Respiratory muscle training in stroke patients with respiratory muscle weakness, dysphagia, and dysarthria - a prospective randomized trial

Integration of Dysphagia Therapy Techniques into Voice Rehabilitation: Design and Content Validation of a Cross-Therapy Protocol

BACKGROUND

The intricate relationship between swallowing and phonation, sharing anatomical and physiological substrates, underscores a clinical demand for integrated therapeutic approaches. Existing interventions often address these functions in isolation, overlooking their interconnected dynamics.

OBJECTIVE

To design and validate a cross-therapy protocol incorporating dysphagia therapy techniques (maneuvers/exercises) into voice rehabilitation. This protocol aims to exploit the shared biomechanical components of swallowing and phonation to improve both functions simultaneously in patients with underlying hypofunctional laryngeal pathology.

METHODS

A descriptive research design was employed, consisting of three phases: a comprehensive literature review and expert discussions in a German seminar format to conceptualize the protocol; detailed analysis and categorization of swallowing maneuvers/exercises; and content validation by a panel of seven experts through a structured evaluation instrument. The process integrated motor learning and exercise physiology principles to ensure the protocol's clinical applicability and theoretical coherence.

RESULTS

The developed cross-therapy protocol incorporates four core swallowing therapy techniques to voice therapy procedures. Selected swallowing therapy techniques target laryngeal excursion and vocal fold closure because they are critical components of swallowing and phonation. Expert validation yielded a Content Validity Coefficient exceeding 0.90 for most items, indicating high consensus on the protocol's relevance, clarity, and applicability. Adjustments were made based on feedback, enhancing the protocol's precision and user-friendliness.

CONCLUSION

We present a novel, evidence-based therapy protocol for voice and swallowing difficulties resulting from hypofunctional laryngeal pathology. Its development marks a significant step toward bridging the gap between swallowing and voice therapy. Future empirical studies are needed to assess its effectiveness in clinical settings.

Information-motivation-behavioral guided nursing for stroke patients with pulmonary dysfunction: A randomized controlled trial

BACKGROUND

Patients with stroke frequently experience pulmonary dysfunction.

AIM

To explore the effects of information-motivation-behavioral (IMB) skills model-based nursing care on pulmonary function, blood gas indices, complication rates, and quality of life (QoL) in stroke patients with pulmonary dysfunction.

METHODS

We conducted a controlled study involving 120 stroke patients with pulmonary dysfunction. The control group received routine care, whereas the intervention group received IMB-model-based nursing care. Various parameters including pulmonary function, blood gas indices, complication rates, and QoL were assessed before and after the intervention.

RESULTS

Baseline data of the control and intervention groups were comparable. Post-intervention, the IMB model-based care group showed significant improvements in pulmonary function indicators, forced expiratory volume in 1 sec, forced vital capacity, and peak expiratory flow compared with the control group. Blood gas indices, such as arterial oxygen pressure and arterial oxygen saturation, increased significantly, and arterial carbon dioxide partial. pressure decreased significantly in the IMB model-based care group compared with the control group. The intervention group also had a lower complication rate (6.67% vs 23.33%) and higher QoL scores across all domains than the control group.

CONCLUSION

IMB model-based nursing care significantly enhanced pulmonary function, improved blood gas indices, reduced complication rates, and improved the QoL of stroke patients with pulmonary dysfunction. Further research is needed to validate these results and to assess the long-term efficacy and broader applicability of the model.

Effects of extracorporeal diaphragm pacing combined with inspiratory muscle training on respiratory function in people with stroke: a randomized controlled trial

OBJECTIVES

To evaluate the effect of external diaphragmatic pacing (EDP) combined with inspiratory muscle training on respiratory function in post-stroke patients.

METHODS

Patients with stroke were enrolled from the First Affiliated Hospital of Soochow University in China between 2021 and 2022. The patients were randomized into an EDP treatment group (control group) or an EDP treatment plus inspiratory muscle training group (experimental group). Each therapy was administered once a day for 6 days per week. The peak inspiratory flow (PIF), maximal inspiratory pressure (MIP), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC% ratio, and diaphragm thickness and mobility were measured and compared between the two groups after 4 weeks.

RESULTS

After 4 weeks of intervention, respiratory muscle function indicators including PIF (95% CI: 0.21-1.28, p = 0.008) and MIP (95% CI: 6.92-25.44, p = 0.001) significantly improved in the experimental group. Diaphragmatic thickness also significantly increased in the experimental group (p < 0.05), while diaphragmatic excursion showed no significant difference between the two groups. Additionally, FVC (95% CI: 0.14-1.14, p = 0.013) and FEV1 (95% CI: 0.20-1.06, p = 0.005) demonstrated a significant increase in the experimental group, whereas FEV1/FVC% (95% CI: -0.84 to 9.36, p = 0.099) exhibited no significant group difference.

CONCLUSION

EDP combined with inspiratory muscle training in individuals with stroke provides greater benefits than EDP alone in terms of respiratory function recovery, except for the parameters of diaphragmatic excursion and FEV1/FVC%.

Effects of respiratory muscle training on post-stroke rehabilitation: A systematic review and meta-analysis

BACKGROUND

Stroke often results in significant respiratory dysfunction in patients. Respiratory muscle training (RMT) has been proposed as a rehabilitative intervention to address these challenges, but its effectiveness compared to routine training remains debated. This systematic review and meta-analysis aim to evaluate the effects of RMT on exercise tolerance, muscle strength, and pulmonary function in post-stroke patients.

AIM

To systematically assess the efficacy of RMT in improving exercise tolerance, respiratory muscle strength, and pulmonary function in patients recovering from a stroke, and to evaluate whether RMT offers a significant advantage over routine training modalities in enhancing these critical health outcomes in the post-stroke population.

METHODS

Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines, a comprehensive search across PubMed, Embase, Web of Science, and the Cochrane Library was conducted on October 19, 2023, without temporal restrictions. Studies were selected based on the predefined inclusion and exclusion criteria focusing on various forms of RMT, control groups, and outcome measures [including forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), maximal voluntary ventilation (MVV), peak expiratory flow (PEF), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), and 6-min walking test (6MWT)]. Only randomized controlled trials (RCTs) were included. Data extraction and quality assessment were conducted independently by two reviewers using the Cochrane Collaboration's risk of bias tool. Statistical analyses, including those using the fixed-effect and random-effects models, sensitivity analysis, and publication bias assessment, were performed using Review Manager software.

