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Sasegbon A, Cheng I, Labeit B, Lapa S, Rommel N, Hamdy S. New and Evolving Treatments for Neurologic Dysphagia. Drugs 2024; 84:909-932. [PMID: 38954267 DOI: 10.1007/s40265-024-02064-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/06/2024] [Indexed: 07/04/2024]
Abstract
Despite swallowing being a frequently performed daily function, it is highly complex. For a safe swallow to occur, muscles within the head, neck, and thorax need to contract in a concerted pattern, controlled by several swallowing centers at multiple levels of the central nervous system, including the midbrain, cerebral cortex, and cerebellum in addition to five cranial nerves. Dysphagia, or difficulty swallowing, is caused by a long list of pathologic processes and diseases, which can interfere with various stages along the swallowing sensorimotor pathway. When present, dysphagia leads to increased mortality, morbidity, hospital length of stay, and reduced quality of life. Current dysphagia management approaches, such as altering the texture and consistency of foods and fluids and teaching patients rehabilitative exercises, have been broadly unchanged for many years and, in the case of texture modification, are of uncertain effectiveness. However, evidence is emerging in support of new medication-based and neuromodulatory treatment approaches. Regarding medication-based therapies, most research has focused on capsaicinoids, which studies have shown are able to improve swallowing in patients with post-stroke dysphagia. Separately, albeit convergently, in the field of neuromodulation, there is a growing and positive evidential base behind three non-invasive brain stimulation techniques: repetitive transcranial magnetic stimulation (rTMS), transcranial direct current stimulation (TDCS), and pharyngeal electrical stimulation (PES). Should some or all of these emerging therapies fulfill their promise, dysphagia-related patient outcomes may be improved. This paper describes the current state of our understanding regarding new medication and neuromodulation-based neurogenic oropharyngeal dysphagia treatments.
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Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK
| | - Ivy Cheng
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK
- Academic Unit of Human Communication, Learning, and Development, Faculty of Education, The University of Hong Kong, Hong Kong, China
- Institute for Biomagnetism and Biosignal Analysis, University of Münster, Münster, Germany
- Universitätsklinikum Münster, Münster, Germany
| | - Bendix Labeit
- Department of Neurology, Medical Faculty, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Sriramya Lapa
- Department of Neurology, Goethe University and University Hospital, Frankfurt, Germany
| | - Nathalie Rommel
- Deglutology, Experimental Otorhinolaryngology, Department of Neurosciences, University of Leuven, Leuven, Belgium
- Department of Gastroenterology, Neurogastroenterology and Motility, University Hospitals Leuven, Leuven, Belgium
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, School of Medical Sciences, Centre for Gastrointestinal Sciences, University of Manchester, Manchester, UK.
- Centre for Gastrointestinal Sciences, Salford Royal Foundation Trust, University of Manchester, Clinical Sciences Building, Manchester, Eccles Old Road, Salford, M6 8HD, UK.
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Shen M, Zhang L, Li C, Wei X, Li Y, Wu H, Zhang X, Gao S, Ma Y, Ma Y. Repetitive transcranial magnetic stimulation as a therapy for post-stroke dysphagia: An overview of systematic reviews and meta-analysis. Clin Rehabil 2024:2692155241264757. [PMID: 39053022 DOI: 10.1177/02692155241264757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
OBJECTIVE Post-stroke dysphagia is a common swallowing disorder that occurs after a stroke, leading to an increased risk of aspiration pneumonia and malnutrition. There is a pressing need for effective and safe interventions for its rehabilitation. This review aims to answer two key scientific questions: (1) What is the efficacy of repetitive transcranial magnetic stimulation in the rehabilitation of post-stroke dysphagia? (2) Is repetitive transcranial magnetic stimulation a safe intervention for post-stroke dysphagia? DATA SOURCES A comprehensive search was conducted across four electronic databases: PubMed, Cochrane Library, Web of Science, and Embase. The search aimed to identify relevant studies concerning our topic of interest and was completed on 28 May 2024. REVIEW METHODS In accordance with the PRISMA checklist, a comprehensive search of four databases was conducted, which identified 13 relevant systematic reviews. The inclusion criteria