Expiratory muscle strength training improves swallowing and respiratory outcomes in people with dysphagia: A systematic review

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

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

Identifying Non-Traditional Approaches to Swallowing Rehabilitation: A Scoping Review

In recent years, dysphagia care has shifted toward a more patient-centered approach. This means that dysphagia clinicians are considering more factors in the treatment process including the goals of care, quality of life, and cultural values. The purpose of this scoping review was to examine relevant research and identify dysphagia interventions outside of those traditionally used by dysphagia clinicians that may improve swallowing function. A review of relevant studies was conducted using search terms related to swallowing and treatment. The search yielded 8439 unique studies. Of the 283 articles that underwent a full-text review, 37 articles were included in the final review. These articles highlighted three potential areas of non-traditional dysphagia intervention that may serve to provide holistic care, while also aiming to improve swallowing mechanisms: acupuncture and Eastern medicine interventions, vocal exercises, and physical function exercises. The results suggest that dysphagia clinicians should work collaboratively with other allied health professionals and consider non-traditional approaches to dysphagia care. Through the identification of potentially effective but non-traditional or non-Eurocentric interventions for dysphagia care, clinicians may promote a culturally relevant, patient-centered approach, in turn increasing patient acceptance of treatment plans and compliance. Future research should explore the efficacy and feasibility of these interventions in dysphagia rehabilitation, as well as their effectiveness compared to more traditional approaches.

The Effect of Respiratory Muscle Training on Swallowing Function in Patients With Stroke: A Systematic Review and Meta-Analysis

BACKGROUND

The improvement of swallowing function after stroke is a significant challenge faced by patients and health care professionals. However, the current evidence synthesis of the effects of respiratory muscle training (RMT) on swallowing function is limited.

OBJECTIVE

To assess the effectiveness of RMT on swallowing recovery in patients undergoing stroke.

METHODS

The CKNI, WanFang Data, PubMed, CINAHL, Web of Science, Embase, MEDLINE, and Cochrane Library databases were searched for studies evaluating RMT interventions' effect on swallowing outcomes. Risks of bias were evaluated using the approach recommended by the Cochrane Collaboration tool and a summary of findings table was generated using the GRADE approach. Outcomes were synthesized using a random-effects meta-analysis model.

RESULTS

RMT interventions reduced the risk of aspiration (SMD = 1.19; 95% CI, 0.53-1.84), the recovery process of water swallowing function (RR = 1.22; 95% CI, 1.05-1.42), and the activity of the swallowing muscles (SMD = 2.91; 95% CI, 2.22-3.61). However, there was no significant effect of RMT on the functional level of oral intake (SMD = 0.70; 95% CI, -0.03 to 1.42).

CONCLUSIONS

RMT can be regarded as an innovative, auxiliary means in the near future to better manage and improve swallowing function, given its improving effect on work outcomes in this review.

Do proprioceptive neuromuscular facilitation techniques improve respiratory parameters and swallowing in people with multiple sclerosis: A randomized-controlled study

AIM

This study aims to investigate the effects of Proprioceptive Neuromuscular Facilitation (PNF) techniques on respiratory parameters, swallowing, functional capacity, fatigue, and quality of life in people with Multiple Sclerosis (PwMS).

METHOD

Thirty-four PwMS were included and randomized into the PNF Group (mean age: 43.23±10.55/years) or Control Group (mean age:38.47±8.18/years). In the PNF group, head-neck, upper extremity, trunk, and breathing techniques were applied three days/eight weeks. The control group continued home-based breathing exercises. Forced expiratory volume in one second (FEV1), forced vital capacity (FVC), FEV1/FVC, peak expiratory flow (PEF), forced expiratory flow 25-75 % (%FEF 25-75), peak cough flow (PCF), maximal inspiratory (MIP) and expiratory pressures (MEP) were and two minutes walking test (2MWT) were measured. Dysphagia in Multiple Sclerosis (DYMUS), Eating Assessment Tool (EAT-10), Fatigue Severity Scale (FSS) and Multiple Sclerosis Quality of Life (MusiQoL) were questioned.