RESULTS

A total of 15 RCTs were included. Results indicated significant improvements in MIP (12.51 cmH2O increase), MEP (6.24 cmH2O increase), and various pulmonary function parameters (including FEV1, FVC, MVV, and PEF). A substantial increase in 6MWT distance (22.26 meters) was also noted. However, the heterogeneity among studies was variable, and no significant publication bias was detected.

CONCLUSION

RMT significantly enhances walking ability, respiratory muscle strength (MIP and MEP), and key pulmonary function parameters (FEV1, FVC, MVV, and PEF) in post-stroke patients. These findings support the incorporation of RMT into post-stroke rehabilitative protocols.

Study on the treatment of dysphagia after stroke with electromyographic biofeedback intensive training

BACKGROUND

Dysphagia, or swallowing disorder, is a common complication following stroke, significantly impacting patients' quality of life. Electromyographic biofeedback (EMGBF) therapy has emerged as a potential rehabilitation technique to improve swallowing function, but its efficacy in comparison with conventional treatments remains to be further explored.

AIM

To investigate the effects of different treatment intensities of EMGBF on swallowing function and motor speed after stroke.

METHODS

The participants were divided into three groups, all of which received routine neurological drug therapy and motor function rehabilitation training. On the basis of routine swallowing disorder training, the EMGBF group received additional EMGBF training, while the enhanced EMGBF group received two additional training sessions. Four weeks before and after treatment, the degree of swallowing disorder was evaluated using the degree of swallowing disorder score (VGF) and the Rosenbek penetration-aspiration scale (PAS).

RESULTS

Initially, there was no significant difference in VGF and PAS scores among the groups (P > 0.05). After four weeks, all groups showed significant improvement in both VGF scores and PAS scores. Furthermore, the standardized swallowing assessment and videofluoroscopic dysphagia scale scores also improved significantly post-treatment, indicating enhanced swallowing function and motor function of the hyoid-bone laryngeal complex, particularly in the intensive EMGBF group.

CONCLUSION

EMGBF training is more effective than traditional swallowing training in improving swallowing function and the movement rate of the hyoid laryngeal complex in patients with post-stroke dysphagia.

"Effects of threshold respiratory muscle training on respiratory muscle strength, pulmonary function and exercise endurance after stroke: a meta-analysis"

BACKGROUND

Most studies on improvements in respiratory muscle strength, activities of daily living (ADL) and quality of life (QoL) in stroke patients receiving threshold respiratory muscle training (TRMT) have small sample sizes, and some studies have contradictory results.

OBJECTIVES

To evaluate the effectiveness of TRMT on respiratory muscle strength, pulmonary function and exercise endurance in stroke patients.

MATERIALS AND METHODS

PubMed, Cochrane Library, Physical Therapy Evidence Database (PEDro), Embase (via OVID) and Web of Science databases were searched for randomized controlled trial (RCT) from inception to January 17, 2024. The primary outcome was maximum inspiratory pressure (MIP) or maximum expiratory pressure (MEP). Secondary outcomes included pulmonary function measured by forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF), and exercise endurance measured by 6-minute walk test (6MWT).

RESULTS

A total of eight randomized controlled trials(RCTs), including 305 persons, were included in this study. The training time ranged from 3 weeks to 10 weeks. Among them, the intervention group in 4 studies used inspiratory muscle training, and the other 4 studies used inspiratory muscle training and expiratory muscle training. For the primary outcome, TRMT significantly improved MIP (mean=14.68 cmH2O, 95 %CI=2.28 to 27.09 cmH2O, P=0.02) and MEP (mean=9.37 cmH2O, 95 %CI=2.89 to 15.84 cmH2O, P=0.005) in stroke patients. Regarding the secondary outcomes, TRMT improved FVC, FEV1 and 6MWT (P<0.05) but did not significantly improve PEF.

CONCLUSION

TRMT improved inspiratory muscle strength and expiratory muscle strength, improved exercise endurance, and improved FVC and FEV1 of pulmonary function but did not significantly improve PEF.

Hypotussic cough in persons with dysphagia: biobehavioral interventions and pathways to clinical implementation

Cough is a powerful, protective expulsive behavior that assists in maintaining respiratory health by clearing foreign material, pathogens, and mucus from the airways. Therefore, cough is critical to survival in both health and disease. Importantly, cough protects the airways and lungs from both antegrade (e.g., food, liquid, saliva) and retrograde (e.g., bile, gastric acid) aspirate contents. Aspiration is often the result of impaired swallowing (dysphagia), which allows oral and/or gastric contents to enter the lung, especially in individuals who also have cough dysfunction (dystussia). Cough hyposensitivity, downregulation, or desensitization- collectively referred to as hypotussia- is common in individuals with dysphagia, and increases the likelihood that aspirated material will reach the lung. The consequence of hypotussia with reduced airway clearance can include respiratory tract infection, chronic inflammation, and long-term damage to the lung parenchyma. Despite the clear implications for health, the problem of managing hypotussia in individuals with dysphagia is frequently overlooked. Here, we provide an overview of the current interventions and treatment approaches for hypotussic cough. We synthesize the available literature to summarize research findings that advance our understanding of these interventions, as well as current gaps in knowledge. Further, we highlight pragmatic resources to increase awareness of hypotussic cough interventions and provide support for the clinical implementation of evidence-based treatments. In culmination, we discuss potential innovations and future directions for hypotussic cough research.

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Pulmonary Function Tests Post-Stroke. Correlation between Lung Function, Severity of Stroke, and Improvement after Respiratory Muscle Training

Stroke is a significant cause of mortality and chronic morbidity caused by cardiovascular disease. Respiratory muscles can be affected in stroke survivors, leading to stroke complications, such as respiratory infections. Respiratory function can be assessed using pulmonary function tests (PFTs). Data regarding PFTs in stroke survivors are limited. We reviewed the correlation between PFTs and stroke severity or degree of disability. Furthermore, we reviewed the PFT change in stroke patients undergoing a respiratory muscle training program. We searched PubMed until September 2023 using inclusion and exclusion criteria in order to identify studies reporting PFTs post-stroke and their change after a respiratory muscle training program. Outcomes included lung function parameters (FEV1, FVC, PEF, MIP and MEP) were measured in acute or chronic stroke survivors. We identified 22 studies of stroke patients, who had undergone PFTs and 24 randomised controlled trials in stroke patients having PFTs after respiratory muscle training. The number of patients included was limited and studies were characterised by great heterogeneity regarding the studied population and the applied intervention. In general, PFTs were significantly reduced compared to healthy controls and predicted normal values and associated with stroke severity. Furthermore, we found that respiratory muscle training was associated with significant improvement in various PFT parameters and functional stroke parameters. PFTs are associated with stroke severity and are improved after respiratory muscle training.