were systematic reviews that evaluated the efficacy and safety of repetitive transcranial magnetic stimulation for post-stroke dysphagia. Exclusion criteria were reviews that did not focus on post-stroke dysphagia or did not evaluate repetitive transcranial magnetic stimulation as a therapeutic intervention. The quality, bias, reporting, and overall evidence quality of these reviews were assessed using validated tools, including the AMSTAR 2 tool for assessing the methodological quality of systematic reviews, the ROBIS tool for assessing the risk of bias, and the GRADE approach for evaluating the overall quality of evidence. This rigorous approach ensures that our review provides a comprehensive and reliable overview of the current state of knowledge on the use of repetitive transcranial magnetic stimulation for post-stroke dysphagia. RESULTS The sample sizes for the individual studies included in the systematic reviews/meta-analyses ranged from 66 to 555. The total number of participants across all studies included in the overall analyses was 752. The evidence was limited by the methodological flaws and heterogeneity of the systematic reviews. The quality of the evidence varied from high to low, with most outcomes having moderate quality. Future research should adopt more rigorous, standardized, and comprehensive designs to confirm the efficacy and safety of repetitive transcranial magnetic stimulation for post-stroke dysphagia. The main reason for downgrading the evidence quality was the small sample size and high heterogeneity of the primary studies. CONCLUSION This overview synthesized research on repetitive transcranial magnetic stimulation for dysphagia, aiming to inform clinical and policy decisions. However, the current evidence does not conclusively establish the safety and efficacy of repetitive transcranial magnetic stimulation for post-stroke dysphagia rehabilitation. The studies reviewed varied in quality, and many were of poor quality. Therefore, while some studies suggest potential benefits of repetitive transcranial magnetic stimulation, these findings should be interpreted with caution. There is a pressing need for more rigorous, high-quality research to validate the use of repetitive transcranial magnetic stimulation for post-stroke dysphagia rehabilitation. The implications of these findings for clinical practice and policy will be clearer once we have more robust, evidence-based recommendations.
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Affiliation(s)
- Min Shen
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Linlin Zhang
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Chunjing Li
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Xiaocen Wei
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yang Li
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Hongxue Wu
- Department of Rehabilitation, The First Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, China
| | - Xiaobin Zhang
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Shuzhong Gao
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yuning Ma
- Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Yuxia Ma
- Shandong University of Traditional Chinese Medicine, Jinan, China
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Sasegbon A, Cheng I, Hamdy S. The neurorehabilitation of post-stroke dysphagia: Physiology and pathophysiology. J Physiol 2024. [PMID: 38517302 DOI: 10.1113/jp285564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 02/29/2024] [Indexed: 03/23/2024] Open
Abstract
Swallowing is a complex process involving the precise contractions of numerous muscles of the head and neck, which act to process and shepherd ingested material from the oral cavity to its eventual destination, the stomach. Over the past five decades, information from animal and human studies has laid bare the complex network of neurones in the brainstem, cortex and cerebellum that are responsible for orchestrating each normal swallow. Amidst this complexity, problems can and often do occur that result in dysphagia, defined as impaired or disordered swallowing. Dysphagia is common, arising from multiple varied disease processes that can affect any of the neuromuscular structures involved in swallowing. Post-stroke dysphagia (PSD) remains the most prevalent and most commonly studied form of dysphagia and, as such, provides an important disease model to assess dysphagia physiology and pathophysiology. In this review, we explore the complex neuroanatomical processes that occur during normal swallowing and PSD. This includes how strokes cause dysphagia, the mechanisms through which natural neuroplastic recovery occurs, current treatments for patients with persistent dysphagia and emerging neuromodulatory treatments.