RESULTS

After treatment, MIP, MEP,%FEV1/FVCpred,%PEFpred,%FEF 25-75pred, PCF, DYMUS, EAT-10, FSS, and MUSIQoL were improved in the PNF group while MIP, MEP, PCF, DYMUS, EAT-10, MUSIQoL, and 2 MWT were improved in the control group (p < 0.05 for all). In the between-group analysis of the mean differences, the%FEV1pred was significantly different in favor of the PNF Group (p = 0.011), and MIP was significantly different in favor of the Control Group (p = 0.013).

DISCUSSION

The PNF techniques can improve respiratory muscle strength, respiratory functions, cough efficiency, swallowing functions, and quality of life in mild to moderate PwMS. However, these improvements were not superior except for%FEV1pred compared to home-based breathing exercises.

Concurrent Validity of a Low-Cost Manometer for Objective Assessments of Respiratory Muscle Strength

OBJECTIVE(S)

This study examined the agreement in maximal expiratory (MEP) and inspiratory (MIP) pressure readings between two digital manometers: (1) the MicroRPM - the gold-standard manometer for respiratory muscle strength testing; and (2) the LDM - a low-cost, commercially available, alternative manometer.

METHODS

Positive (MEP) and negative (MIP) pressures were simultaneously applied to the MicroRPM and LDM using a 3-liter syringe within a controlled laboratory setting. Pressure readings were compared, and agreement was analyzed using Lin's concordance correlation (ρc ). Agreement was interpreted as 'poor' if <0.90, 'moderate' if 0.90 - <0.95, 'substantial' if 0.95 - <0.99, and 'excellent' if ≥0.99. Twenty percent of the pressure trials were repeated by a second researcher to examine test-retest reliability.

RESULTS

A total of 150 trials were completed, ranging from -167 to +208 cmH2 O. There was a median absolute difference of 0.3 cmH2 O in pressure readings between the MicroRPM and the LDM. Lin's concordance correlation revealed 'excellent' agreement between the LDM and MicroRPM devices, with test-retest reliability assessment revealing 'substantial-to-excellent' agreement between the LDM and MicroRPM devices, with a concordance correlation coefficient of ρc  = 0.999 (95% CI: 0.999-0.999).

CONCLUSIONS

There was a median difference of 1.0% in MEP and MIP pressure readings consistently observed between the LDM and MicroRPM. Despite these relatively small differences, excellent agreement between the two manometers was present. These data suggest the LDM may be a valid, lower cost alternative to the MicroRPM for objectively assessing respiratory strength in clinical practice; however, additional research is needed in healthy adults and in patient populations.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:1831-1836, 2024.

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.

Characterizing Swallowing Impairment in a Post-Lung Transplant Population

BACKGROUND

Lung transplant recipients carry significant pre- and post-lung transplant dysphagia risk factors related to altered respiratory-swallow coordination as well as acute injury and decompensation resulting in the acute post-lung transplant recovery period. However, we are only beginning to understand the potential physiological contributors to altered swallowing in this population.

METHOD

A retrospective, cross-sectional, cohort study of post-lung transplant patients was performed. All participants received a modified barium swallow study (MBSS) as part of standard care during their acute hospitalization using the Modified Barium Swallow Impairment Profile (MBSImP) protocol and scoring metric. A combination of MBSImP scores, Penetration-Aspiration Scale (PAS) scores, Functional Oral Intake Scale (FOIS) scores, International Dysphagia Diet Standardization Initiative (IDDSI) scale levels, and the time from lung transplant to MBSS was collected, as well as measures of swallowing impairment and swallowing-related outcomes. Differences in swallowing physiology and swallowing-related outcomes between participants with typical versus atypical PAS were explored.