Assessing the effect of transcranial magnetic stimulation on peak cough flow in patients with supratentorial cerebral infarction: A retrospective cohort study

Respiratory dysfunction following supratentorial cerebral infarction leads to pneumonia and is a major cause of mortality. Decreased voluntary cough function impairs the ability to clear mucus or secretions from the airways and increases the risk of aspiration pneumonia. Peak cough flow (PCF) is one of the objective tools for evaluating voluntary cough function. Repetitive transcranial magnetic stimulation (rTMS) could be applied to the respiratory motor cortex to improve respiratory function. Little is known about the effect of rTMS on PCF in patients with supratentorial cerebral infarction during the subacute period. This study aimed to determine whether rTMS treatment could improve PCF in patients with supratentorial cerebral infarction. We retrospectively recruited patients with subacute supratentorial cerebral infarction who underwent a PCF test. The rTMS group received a combination of rTMS treatment for 2 weeks and conventional rehabilitation for 4 weeks. However, the control group underwent only conventional rehabilitation for 4 weeks. PCF tests were performed before and after treatment and the results were compared between the 2 groups. In total, 145 patients with supratentorial cerebral infarctions were recruited. The PCF parameters before and after treatment increased in both the rTMS and control groups. However, the rTMS group showed a greater increase in PCF values compared with the control group. In patients with supratentorial cerebral infarction, the combination of conventional rehabilitation and rTMS in the subacute period may be helpful in improving voluntary cough function compared with conventional rehabilitation alone.

Dosages of Swallowing Exercises Prescribed in Stroke Rehabilitation: A Medical Record Audit

This study investigated how swallowing exercise dosage is recorded, and what swallowing exercise dosages are reported in a stroke rehabilitation setting. We additionally explored the relation between mean daily swallowing repetitions and likelihood of improvement in functional swallowing status and considered how swallowing exercise dosages in practice compared to evidence-based principles of neural plasticity and strength training. We audited medical records for 42 patients with post-stroke dysphagia admitted to an inpatient rehabilitation unit over 18 months. Data were collected on participant characteristics, swallowing exercises and dosages, and clinical outcomes. The relation between dosage and outcomes was investigated using logistic regression analysis. On average, patients were seen for a median of 2.4 swallowing intervention sessions per week (IQR: 1.7) over 21 days (IQR: 16) and received a median 44.5 swallowing exercise repetitions per session (IQR: 39.6). Results indicated variable reporting of swallowing exercise dosages. Frequency, intervention duration, exercise type, and number of repetitions were routinely recorded in medical records, while intensity, session length, content, and adherence to home exercise programs were not. Frequency of swallowing intervention was lower in practice compared to research studies, and swallowing exercises did not follow specificity or progressive resistance principles. Likelihood of improvement in swallowing status was partially explained by age (B = -.015, p = .007) but not by mean daily swallowing exercise repetitions. This study illustrates dosages of swallowing exercises used in clinical practice. Results highlight the need for improved consideration and reporting of dosage, and application of evidence-based principles to swallowing exercise dosages.

Trunk training following stroke

BACKGROUND

Previous systematic reviews and randomised controlled trials have investigated the effect of post-stroke trunk training. Findings suggest that trunk training improves trunk function and activity or the execution of a task or action by an individual. But it is unclear what effect trunk training has on daily life activities, quality of life, and other outcomes.

OBJECTIVES

To assess the effectiveness of trunk training after stroke on activities of daily living (ADL), trunk function, arm-hand function or activity, standing balance, leg function, walking ability, and quality of life when comparing with both dose-matched as non-dose-matched control groups.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register, CENTRAL, MEDLINE, Embase, and five other databases to 25 October 2021. We searched trial registries to identify additional relevant published, unpublished, and ongoing trials. We hand searched the bibliographies of included studies.

