiration pneumonia. The key risk factors were the presence of a tracheostomy tube, the use of ventilation and anterior spinal cord surgery. There was little mention regarding specific practice patterns, but an interdisciplinary approach was suggested as the most efficient model.

Conclusions

Specific guidelines and management options need to be considered for a South African context, given the high incidence of trauma-related injuries. There needs to be locally produced research, providing suggestions on how different team members can screen and identify dysphagia within this population. Solutions need to be unique, and contextually responsive and appropriate.

Clinical implications

The team members and the roles of these different team members need to be re-examined in order to ensure the early identification and management of cervical SCI patients who are at risk of developing a dysphagia.

State of the evidence about rehabilitation interventions in patients with dysphagia

INTRODUCTION

Rather than a separate nosological entity, dysphagia must be considered as a symptom of other pathological conditions, which afflicts patients admitted to numerous medical departments (rehabilitation, neurology, geriatrics, internal medicine, etc.) These disorders share the need for timely access to quality care and multidisciplinary treatment, including rehabilitation. The purpose of this study was to conduct a review of the current guidelines' recommendations in the literature and provide recommendations on the rehabilitative management of the patient with dysphagia.

EVIDENCE ACQUISITION

The search was carried out through the main databases (Medline, PEDro, Cochrane Database and Google Scholar). All the articles concerning rehabilitation management of dysphagia, published in the last 10 years, have been included.

EVIDENCE SYNTHESIS

Bibliographic research has provided thirteen guidelines. The literature analysed focuses mainly on the screening, the evaluation and the planning of multidisciplinary treatment. The literature agrees in recommending as cornerstones in the treatment of the dysphagic patient dietary changes, rehabilitation training (particularly muscle strengthening exercises and coordination) and early use of alternative nutrition in patients severely compromised.

CONCLUSIONS

The dysphagic patient requires the deployment of a range of skills by a multiprofessional and multi-disciplinary team. Speech and language pathologists in cooperation with specialists of rehabilitation have the task of managing the various stages, ranging from the early identification of the symptom to the setting of the treatment plan. Due to the lack of standardized protocols, it is necessary to implement the research path, especially regarding rehabilitation intervention.

The experiences of individuals with cervical spinal cord injury and their family during post-injury care in non-specialised and specialised units in UK

BACKGROUND

Individuals with acute cervical spinal cord injury require specialised interventions to ensure optimal clinical outcomes especially for respiratory, swallowing and communication impairments. This study explores the experiences of post-injury care for individuals with cervical spinal cord injury and their family members during admissions in specialised and non-specialised units in the United Kingdom.

METHODS

Semi-structured interviews were undertaken with individuals with a cervical spinal cord injury and their family member, focussing on the experience of care across units. Eight people with spinal cord injury levels from C2 to C6, were interviewed in their current care settings. Six participants had family members present to support them. Interviews were audio-recorded and transcribed with data inputted into NVivo for thematic analysis.

RESULTS

The study identified six themes from the participant interviews that highlighted different experiences of care in non-specialised and specialised settings. A number of these were related to challenges with the system, whilst others were about the personal journey of recovery. The themes were titled as: adjustment, transitions, "the golden opportunity", "when you can't eat", communication, and "in the hands of the nurses and doctors".

CONCLUSIONS

Whilst participants reported being well cared for in non-specialised units, they felt that they did not receive specialist care and this delayed their rehabilitation. Participants were dependent on healthcare professionals for information and care and at times lost hope for recovery. Staff in non-specialised units require training and guidance to help provide support for those with dysphagia and communication difficulties, as well as reassurance to patients and families whilst they wait for transfer to specialised units.