RESULTS

Forty-two participants met our prespecified inclusion criteria. We identified atypical laryngeal penetration and/or aspiration in 52.4% of our post-lung transplant cohort. Silent aspiration occurred in 75% of those patients who aspirated. Comparing typical versus atypical PAS scores, we found statistically significant associations with laryngeal elevation (Component 8), p < .0001; anterior hyoid excursion (Component 9), p = .0046; epiglottic movement (Component 10), p = .0031; laryngeal vestibule closure (Component 11), p < .0001; pharyngeal stripping (Component 12), p = .0058; pharyngeal total scores, p = .0001; FOIS scores, p = .00264; and IDDSI liquid levels, p = .0009.

CONCLUSIONS

Swallowing impairment resulting in abnormal bolus invasion is prevalent in post-lung transplant patients. Airway invasion in this cohort was related to pharyngeal swallow impairment and resulted in modified oral intake. Our findings help expand upon prior literature, which only reported the incidence of aspiration and pathological laryngeal penetration. Our results suggest that the potential for aerodigestive system impairment and negative sequela should not be underestimated in the post-lung transplant population.

Advances in the Treatment of Dysphagia in Neurological Disorders: A Review of Current Evidence and Future Considerations

Dysphagia, which refers to difficult and/or disordered swallowing, is a common problem associated with various neurological diseases such as stroke, motor neuron diseases and neurodegenerative diseases. Traditionally, dysphagia treatments are either compensatory, which includes modifications of bolus texture or feeding posture, or rehabilitative, which includes behavioral exercises and sensory stimulation. Despite being widely adopted in clinical practice, recent views have challenged the clinical efficacy of these treatments due to the low level of evidence supported by mainly non-controlled studies. As such, with advancements in technology and scientific research methods, recent times have seen a surge in the development of novel dysphagia treatments and an increasing number of robust randomized controlled clinical trials. In this review, we will review the clinical evidence of several newly introduced treatments for dysphagia in the last two decades, including rehabilitative exercises, biofeedback, pharmacological treatments, neuromodulation treatments and soft robotics. Despite the recent improvements in the quality of evidence for the efficacy of dysphagia treatments, several critical issues, including heterogeneity in treatment regimens, long-term treatment effects, underlying mechanisms of some neuromodulation treatments, and the effects of these techniques in non-stroke dysphagia, remain to be addressed in future clinical trials.

Speech and language therapy service provision in spinal injury units compared to major trauma centres in England: Are services matched?

BACKGROUND

National UK guidance makes recommendations for speech and language therapy staffing levels in critical care and rehabilitation settings. Traumatic spinal cord injury patients often require admission primarily to critical care services within a major trauma centre prior to transfer to a specialist spinal injury unit but may not receive similar levels of care. Dysphagia and communication difficulties are recognised features of cervical spinal cord injury; however, little is known about access to speech and language therapy services to provide rehabilitation and improve outcomes.

AIMS

The aim of this study was to compare the workforce and clinical practices of speech and language therapy services in eight spinal injury units and four major trauma centres in England through an online survey.

METHODS & PROCEDURES

An online survey was created with 26 multiple-choice questions across seven sub-sections, with options for free-text comments. These were sent to a named speech and language therapy contact at each of the specified units. Responses were uploaded into Excel for analyses, which included descriptive statistics and analysis of themes.

OUTCOMES & RESULTS

Responses were received from 92% (11/12) speech and language therapy services invited, which included seven out of eight spinal injury units and all four major trauma centres. No units met national staffing recommendations. Staff in spinal injury units provided an average of 27 h per week input to the unit compared to 80 h in a major trauma centre. Despite caseload variations, speech and language range of therapy involvement and prioritisation process were equivalent. Access to instrumental assessment varied, with less use of Fibreoptic Endoscopic Evaluation of Swallowing in spinal injury units despite its clinical value to the spinal cord injury caseload.

CONCLUSIONS & IMPLICATIONS

Speech and language therapy services delivering post-acute and long-term rehabilitation to spinal cord injury patients are limited by their resources and capacity, which restricts the level of therapy delivered to patients. This may have an impact on clinical outcomes for communication and swallowing impairments. Further evidence is needed of the interventions delivered by speech and language therapists and outcomes will be beneficial alongside benchmarking similar services.