SELECTION CRITERIA

We selected randomised controlled trials comparing trunk training versus non-dose-matched or dose-matched control therapy including adults (18 years or older) with either ischaemic or haemorrhagic stroke. Outcome measures of trials included ADL, trunk function, arm-hand function or activity, standing balance, leg function, walking ability, and quality of life.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two main analyses were carried out. The first analysis included trials where the therapy duration of control intervention was non-dose-matched with the therapy duration of the experimental group and the second analysis where there was comparison with a dose-matched control intervention (equal therapy duration in both the control as in the experimental group).  MAIN RESULTS: We included 68 trials with a total of 2585 participants. In the analysis of the non-dose-matched groups (pooling of all trials with different training duration in the experimental as in the control intervention), we could see that trunk training had a positive effect on ADL (standardised mean difference (SMD) 0.96; 95% confidence interval (CI) 0.69 to 1.24; P < 0.001; 5 trials; 283 participants; very low-certainty evidence), trunk function (SMD 1.49, 95% CI 1.26 to 1.71; P < 0.001; 14 trials, 466 participants; very low-certainty evidence), arm-hand function (SMD 0.67, 95% CI 0.19 to 1.15; P = 0.006; 2 trials, 74 participants; low-certainty evidence), arm-hand activity (SMD 0.84, 95% CI 0.009 to 1.59; P = 0.03; 1 trial, 30 participants; very low-certainty evidence), standing balance (SMD 0.57, 95% CI 0.35 to 0.79; P < 0.001; 11 trials, 410 participants; very low-certainty evidence), leg function (SMD 1.10, 95% CI 0.57 to 1.63; P < 0.001; 1 trial, 64 participants; very low-certainty evidence), walking ability (SMD 0.73, 95% CI 0.52 to 0.94; P < 0.001; 11 trials, 383 participants; low-certainty evidence) and quality of life (SMD 0.50, 95% CI 0.11 to 0.89; P = 0.01; 2 trials, 108 participants; low-certainty evidence). Non-dose-matched trunk training led to no difference for the outcome serious adverse events (odds ratio: 7.94, 95% CI 0.16 to 400.89; 6 trials, 201 participants; very low-certainty evidence). In the analysis of the dose-matched groups (pooling of all trials with equal training duration in the experimental as in the control intervention), we saw that trunk training had a positive effect on trunk function (SMD 1.03, 95% CI 0.91 to 1.16; P < 0.001; 36 trials, 1217 participants; very low-certainty evidence), standing balance (SMD 1.00, 95% CI 0.86 to 1.15; P < 0.001; 22 trials, 917 participants; very low-certainty evidence), leg function (SMD 1.57, 95% CI 1.28 to 1.87; P < 0.001; 4 trials, 254 participants; very low-certainty evidence), walking ability (SMD 0.69, 95% CI 0.51 to 0.87; P < 0.001; 19 trials, 535 participants; low-certainty evidence) and quality of life (SMD 0.70, 95% CI 0.29 to 1.11; P < 0.001; 2 trials, 111 participants; low-certainty evidence), but not for ADL (SMD 0.10; 95% confidence interval (CI) -0.17 to 0.37; P = 0.48; 9 trials; 229 participants; very low-certainty evidence), arm-hand function (SMD 0.76, 95% CI -0.18 to 1.70; P = 0.11; 1 trial, 19 participants; low-certainty evidence), arm-hand activity (SMD 0.17, 95% CI -0.21 to 0.56; P = 0.38; 3 trials, 112 participants; very low-certainty evidence). Trunk training also led to no difference for the outcome serious adverse events (odds ratio (OR): 7.39, 95% CI 0.15 to 372.38; 10 trials, 381 participants; very low-certainty evidence). Time post stroke led to a significant subgroup difference for standing balance (P < 0.001) in non-dose-matched therapy. In non-dose-matched therapy, different trunk therapy approaches had a significant effect on ADL (< 0.001), trunk function (P < 0.001) and standing balance (< 0.001). When participants received dose-matched therapy, analysis of subgroup differences showed that the trunk therapy approach had a significant effect on ADL (P = 0.001), trunk function (P < 0.001), arm-hand activity (P < 0.001), standing balance (P = 0.002), and leg function (P = 0.002). Also for dose-matched therapy, subgroup analysis for time post stroke resulted in a significant difference for the outcomes standing balance (P < 0.001), walking ability (P = 0.003) and leg function (P < 0.001), time post stroke significantly modified the effect of intervention.  Core-stability trunk (15 trials), selective-trunk (14 trials) and unstable-trunk (16 trials) training approaches were mostly applied in the included trials.

AUTHORS' CONCLUSIONS

There is evidence to suggest that trunk training as part of rehabilitation improves ADL, trunk function, standing balance, walking ability, upper and lower limb function, and quality of life in people after stroke. Core-stability, selective-, and unstable-trunk training were the trunk training approaches mostly applied in the included trials. When considering only trials with a low risk of bias, results were mostly confirmed, with very low to moderate certainty, depending on the outcome.

Dosages of swallowing exercises in stroke rehabilitation: a systematic review

PURPOSE

To investigate the dosages of swallowing exercises reported in intervention studies on post-stroke dysphagia through systematic review.

METHODS

Five electronic databases were searched from inception until February 2022 with reference tracing of included studies. Studies were included, where adults with post-stroke dysphagia received rehabilitative, behavioural swallowing exercises, pre/post outcomes were reported, and intervention dosage was described in detail, including frequency, intensity, time, and type of exercise. Two reviewers independently screened studies and rated quality using ASHA Levels of Evidence tool. Data was tabulated and narratively described.

RESULTS

54 studies were included with a total 1501 participants. Studies included 28 randomised controlled trials, 8 non-randomised controlled trials, 12 pre/post studies, 3 retrospective case controls and 3 case studies. Results showed inconsistent reporting of intervention dosage, with intensity the least consistently reported dosage component. While swallowing intervention was most commonly provided five times per week for four weeks, there was a wide breadth of type, frequency, intensity and duration of swallowing exercises reported. Dosage under-reporting and variation was particularly observed in "standard care" co-interventions or control groups. Study strengths included following PRISMA guidelines, providing a comprehensive review of swallowing exercise methodology and dosages, and including non-English studies. The limitation was lack of meta-analysis due to the heterogeneity of included studies.

CONCLUSIONS

Dosages of swallowing exercises are inconsistently reported and vary significantly in post-stroke dysphagia studies. Results indicate the need for consistent and comprehensive dosage reporting in dysphagia studies, and for further research into evidence-based principles to optimise swallowing exercise dosages.

SYSTEMATIC REVIEW REGISTRATION NUMBER

131294.

Changes in ultrasonic vocalizations after unilateral cerebral ischemia in a rat stroke model

Stroke frequently results in communication impairments that negatively impact quality of life and overall recovery, yet the biological mechanisms underlying these changes are not well understood. Ultrasonic vocalizations (USVs) in rodent models of disease and aging have been used to improve our understanding of the biological mechanisms that underlie vocal deficits and their response to interventions. Changes in USVs after middle cerebral artery occlusion (MCAO) in mice have been reported, yet rat models have significant anatomical and behavioral advantages over mice, including the ability to vocally train rats with an established paradigm. We sought to determine whether a unilateral MCAO rat stroke model provides a biologically and behaviorally relevant way to study post stroke vocalization deficits. We hypothesized that left MCAO would be associated with changes in USVs. Six weeks after MCAO or sham-control surgery, USVs were recorded in rats using an established mating paradigm. Stroke was associated with differences in USV acoustics including more frequent use of simple calls characterized by shorter durations and restricted bandwidths. These parameters were also found to correlate with post stroke lingual weakness. This is the first study to describe changes to rat USVs using a stroke model. These results suggest the unilateral MCAO rat stroke model is a biologically and behaviorally relevant model to understand how stroke affects vocal behaviors.

The Additive Effectiveness of Inspiratory Muscle Training on Glottic Closure and Subjective Voice Outcomes of Patients With Benign Lesion After Hyaluronic Acid Laryngoplasty

OBJECTIVES

For patients with glottic insufficiency disease, injection laryngoplasty is a rapid and efficient management option that complements voice therapy. Some studies have indicated that respiratory muscle training may also show promise in patients with voice disorders. However, the effect of respiratory muscle training in patients with glottic insufficiency was reported to be limited, and whether it provides additional benefit after standard management requires further evaluation. We aimed to investigate the effectiveness of inspiratory muscle training on glottis closure and patient-reported voice quality in glottic insufficiency patients who had been treated with hyaluronic acid injection.

STUDY DESIGN

Retrospective observational study.

