Effect of Expiratory Muscle Strength Training on Swallowing and Cough Functions in Patients With Neurological Diseases: A Meta-analysis

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.

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

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

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.

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.

Effects of Respiratory Muscle Strength Training on Respiratory-Related Impairments of Parkinson's Disease

In addition to typical motor dysfunction, Parkinson's disease is also characterized by respiratory-related dysfunction. As a means of rehabilitation, respiratory muscle strength training (RMST) has been applied to restore Parkinson's disease (PD) functions. However, the current clinical value of RMST in the application for PD has not been widely established. This article aims to review the research progress of the application of RMST in PD rehabilitation to provide new sight into respiratory-related impairments management in people with PD.

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.

Diagnosis and treatment of neurogenic dysphagia - S1 guideline of the German Society of Neurology

Introduction

Neurogenic dysphagia defines swallowing disorders caused by diseases of the central and peripheral nervous system, neuromuscular transmission, or muscles. Neurogenic dysphagia is one of the most common and at the same time most dangerous symptoms of many neurological diseases. Its most important sequelae include aspiration pneumonia, malnutrition and dehydration, and affected patients more often require long-term care and are exposed to an increased mortality. Based on a systematic pubmed research of related original papers, review articles, international guidelines and surveys about the diagnostics and treatment of neurogenic dysphagia, a consensus process was initiated, which included dysphagia experts from 27 medical societies.

Recommendations

This guideline consists of 53 recommendations covering in its first part the whole diagnostic spectrum from the dysphagia specific medical history, initial dysphagia screening and clinical assessment, to more refined instrumental procedures, such as flexible endoscopic evaluation of swallowing, the videofluoroscopic swallowing study and high-resolution manometry. In addition, specific clinical scenarios are captured, among others the management of patients with nasogastric and tracheotomy tubes. The second part of this guideline is dedicated to the treatment of neurogenic dysphagia. Apart from dietary interventions and behavioral swallowing treatment, interventions to improve oral hygiene, pharmacological treatment options, different modalities of neurostimulation as well as minimally invasive and surgical therapies are dealt with.

Conclusions

The diagnosis and treatment of neurogenic dysphagia is challenging and requires a joined effort of different medical professions. While the evidence supporting the implementation of dysphagia screening is rather convincing, further trials are needed to improve the quality of evidence for more refined methods of dysphagia diagnostics and, in particular, the different treatment options of neurogenic dysphagia. The present article is an abridged and translated version of the guideline recently published online (https://www.awmf.org/uploads/tx_szleitlinien/030-111l_Neurogene-Dysphagie_2020-05.pdf).

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.

Clinical trial readiness study of distal myopathy and dysphagia in nephropathic cystinosis

BACKGROUND

Nephropathic cystinosis is a lysosomal storage disorder with late-onset systemic complications, such as myopathy and dysphagia. Currently employed outcome measures lack sensitivity and responsiveness for dysphagia and myopathy, a limitation to clinical trial readiness.

METHODS

We evaluated 20 patients with nephropathic cystinosis in two visits over the course of a year to identify outcomes sensitive to detect changes over time. Patients also underwent an expiratory muscle strength training program to assess any effects on aspiration and dysphagia.

RESULTS

There were significant differences in the Timed Up and Go Test (TUG) and Timed 25-Foot Walk (25-FW) between baseline and 1-y follow-up (P < .05). Maximum expiratory pressure (MEP) and peak cough flow (PCF) significantly improved following respiratory training (P < .05).

CONCLUSIONS

Improved respiratory outcomes may enhance patients ability to expel aspirated material from the airway, stave off pulmonary sequelae associated with chronic aspiration, and yield an overall improvement in physical health and well-being.