WHAT THIS PAPER ADDS

What is already known on this subject In England, people who sustain a spinal cord injury are admitted to a major trauma centre prior to transfer to a specialist spinal injury unit. Dysphagia and communication impairments are recognised as a complication of cervical spinal cord injury and benefit from speech and language therapy intervention. National recommendations exist for staffing levels, expertise and competencies for speech and language therapists working in critical care and rehabilitation units. What this study adds This study identified variations in the levels of speech and language therapy staffing, seniority, service delivery and access to instrumental assessments for dysphagia between major trauma centres and spinal injury units. None of the services complied with national staffing recommendations. Clinical implications of this study Speech and language therapy services in spinal injury units are often available part-time or have limited access to diagnostic tools which limits the range and intensity of rehabilitation input available. This has clinical implications for outcomes for swallowing and communication as well as long-term consequences for integrating back into community.

Respiratory Muscle Training Reduces Respiratory Complications and Improves Swallowing Function After Stroke: A Systematic Review and Meta-Analysis

OBJECTIVE

To investigate if respiratory muscle training is capable of reducing the occurrence of respiratory complications and improving dysphagia (swallowing or cough function) after stroke?

DESIGN

Systematic review of randomized control trials based on the Cochrane guidelines.

PARTICIPANTS

Patients (> 18 years old) were diagnosed with stroke.

INTERVENTION

Respiratory muscle training aimed at increasing respiratory muscles' strength by using the threshold resistance trainer or flow-oriented resistance trainer.

OUTCOME MEASURES

Respiratory complications, swallowing and cough function.

RESULTS

Eleven trials (n=523 participants) were included . Respiratory muscle training reduced the risk of respiratory complications (RR0.51, 95%CI 0.28 to 0.93, I² = 0%,P=0.03, ARD =0.068, NNT=14.71) compared with no/sham respiratory intervention. It also decreased the liquid type PAS scores by 0.81 (95% CI -1.19 to -0.43, I² = 39%, P<0.0001). There was no significant association between respiratory muscle training and FOIS scores, cough function:increased FOIS scores by 0.47 (95%CI -0.45 to 1.39, I² = 55%, P=0.32), decreased PECF-VC by 18.70 L/min (95%CI -59.74 to 22.33, I² = 19%, P=0.37) and increased PECF-RC by 0.05 L/min (95% CI -40.78 to 40.87 I2 = 0%, P=1.00) .

CONCLUSION

This meta-analysis provided evidence that respiratory muscle training is effective in reducing the risk of respiratory complications, and improving dysphagia by reducing penetration or aspiration during swallowing liquid bolus after stroke. However, there was no sufficient evidence to determine that respiratory muscle training improves cough function. Additional multi-center studies using larger patient cohorts are required to validate and support these findings. Furthermore, long-term follow-up studies should be performed to measure outcomes, at the same time avoiding bias due to confounding factors such as heterogeneity of the etiologies of dysphagia.

Clinical Practice Patterns of Speech-Language Pathologists Delivering Dysphagia Services to Persons with COPD: Analysis of Survey Outcomes

Swallowing impairments co-occur with chronic obstructive pulmonary disease (COPD) leading to aspiration, disease exacerbations, and malnutrition. This pilot survey study aimed to identify current clinical practice patterns for swallowing evaluation and treatment in persons with COPD. A 35-question Qualtrics survey was deployed to medical speech-language pathology (SLP) social media sites and professional boards; flyers were distributed at a professional conference. Forty-eight SLPs completed the study. SLPs routinely include a clinical swallow examination (96%), videofluoroscopic swallowing study (79%), adjunctive respiratory measures (respiratory rate [83%], and pulse oximetry [67%], respiratory-swallow pattern [77%]) but less frequently include fiberoptic endoscopic evaluation of swallowing (23%). Self-reported advanced clinical experience and expert respiratory analysis skills were associated with adjunctive respiratory measure (respiratory rate, pulse oximetry) inclusion during assessment. Compensatory strategy training (77%) is a preferred treatment for dysphagia in COPD; however, respiratory-swallow pattern training and expiratory muscle strength training are increasing in use. SLPs self-report a comprehensive, individualized patient-centered care approach with inclusion of adjunctive respiratory-focused methods in dysphagia evaluation and treatment practice in persons with COPD. Advances in the identification of the integral role of respiratory function in swallowing integrity may be translating to clinical practice methods for dysphagia management in persons with COPD.