METHODS

We included 46 patients with glottic insufficiency who had undergone hyaluronic acid injection. Twenty of them had undergone inspiratory muscle training during three months. We measured patients' changes in glottic status according to the normalized glottal gap area and bowing index, as well as voice quality of life according to the voice handicap index 10 and the voice outcome survey, before and after training.

RESULTS

Patients who underwent inspiratory muscle training had higher odds of experiencing better improvement in all scores. The range of odds ratios ranged from 2.5 to 6.3 for changes in scores, and from 3.8 to 22.2 for changes in score percentages. Of note, the effect of training on percentage changes in the normalized glottal gap area score was significant (P= 0.0127) after adjustment for the duration of vocal disease, body mass index and BMI, and history of gastroesophageal reflux disease.

CONCLUSIONS

Inspiratory muscle training can improve the glottal gap after injection laryngoplasty, and may be applied in clinical practice.

Clinical study on tri-tongue acupuncture combined with low-frequency electrical stimulation for treating post-stroke dysarthria

BACKGROUND

Few studies have investigated low-frequency electrical stimulation combined with tri-tongue acupuncture for the treatment of post-stroke dysarthria. This randomized clinical study assessed the correlation between the clinical efficacy of low-frequency electrical stimulation combined with tri-tongue acupuncture in patients with post-stroke dysarthria.

AIM

To investigate the clinical effects of tri-tongue acupuncture combined with low-frequency electrical stimulation for treating post-stroke dysarthria.

METHODS

Ninety patients with post-stroke dysarthria, who were admitted to our hospital from December 2019 to June 2021, were selected and equally divided into two groups (n = 45/group) according to the random number table method. Tri-tongue acupuncture was administered in the control group. The treatment group received both tri-tongue acupuncture and low-frequency electrical stimulation. The clinical efficacy, Western Aphasia Battery (WAB) score, general quality of life inventory (GQOLI-74) score, Frenchay Dysarthria Assessment score, and speech function grades were compared and analyzed between both groups.

RESULTS

The overall efficacy in the treatment group was better than that in the control group (P < 0.05). Before treatment, the WAB, Frenchay Dysarthria Assessment, or GQOLI-74 scores (P > 0.05) did not differ between the groups. After therapy, the WAB, Frenchay Dysarthria Assessment, and GQOLI-74 scores in both groups increased significantly (P < 0.05), and the treatment group exhibited a significantly greater increase than that of the controls (P < 0.05). Moreover, the classification of speech function did not differ between the two groups before treatment (P > 0.05), whereas significant improvements were observed in both groups after treatment (P < 0.05). The degree of improvement in the treatment group was greater than that in the control group (P < 0.05).

CONCLUSION

Low-frequency electrical stimulation, in conjunction with tri-tongue acupuncture, exhibits a good clinical effect on post-stroke dysarthria.

The relationship of respiratory functions and respiratory muscle strength with trunk control, functional capacity, and functional independence in post‐stroke hemiplegic patients

BACKGROUND

Cardiorespiratory system involvement and early fatigue observed in stroke patients complicate the rehabilitation process and affect their ability to perform daily activities and functional independence.

AIM

It was aimed to determine the relationship between respiratory functions and respiratory muscle strength with trunk control, functional capacity, and functional independence in hemiplegic patients after stroke.

MATERIALS AND METHODS

Twenty-five volunteers who were diagnosed with post-stroke hemiplegia were included in the study. Sociodemographic and physical characteristics were recorded. Pulmonary function test (PFT), respiratory muscle strength, Trunk Impairment Scale (TIS), Timed-Up and Go Test (TUG), and Barthel Index (BI) were applied.

RESULTS

There was a moderate negative correlation between TUG scores and PFT results (r = 0.413-0.502; p = 0.011-0.04), except for PEF (%) and FEV1/FVC. Also, there were statistically significant correlation between TIS scores and FEV1(%) (r = 0.505; p = 0.012), FVC(%) (r = 0.449; p = 0.024). On the other hand, there was no statistically significant relationship between BI results and any parameter of the PFT (p > 0.05). There was no statistically significant correlation between respiratory muscle strength and TUG, TIS, BI (p > 0.05).

CONCLUSION

It has been shown that respiratory functions are associated with functional capacity and trunk control. However, it was found that there was no relationship between respiratory muscle strength and functional capacity, trunk control, and functional independence. It is thought that considering these parameters in the assessment of patients will contribute to the creation of individual and effective rehabilitation programs. The respiratory system should be systematically assessed in stroke rehabilitation and considered as part of a holistic approach.

CLINICAL TRIAL REGISTRATION

NCT05290649 (retrospectively registered) (clinicaltrials.gov).

Impact of Physical Activity on COVID-19

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is seriously endangering human health worldwide. This study finds effective intervention modalities of physical activity on COVID-19 through a narrative review.

METHODS

In this study, 41 papers were selected for a narrative literature review after a comprehensive database search from 20 December 2019, to 30 August 2022.

RESULTS

41 articles meet the established criteria, and in this review, we comprehensively describe recent studies on exercise and COVID-19, including the impact and recommendations of exercise on COVID-19 prevention, patients with COVID-19, and noninfected populations.

CONCLUSIONS

The literature suggests that physical activity (PA) contributes to the prevention and treatment of COVID-19, can promote recovery of physical function, alleviate post-acute COVID-19 syndrome, and improve patients' psychological well-being. It is recommended to develop appropriate exercise prescriptions for different populations under the guidance of a physician.

Application of Nursing Outcome-Oriented Integrated Zero-Defect Nursing Combined with Respiratory Function Training in Long-Term Bedridden Patients Undergoing Stroke

Objective

To explore the application effect of nursing outcome-oriented integrated zero-defect nursing combined with respiratory function training in long-term bedridden patients with stroke.

Methods

A total of 120 long-term bedridden patients with stroke were randomly divided into three groups: groups A, B, and C. Group A was given nursing outcome-oriented integrated zero-defect nursing combined with respiratory function training, group B was given nursing outcome-oriented integrated zero-defect nursing, and group C was given routine nursing. Rosenbek aspiration degree classification criteria were used to evaluate the incidence of aspiration; blood oxygen saturation, arterial oxygen partial pressure, and respiratory pressure were compared before and after the intervention. The swallowing function was evaluated by a water swallowing test (WST). The quality of life was assessed using the Generic Quality of Life Inventory-74 (GQOLI-74).