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Affiliation(s)
- Ayodele Sasegbon
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, Salford Royal Foundation Trust, University of Manchester, Manchester, UK
| | - Ivy Cheng
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, Salford Royal Foundation Trust, University of Manchester, Manchester, UK
- Academic Unit of Human Communication, Learning, and Development, Faculty of Education, The University of Hong Kong, Hong Kong, China
- Institute for Biomagnetism and Biosignalanalysis, University of Münster, Münster, Germany
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Centre for Gastrointestinal Sciences, Faculty of Biology, Medicine and Health, Salford Royal Foundation Trust, University of Manchester, Manchester, UK
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Li T, Duan XY, Zou XM, Huang X, Kang YJ, Sun MZ. Commentary: The effectiveness of repetitive transcranial magnetic stimulation for post-stroke dysphagia: A systematic review and meta-analysis. Front Hum Neurosci 2022; 16:1018885. [DOI: 10.3389/fnhum.2022.1018885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/02/2022] [Indexed: 12/04/2022] Open
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Cosentino G, Todisco M, Giudice C, Tassorelli C, Alfonsi E. Assessment and treatment of neurogenic dysphagia in stroke and Parkinson's disease. Curr Opin Neurol 2022; 35:741-752. [PMID: 36226719 DOI: 10.1097/wco.0000000000001117] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
PURPOSE OF REVIEW Neurogenic dysphagia worsens quality of life and prognosis of patients with different neurological disorders. Management of neurogenic dysphagia can be challenging. This review provides a comprehensive overview of current evidence on screening, diagnosis, and treatment of neurogenic dysphagia in stroke and Parkinson's disease, suggesting clues for clinical practice. RECENT FINDINGS The pros and cons of diagnostic techniques are discussed in the light of updated evidence. Findings from recent meta-analyses of different treatment approaches, including traditional dysphagia therapy, peripheral and central neurostimulation techniques, and treatment with botulinum toxin, are critically discussed, emphasizing inconsistencies and controversial issues. SUMMARY Screening tests and clinical swallow examination should be routinely performed in neurological patients at risk for dysphagia. In patients testing positive for dysphagia, first-line instrumental investigations, represented by fiberoptic endoscopic evaluation of swallowing or videofluoroscopic swallow study, should be performed to confirm the presence of dysphagia, to assess its severity, and to inform the treatment. Second-line and third-line instrumental methods can be used in selected patients to clarify specific pathophysiological aspects of oropharyngeal dysphagia. Treatment strategies should be personalized, and combination of traditional dysphagia therapy with innovative treatment approaches may increase the chance of restoring effective and safe swallowing.
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Affiliation(s)
- Giuseppe Cosentino
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation
- Department of Brain and Behavioral Sciences, University of Pavia
| | - Massimiliano Todisco
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation
- Department of Brain and Behavioral Sciences, University of Pavia
| | - Carla Giudice
- Department of Brain and Behavioral Sciences, University of Pavia
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Cristina Tassorelli
- Department of Brain and Behavioral Sciences, University of Pavia
- Headache Science and Neurorehabilitation Center, IRCCS Mondino Foundation, Pavia, Italy
| | - Enrico Alfonsi
- Translational Neurophysiology Research Unit, IRCCS Mondino Foundation
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Transcranial magnetic stimulation versus transcutaneous neuromuscular electrical stimulation in post stroke dysphagia: A clinical randomized controlled trial. J Stroke Cerebrovasc Dis 2022; 31:106554. [PMID: 35691184 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/01/2022] [Accepted: 05/08/2022] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES To evaluate the efficacy of high-frequency repeated transcranial magnetic stimulation (rTMS) applied contralesionally versus transcutaneous neuromuscular electrical stimulation (TNES) in acute post-stroke dysphagic patients. MATERIALS AND METHODS A randomized, parallel, comparative, controlled trial was conducted on patients with acute ischemic stroke who were admitted to our department. Fifteen patients received rTMS, 15 patients received TNES, and 15 patients were recruited as a control group. Between the second and tenth days after a stroke, patients were enrolled. The study and follow-up periods were completed by all patients. RESULTS Among the screened patients, 45 (31.47%) right-handed patients were diagnosed with post-stroke dysphagia with a mean age of 60.53 ± 8.23 years. Immediately after intervention both rTMS and TNES groups significantly improve the swallowing disturbance questionnaire (SDQ) and penetration aspiration scale (PAS), compared to the control (p < 0.001 and p = 0.027), respectively. rTMS was more effective than TNES in reducing SDQ and PAS (p < 0.05). rTMS and TNES improved the Yale Pharyngeal Residue Severity Rating Scale (YPRSRS) significantly (p = 0.002); however, their efficacy was comparable (p > 0.05). A significant (p < 0.001) strong negative correlation was observed between the grade of weakness and all scores. CONCLUSION Our findings showed that high-frequency rTMS and TNES effectively improved the clinical condition of acute post-stroke dysphagic patients in terms of swallowing disturbance assessed by SDQ, pharyngeal residue assessed by YPRSRS, and the severity of penetration and aspiration events evaluated by PAS, compared to the controls. The outcomes of high-frequency rTMS were more favorable than those of TNES in terms of SDQ and PAS.
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