Signs of dysphagia and associated outcomes regarding mortality, length of hospital stay and readmissions in acute geriatric patients: Observational prospective study

BACKGROUND AND AIMS

Dysphagia is a prevalent disorder in acute geriatric patients. This observational prospective study aimed at investigating adverse clinical outcomes linked to signs of dysphagia, including mortality, length of hospital stay (LOS), readmissions, among patients aged ≥ 65 years at a Danish acute medical unit (AMU).

METHODS

Signs of dysphagia were assessed using bedside screening tools including the Eating Assessment Tool (EAT-10), a 30 mL Water Swallowing Test (WST) and the Gugging Swallowing Screen tool (GUSS), as described in the preceding cross-sectional study. Data for the follow-up was twice retrieved from electronic medical charts 30 days and 90 days after the patients' primary admission to the hospital. Statistical analysis included non-parametric tests of independence and proportional hazards modelling.

RESULTS

444 patients were recruited, 334 of whom completed the dysphagia screening with 144 (43.1 %) showing signs of dysphagia. Patients with signs of dysphagia, compared to those without, experienced higher mortality after 30 days (12.5 % vs. 1.6 %, p < 0.001) and 90 days (21.5 % vs. 5.8 %, p < 0.001), longer LOS (median [Q1; Q3]: 4 [2; 8] vs. 3 [1; 6] days, p = 0.004), more total hospital days (THD) during both the 30-day and 90-day follow-up (for 90d: median [Q1; Q3]: 6 [2.25; 12] vs. 4 [2; 9] days, p = 0.007), but no significant difference in frequency of readmissions. Multivariate proportional hazards modelling revealed signs of dysphagia, low performance status and high comorbidity to be independent risk factors for mortality. High comorbidity and low hemoglobin, but not signs of dysphagia, were revealed as independent risk factors for readmission.

CONCLUSION

Dysphagia is a notable risk factor linked to increased mortality and length of hospital stay (LOS) for acute geriatric patients in general, not just those suffering from stroke, head and neck cancer or neurodegenerative diseases. Further research is needed to investigate the effectiveness and feasibility of systematic dysphagia screening within this population.

Using Ultrasound to Document the Effects of Expiratory Muscle Strength Training (EMST) on the Geniohyoid Muscle

Expiratory muscle strength training (EMST) is an exercise program designed to strengthen the muscles of expiration by increasing expiratory load during breathing exercises using either resistive or pressure threshold devices. Previous research has shown that EMST may increase submental suprahyoid muscle activity as measured with surface electromyography. The impact of EMST on submental muscles is of interest to those who treat dysphagia. The purpose of this study was to determine whether the cross-sectional area of the geniohyoid muscle changes as observed with ultrasound during a 5-week EMST program performed at 75% of maximum expiratory strength using the EMST150 device in healthy adults. Ten healthy adults participated in the 5-week program. Maximum expiratory pressure (MEP) and cross-sectional area of the geniohyoid muscle were measured weekly. Geniohyoid cross-sectional area was measured from ultrasound images recorded in the coronal plane. Repeated Measures ANOVA was used to determine whether there were significant changes among the dependent variables over the study period. Both MEP and geniohyoid area increased significantly in response to a 5-week program of EMST. EMST in healthy adults is effective at strengthening the geniohyoid muscle as reflected by significantly increased cross-sectional area measured with B-mode ultrasound. This is the first study to document weekly change in muscle morphology as a result of EMST. Increasing geniohyoid muscle mass and consequent strength through a program of EMST may be beneficial for persons with pharyngeal stage dysphagia resulting from reduced hyolaryngeal elevation, reduced laryngeal closure, or reduced UES opening.