Results

After treatment, the Rosenbek aspiration degree of groups A and B were better than those of group C (P < 0.05); the improvement degree of respiratory function indexes in group A was better than those in B and C, and the blood oxygen saturation and arterial blood oxygen partial pressure in group B were better than those in C (P < 0.05). The incidence of complications in groups A and B was lower than that in C, and complications in group A were lower than that in B (P < 0.05). After treatment, the scores of psychological function, social function, and material life status of the three groups were increased, and each score of groups A and B was higher than that of C, and each score of group A was higher than that of B (P < 0.05).

Conclusion

Nursing outcome-oriented integrated zero-defect nursing combined with respiratory function training can effectively improve aspiration, respiratory function, swallowing function, complication rate, and quality of life in long-term bedridden patients with stroke.

Repetitive transcranial magnetic stimulation combined with respiratory muscle training for pulmonary rehabilitation after ischemic stroke—A randomized, case-control study

Respiratory muscle weakness often occurs after stroke, which can lead to pulmonary dysfunction (PD). Pulmonary dysfunction prolongs the length of hospital stay and increases the risk of death. In a prospective, randomized, case-control study, we used musculoskeletal ultrasonography (MSUS), and pulmonary function tester to objectively evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) combined with respiratory muscle training (RMT) in the treatment of PD in patients with acute ischemic stroke. Sixty-two stroke patients with PD were recruited and eventually 60 patients participated in this study. The control group was treated with RMT, and the treatment group was treated with rTMS on the basis of RMT. Treatment occurred five times a week for 8 weeks. Before and after treatment, diaphragmatic thickness (DT), diaphragmatic thickening fraction (DTF) and diaphragmatic mobility (DM) in patients, bilateral chest wall were measured by MSUS. Meanwhile, FVC, FEV1, FEV1/FVC, PEF, and MVV tested by pulmonary function tester was used to evaluate the improvement of lung functional. activities of daily living (ADL) was used as an objective criterion to evaluate the overall functional recovery of patients before and after treatment. After treatment, DT, DTF, and DM values improved significantly in both the affected and unaffected sides. The FVC, FEV1, FEV1/FVC, PEF, MVV, and ADL were all increased after the treatment. Combined treatment showed a stronger increase than that by RMT treatment alone. The study preliminarily shows that rTMS and RMT could improve lung functional after acute ischemic stroke.

Is there a role of pulmonary rehabilitation in extrapulmonary diseases frequently encountered in the practice of physical medicine and rehabilitation?

There is a group of diseases such as low back pain, osteoporosis, fibromyalgia and obesity for which pulmonary rehabilitation can be applied. Although these diseases do not directly impact the lungs, respiratory dysfunction occurs through various mechanisms during the disease process and complicates the underlying primary disease. Respiratory dysfunction and spirometric abnormalities have been observed from the early stages of these diseases, even without obvious signs and symptoms. These patients should be carefully evaluated for pulmonary problems as a sedentary lifestyle may hide the presence of respiratory symptoms. Once pulmonary problems have been detected, pulmonary rehabilitation should be added to the routine treatment of the primary disease.

The Effectiveness of Repetitive Transcranial Magnetic Stimulation for Post-stroke Dysphagia: A Systematic Review and Meta-Analysis

Background

Repetitive transcranial magnetic stimulation (rTMS) applied to the mylohyoid cortical region has positive clinical effects on post-stroke. Therefore, we conducted a meta-analysis to investigate the efficacy of rTMS for patients with post-stroke dysphagia.

Methods

According to PRISMA guidelines, we searched the databases of MEDLINE (PubMed), Cochrane Library, Embase, Web of Science, CNKI, Wangfang. We searched for studies of randomized controlled trials (RCTs) of rTMS to treat dysphagia after stroke and screened by inclusion and exclusion criteria. Features of RCTs were extracted. The heterogeneity of the trials was measured by I 2 statistic.

Results

In total, 11 RCTs with 463 dysphagia patients fulfilled our inclusion criteria. In our analysis, rTMS demonstrated a great beneficial effect for post-stroke dysphagia when combined with traditional swallowing exercises. Moreover, a greatly significant difference (P = 0.008) was noted based on stimulation frequency (high frequency vs. low frequency). Additionally, no significant difference (P = 0.53) was observed based on stimulation site (affected vs. unaffected hemisphere).

Conclusions

Overall, rTMS can effectively accelerate the improvement of swallowing function in patients with post-stroke swallowing disorders.

Neurogenic Dysphagia and Nutrition in Disorder of Consciousness: An Overview with Practical Advices on an "Old" but Still Actual Clinical Problem

Neurogenic dysphagia is a difficulty in swallowing food caused by disease or impairment of the nervous system, including stroke and traumatic brain injury. The most clinically apparent complication of neurogenic dysphagia is pulmonary aspiration, which may manifest itself acutely as choking or coughing, respiratory distress, wheezing, gasping or gurgling, and tachycardia. However, chronic symptoms, including weight loss, production of excessive oral secretions and aspiration pneumonia, may be also present, especially in patients with a disorder of consciousness (DOC). Usually, patients with dysphagia after the acute phase need to be treated with enteral nutrition using a feeding tube. This avoids patient malnutrition and supports the rehabilitation program. This narrative review aims to investigate dysphagia and its complications and management in patients with DOC. Clinical indications and practical advice on how to assess and treat this complex problem are also provided.

Comparing the Effects of Short-Term Liuzijue Exercise and Core Stability Training on Balance Function in Patients Recovering From Stroke: A Pilot Randomized Controlled Trial

Aims

Liuzijue Qigong (LQG) exercise is a traditional Chinese exercise method in which breathing and pronunciation are combined with movement guidance. Breathing is closely related to balance, and LQG, as a special breathing exercise, can be applied to balance dysfunction after stroke. The purpose of this study was to observe the clinical effects of short-term LQG exercise on balance function in patients recovering from stroke.

Methods

Stroke patients were randomly divided into an Intervention Group (IG) (n = 80) and a Control Group (CG) (n = 80). The IG received conventional rehabilitation training plus LQG and the CG received conventional rehabilitation training plus Core Stability Training (CST). All patients received treatment once a day, 5 times a week for 2 weeks. The primary outcome was Berg Balance Scale (BBS). Secondary outcome measures were static standing and sitting balance with eyes open and closed, Fugl-Meyer Assessment (FMA), Maximum Phonation Time (MPT), Modified Barthel Index (MBI) and diaphragm thickness and mobility during quiet breath (QB) and deep breath (DB).