Speech Pathology Services Are Integral, but Underutilized in Tracheostomy Rehabilitation

STUDY DESIGN

Retrospective case series.

OBJECTIVE

Speech language pathology (SLP) is an underutilized but important component in rehabilitation after tracheostomy. The purpose of this study was to determine rates of SLP utilization and to streamline tracheostomy decannulation to be more efficient and safer through increased utilization of SLP.

METHODS

Adult patients who underwent tracheostomy from April 2016 to December 2018 were evaluated. The primary outcome was completion of any SLP evaluation after tracheostomy, and secondary outcomes were duration from surgery to evaluation, speaking valve and swallow study utilization, downsize and decannulation rates, mean duration of cannulation, and complications.

RESULTS

A total of 255 subjects were included, where 197 (77.3%) underwent SLP evaluation. A minority received a speaking valve (33.7%), while approximately half underwent a swallow study (52.9%). There was a delay in SLP evaluation, with mean duration from surgery to SLP evaluation of 5.9 ± 8.0 days. There was consistent improvement in downsize and decannulation rates in all cohorts that utilized SLP services. Tracheostomy indication of head and neck cancer, trauma, completing a successful swallow study conferred increased odds of eventual decannulation, while obesity and tracheostomy history conferred lower odds. An interdisciplinary decannulation pathway was created, based on literature review and results, to assist in decision-making while progressing toward decannulation.

CONCLUSION

Speech language pathologists are underutilized for rehabilitation of tracheostomy patients, where they are able to offer many skills to diagnose, treat, manage, and troubleshoot, as patients advance through the decannulation process.

The addition of respiratory muscle strength training to facilitate swallow and pulmonary rehabilitation following massive tissue loss and severe deconditioning: A case series

INTRODUCTION

Impaired respiratory and swallow function in patients with intensive care unit-acquired deconditioning, such as associated with massive tissue loss, is not uncommon and can require prolonged rehabilitation.

AIM

The aim of the study was to examine the effect of combined inspiratory and expiratory respiratory muscle strength training (RMST) on respiratory and swallow function in two critical care patients with marked deconditioning after massive tissue loss.

METHODS

Case 1 was a 19-year-old male patient with 80% body surface area burns; case 2 was a 45-year-old man with group A streptococcus myositis necessitating quadruple amputation. Both required prolonged intensive care and mechanical ventilation. Both received routine intensive pulmonary and swallow rehabilitation before the trial; however, chronic aspiration and poor secretion clearance remained. At 25 and 26 weeks after initial injury, RMST was performed using EMST150 (expiratory) and Threshold IMT (inspiratory) devices, respectively. At baseline and throughout treatment, data collected included peak expiratory flow (PEF), anthropometry measures, aspiration risk (Penetration-Aspiration Scale [PAS]), pharyngeal clearance (Yale Pharyngeal Residue Scale), secretions (New Zealand Secretion Scale [NZSS]), and functional diet (Functional Oral Intake Scale [FOIS]) via endoscopy.

RESULTS/DISCUSSION

At baseline, the PEF score of case 1 was 41% (predicted age-height norm) and the PEF score of case 2 was 14%, indicating severe expiratory compromise. Both had extreme energy requirements (3300 kcal/day; 3500 kcal/day). The baseline swallowing scores of case 1 and 2 were as follows: PAS, 8 and 8; Yale, 9 and 10; NZSS, 4 and 7; and FOIS, 1 and 1, respectively, indicating profound dysphagia. At week 3 of 7 of RMST, swallow function improved to allow both to commence oral intake, followed by tracheostomy decannulation. At weeks 10 and 11, full dysphagia resolution was achieved (FOIS = 7; PAS = 1, Yale = 2, NZSS = 0), with PEF at 70% and 48% predicted respectively. Both patients continued RMST, and at discharge from the acute facility, PEF was 84% and 80% predicted respectively.

CONCLUSION

The addition of RMST assisted swallow and pulmonary rehabilitation in both cases and was clinically viable to deliver. Controlled validation trials are now required.

Expiratory Muscle Strength Training for Therapy of Pharyngeal Dysphagia in Parkinson's Disease

BACKGROUND

Pharyngeal dysphagia in Parkinson's disease (PD) is a common and clinically relevant symptom associated with poor nutrition intake, reduced quality of life, and aspiration pneumonia. Despite this, effective behavioral treatment approaches are rare.

OBJECTIVE

The objective of this study was to verify if 4 week of expiratory muscle strength training can improve pharyngeal dysphagia in the short and long term and is able to induce neuroplastic changes in cortical swallowing processing.

METHODS

In this double-blind, randomized, controlled trial, 50 patients with hypokinetic pharyngeal dysphagia, as confirmed by flexible endoscopic evaluation of swallowing, performed a 4-week expiratory muscle strength training. Twenty-five participants used a calibrated ("active") device, 25 used a sham handheld device. Swallowing function was evaluated directly before and after the training period, as well as after a period of 3 month using flexible endoscopic evaluation of swallowing. Swallowing-related cortical activation was measured in 22 participants (active:sham; 11:11) using whole-head magnetencephalography.

RESULTS

The active group showed significant improvement in the flexible endoscopic evaluation of swallowing-based dysphagia score after 4 weeks and after 3 months, whereas in the sham group no significant changes from baseline were observed. Especially, clear reduction in pharyngeal residues was found. Regarding the cortical swallowing network before and after training, no statistically significant differences were found by magnetencephalography examination.

CONCLUSIONS

Four-week expiratory muscle strength training significantly reduces overall dysphagia severity in PD patients, with a sustained effect after 3 months compared with sham training. This was mainly achieved by improving swallowing efficiency. The treatment effect is probably caused by peripheral mechanisms, as no changes in the cortical swallowing network were identified. © 2021 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Prevalence, Pathophysiology, Diagnostic Modalities, and Treatment Options for Dysphagia in Critically Ill Patients

Postextubation dysphagia may impose a substantial burden on intensive care unit patients and healthcare systems. Approximately 517,000 patients survive mechanical ventilation during critical care annually. Reports of postextubation dysphagia prevalence are highly variable ranging between 3% and 93%. Of great concern is aspiration leading to the development of aspiration pneumonia when patients resume oral feeding. Screening for aspiration with a water swallow test has been reported to be positive for 12% of patients in the intensive care unit after extubation. This review aims to increase awareness of postextubation dysphagia and provide an updated overview of the current knowledge regarding prevalence, pathophysiology, diagnostic modalities, and treatment options.

Expiratory muscle strength training improves measures of pressure generation and cough strength in a patient with myotonic dystrophy type 1

Expiratory muscle strength training (EMST) exercise programmes aim to improve respiratory function by increasing the force generating capability of expiratory muscles by resistance training. In neuromuscular conditions, in which cough flow generation is often decreased, there is increasing interest in EMST as a therapeutic intervention. We present data showing efficacy of EMST in a patient with adult onset Myotonic Dystrophy Type 1 (DM1). A domiciliary training programme (5 days per week over 32 weeks) resulted in increases in maximum expiratory mouth pressure (from 15 cmH₂O to 38 cmH₂O) and peak cough flow (300 L/min to 390 L/min). Improvements were also seen in maximum inspiratory mouth pressure (26 cmH₂O to 52 cmH₂O) and sniff nasal inspiratory pressure (40 cmH₂O to 69 cmH₂O). No changes were detected in speech or swallowing. This novel study demonstrates that cough flow generation in DM1 may be increased by a programme of expiratory muscle training. A clinical trial of EMST in DM1 is warranted.