Results

Compared with the CG, the IG showed significant improvement in the BBS (10.55 ± 3.78 vs. 9.06 ± 4.50, P = 0.039), MPT (5.41 ± 4.70 vs. 5.89 ± 5.24, P = 0.001), MBI (12.88 ± 6.45 vs. 10.00 ± 4.84, P = 0.003), diaphragmatic mobility during QB (0.54 ± 0.73 vs. 0.33 ± 0.40, P = 0.01) and diaphragmatic mobility during DB (0.99 ± 1.32 vs. 0.52 ± 0.77, P = 0.003), Cop trajectory in the standing position with eyes open (−108.34 ± 108.60 vs. −89.00 ± 140.11, P = 0.034) and Cop area in the standing positions with eyes open (−143.79 ± 431.55 vs. −93.29 ± 223.15, P = 0.015), Cop trajectory in the seating position with eyes open (−19.95 ± 23.35 vs. −12.83 ± 26.64, P = 0.001) and Cop area in the seating position with eyes open (−15.83 ± 9.61 vs. −11.29 ± 9.17, P = 0.002).

Conclusions

The short-term LQG combined with conventional rehabilitation training significantly improved the balance functions of stroke patients. It also improved static standing and sitting balance with the eyes open, diaphragm functions, maximum phonation time and the quality of daily life for stroke patients.

Clinical Trial Registration

http://www.chictr.org.cn/edit.aspx?pid=25313&amp;htm=4, Identifier: ChiCTR1800014864.

Key concepts and opportunities

Neuropalliative care is an emerging field dedicated to applying palliative care approaches to meet the needs of persons living with neurologic illness and their families. The development of this field acknowledges the unique needs of this population, including in terms of neuropsychiatric symptoms, the impact of neurologic illness on personhood, and the logistics of managing neurologic disability. In defining the goals of this field, it is important to distinguish between neuropalliative care as an approach to care, as a skillset, as a medical subspecialty, and as a public health goal as each of these constructs offers their own contributions and opportunities. As a newly emerging field, there are nearly unlimited opportunities to improve care through research, clinical care, education, and advocacy.

Electromyographic study assessing swallowing function in subacute stroke patients with respiratory muscle weakness

BACKGROUND

Dysphagia has been reported to be associated with the descent of the hyolaryngeal complex. Further, suprahyoid muscles play a greater role than infrahyoid muscles in elevation of the hyolarngeal complex. Respiratory muscle training (RMT) can improve lung function, and expiratory muscle strength training can facilitate elevation of the hyoid bone and increase the motor unit recruitment of submental muscles during normal swallowing. This study aimed to investigate the surface electromyography (sEMG) of the swallowing muscles, bilaterally, and the effect of RMT on swallowing muscles in stroke patients with respiratory muscle weakness.

METHODS

Forty patients with first episode of unilateral stroke were included in this retrospective controlled trial. After exclusion of 11 patients with respiratory muscle strength stronger than 70% of the predicted value, 15 were allocated to the RMT group and 14 to the control group. However, eventually, 11 patients in RMT group and 11 patients in control group completed the study. The sEMG of the orbicularis oris, masseter, submental, and infrahyoid muscles were recorded during dry swallowing, water swallowing (2 mL), and forced exhalation against a threshold breathing trainer set at different intensities, at baseline and after 6-week RMT.

RESULTS

Regarding the sEMG of submental muscles, there were significant between-group differences on the latency of the unaffected side (P = .048), significant change from baseline force on the unaffected side (P = .035), and significant between-side difference (P = .011) in the RMT group during dry swallowing. Significant change in the duration from baseline was observed on the affected side of the RMT group when blowing was set at 50% maximal expiratory pressure (MEP; P = .015), and on the unaffected side of the control group when blowing set at 15% MEP (P = .005). Significant difference was observed in the duration between 50% MEP and 15% MEP after 6-week program in the control group (P = .049).

CONCLUSIONS

A 6-week RMT can improve the electric signal of the affected swallowing muscles with more effect on the unaffected side than on the affected side during dry swallowing. Furthermore, RMT with 50% MEP rather than 15% MEP can facilitate greater submental muscle activity on the affected side in stroke patients with respiratory muscle weakness.

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.

Respiratory muscle training improves exercise tolerance and respiratory muscle function/structure post-stroke at short term: A systematic review and meta-analysis

BACKGROUND

Previous reviews relating to the effects of respiratory muscle training (RMT) after stroke tend to focus on only one type of training (inspiratory or expiratory muscles) and most based the results on poor-quality studies (PEDro score ≤4).

OBJECTIVES

With this systematic review and meta-analysis, we aimed to determine the effects of RMT (inspiratory or expiratory muscle training, or mixed) on exercise tolerance, respiratory muscle function and pulmonary function and also the effects depending on the type of training performed at short- and medium-term in post-stroke.

METHODS

Databases searched were MEDLINE, PEDro, CINAHL, EMBASE and Web of Science up to the end of April 2020. The quality and risk of bias for each included study was examined by the PEDro scale (including only high-quality studies) and Cochrane Risk of Bias tool.

RESULTS

Nine studies (463 patients) were included. The meta-analysis showed a significant increase in exercise tolerance [4 studies; n = 111; standardized mean difference [SMD] = 0.65 (95% confidence interval 0.27-1.04)]; inspiratory muscle strength [9 studies; n = 344; SMD = 0.65 (0.17-1.13)]; inspiratory muscle endurance [3 studies; n = 81; SMD = 1.19 (0.71-1.66)]; diaphragm thickness [3 studies; n = 79; SMD = 0.9 (0.43-1.37)]; and peak expiratory flow [3 studies; n = 84; SMD = 0.55 (0.03-1.08)] in the short-term. There were no benefits on expiratory muscle strength and pulmonary function variables (forced expiratory volume in 1 s) in the short-term.

CONCLUSIONS

The meta-analysis provided moderate-quality evidence that RMT improves exercise tolerance, diaphragm thickness and pulmonary function (i.e., peak expiratory flow) and low-quality evidence for the effects on inspiratory muscle strength and endurance in stroke survivors in the short-term. None of these effects are retained in the medium-term. Combined inspiratory and expiratory muscle training seems to promote greater respiratory changes than inspiratory muscle training alone.

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.