Exploring the efficacy of the expiratory muscle strength trainer to improve swallowing in inclusion body myositis: A pilot study

Inclusion Body Myositis (IBM) is the most common acquired myopathy in older individuals with more than two thirds of patients experiencing impaired swallowing. There are currently no standardized exercise therapies to improve or sustain swallowing despite good evidence for exercise therapy in limb muscles. Reduced upper esophageal sphincter opening is a common abnormality associated with dysphagia in IBM. This pilot study recruited IBM patients with abnormal upper esophageal sphincter function and dysphagia into an exercise program. It was hypothesized that regular practice using the Expiratory Muscle Strength Trainer (EMST) device would improve hyolaryngeal movement by strengthening suprahyoid musculature and facilitate opening of the upper esophageal sphincter thereby improving swallowing and quality of life. Overall, IBM patients who used the EMST device demonstrated no improvement in swallowing function. Consistent with that result, there was also no change in measures of quality of life. However, further studies are needed to elucidate whether it has a preventative role in the development or progression of dysphagia in IBM as there is a suggestion that patients with a shorter duration of disease may have had some benefit. This research provides pilot data and recommendations that will guide future studies on exercise therapy and swallowing in this area.

Effects of a comprehensive physical therapy on moderate and severe obstructive sleep apnea- a preliminary randomized controlled trial

BACKGROUND

Critically compromised by upper airway anatomical impaired properties, obstructive sleep apnea (OSA) can be categorized into different phenotypic traits, mainly including oropharyngeal muscle dysfunction. The upper airway muscle strength training was targeted on oropharyngeal muscle dysfunction by re-educating the oropharyngeal muscles to maintain the upper airway patency. OSA was characterized with multilevel collapsibility of the upper airway; however, the programs are still inconsistent and the effects are unknown. Therefore, the purpose of this study was to investigate the effects of a comprehensive physical therapy on OSA.

METHODS

Fifteen subjects with newly diagnosed moderate or severe OSA (AHI ≥ 15) were randomized into intervention and control groups. The intervention group underwent a 12-week-intervention of hospital based physical therapy, while the control group was kept on waiting for 12 weeks. Polysomnography (PSG) data, oropharyngeal and respiratory muscle performance were measured before and after intervention.

RESULTS

In intervention group (n = 8), AHI was significantly improved (from 46.96 ± 19.45 to 32.78 ± 10.78 events/h, p = 0.017); in control group (n = 7), AHI was significantly increased (from 35.77 ± 17.49 to 42.96 ± 17.32 events/h, p = 0.043). While the control group remained no change between pre- and post- intervention, the intervention group demonstrated that other PSG outcomes significantly improved, including arousal index (46.04 ± 18.9 versus 32.98 ± 8.35/h), mean SpO₂ (92.88 ± 2.1 versus 94.13 ± 1.46%), and oxygen desaturation index (ODI) (31.13 ± 19.48 versus 20.57 ± 7.83/h).

CONCLUSION

This comprehensive physical therapy can be prescribed for the significant clinical improvement on sleep apnea for the patients with moderate and severe OSA.

Tongue Rehabilitation Device for Dysphagic Patients

Dysphagia refers to difficulty in swallowing often associated with syndromic disorders. In dysphagic patients’ rehabilitation, tongue motility is usually treated and monitored via simple exercises, in which the tongue is pushed against a depressor held by the speech therapist in different directions. In this study, we developed and tested a simple pressure/force sensor device, named “Tonic Tongue (ToTo)”, intended to support training and monitoring tasks for the rehabilitation of tongue musculature. It consists of a metallic frame holding a ball bearing support equipped with a sterile disposable depressor, whose angular displacements are counterbalanced by extensional springs. The conversion from angular displacement to force is managed using a simple mechanical model of ToTo operation. Since the force exerted by the tongue in various directions can be estimated, quantitative assessment of the outcome of a given training program is possible. A first prototype of ToTo was tested on 26 healthy adults, who were trained for one month. After the treatment, we observed a statistically significant improvement with a force up to 2.2 N (median value) in all tested directions of pushing, except in the downward direction, in which the improvement was slightly higher than 5 N (median value). ToTo promises to be an innovative and reliable device that can be used for the rehabilitation of dysphagic patients. Moreover, since it is a self-standing device, it could be used as a point-of-care solution for in-home rehabilitation management of dysphasia.