Effects of respiratory muscle training on cough function in neurological disorders: A systematic review with meta-analysis

BACKGROUND

Patients with neurological disorders can present the weakness of respiratory muscle and impaired cough function. Previous studies have shown that respiratory muscle strength training (RMT) is an effective method of improving the strength of respiratory muscle. The effects of RMT on cough function remain controversial.

OBJECTIVE

We aimed to analyze randomized controlled trials (RCTs) that investigated the effects of RMT on cough function of patients with neurological disorders.

METHODS

Pubmed, Medline, Embase, and the Cochrane Library were searched electronically for RCTs. Two reviewers independently performed data extraction and quality assessment. Data were analyzed by using RevMan 5.3 software of The Cochrane Collaboration.

RESULTS

Five studies with 185 participants were included. The mean PEDro score was 6.2 (range 5 to 7), showing moderate methodological quality. Random-effects meta-analyses showed that respiratory muscle training improved peak expiratory cough flow of voluntary cough by 2.16 (95% CI 1.16 to 3.17) and involuntary cough by 2.84 (95% CI 1.29 to 4.39), with statistical significance (P < 0.0001, P = 0.0003). The experimental group had an improvement of 0.19 cmH2O (95% CI -0.12 to 0.5) on the maximal inspiratory pressure, 0.09 cmH2O (95% CI -0.23 to 0.42) on the maximal expiratory pressure, but with no statistical significance (P = 0.23, P = 0.58) between groups.

CONCLUSION

Respiratory muscle training was considered as an effective method for improving cough function. However, this review was insufficient to conclude whether respiratory muscle training was effective in improving inspiratory and expiratory muscle strength, this was opposite with previous meta-analysis. These effects might due to the small samples and different diseases.

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.

Pulmonary Rehabilitation in COVID-19 patients: A scoping review of current practice and its application during the pandemic

The novel coronavirus-2019 (COVID-19) pandemic primarily affects the respiratory system. Elderly individuals with comorbidity are severely affected. Survivors weaned from mechanical ventilation are at a higher risk of developing post-intensive care syndrome (PICS). This scoping review, based on 40 recent publications, highlights pulmonary rehabilitation (PR) in COVID-19. There is a paucity of high-quality research on this topic. However, rehabilitation societies including the Turkish Society of Physical Medicine and Rehabilitation have issued PR recommendations in COVID-19 pneumonia with productive cough can benefit from diaphragmatic breathing, pursed-lip breathing, and resistance-breathing training. Besides, those in mechanical ventilation and post-PICS COVID-19 cases, oxygen therapy, early mobilization, airway clearance, aerobic exercise, gradual-graded limb muscle resistance exercise, nutritional and psychological interventions should be consideration. During PR, careful evaluation of vital signs and exercise-induced symptoms is also required. When in-person PR is not possible, telerehabilitation should be explored. However, the long-term effects of PR in COVID-19 need further evaluation.

Pulmonary Rehabilitation in COVID-19 patients: A scoping review of current practice and its application during the pandemic

The novel coronavirus-2019 (COVID-19) pandemic primarily affects the respiratory system. Elderly individuals with comorbidity are severely affected. Survivors weaned from mechanical ventilation are at a higher risk of developing post-intensive care syndrome (PICS). This scoping review, based on 40 recent publications, highlights pulmonary rehabilitation (PR) in COVID-19. There is a paucity of high-quality research on this topic. However, rehabilitation societies including the Turkish Society of Physical Medicine and Rehabilitation have issued PR recommendations in COVID-19 pneumonia with productive cough can benefit from diaphragmatic breathing, pursed-lip breathing, and resistance-breathing training. Besides, those in mechanical ventilation and post-PICS COVID-19 cases, oxygen therapy, early mobilization, airway clearance, aerobic exercise, gradual-graded limb muscle resistance exercise, nutritional and psychological interventions should be consideration. During PR, careful evaluation of vital signs and exercise-induced symptoms is also required. When in-person PR is not possible, telerehabilitation should be explored. However, the long-term effects of PR in COVID-19 need further evaluation.

Physical activity and nutrition guidelines to help with the fight against COVID-19

As the world is witnessing the epidemic of coronavirus disease 2019, emerging genetics and clinical pieces of evidence suggest a similar immunopathology to those of severe acute respiratory syndrome and Middle East respiratory syndrome. Staying at home to prevent the spread of the virus and consequently being largely inactive is associated with unintended consequences. These can actually enhance the infection risk and exacerbate poor health conditions including impaired immune function. Physical activity is a feasible way of improving health, particularly physical and mental health in a time of social isolation. However, people with certain health conditions in these circumstances may need a special physical activity programme in addition to any exercise they may already be performing via online programmes. This review aims to provide practical guidelines during the COVID-19 quarantine period. We suggest performing aerobic, resistance training, respiratory muscle training and yoga in the healthy, and in those with upper respiratory tract illness, patients with lower respiratory tract illness should be restricted to respiratory muscle training and yoga. In addition, vitamins D and C, omega-3 fatty acids, and regular consumption of fruit and vegetables might be considered as nutritional aids to support the immune system in those affected by COVID-19.

Effectiveness of Respiratory Muscle Training for Pulmonary Function and Walking Ability in Patients with Stroke: A Systematic Review with Meta-Analysis

Background: Neurological dysfunction due to stroke affects not only the extremities and trunk muscles but also the respiratory muscles. Aim: to synthesise the evidence available about the effectiveness of respiratory muscle training (RMT) to improve respiratory function parameters and functional capacity in poststroke patients. Methods: a systematic electronic search was performed in the MEDLINE, EMBASE, SPORTDiscus, PEDro and Web of Science databases, from inception to May 2020. Study selection and data extraction: randomised controlled trials (RCTs) that examined the effects of RMT versus non-RMT or sham RMT in poststroke patients. We extracted data about respiratory function, respiratory muscle strength and functional capacity (walking ability, dyspnea, balance, activities of daily life), characteristics of studies and features of RMT interventions (a type of RMT exercise, frequency, intensity and duration). Two reviewers performed study selection and data extraction independently. Results: nineteen RCTs met the study criteria. RMT improved the first second forced expiratory volume (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), maximal expiratory pressure (MEP), maximal inspiratory pressure (MIP) and walking ability (6 min walking test), but not Barthel index, Berg balance scale, and dyspnea. Conclusions: RMT interventions are effective to improve respiratory function and walking ability in poststroke patients.