Effects of expiratory muscle strength training on swallowing function in acute stroke patients with dysphagia

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.

Improvement in Swallowing Function in Patients with Previous Irradiation for Nasopharyngeal Carcinoma by Expiratory Muscle Strength Training

Dysphagia and chronic aspiration are common post-irradiation complications in nasopharyngeal carcinoma (NPC) survivors. Expiratory Muscle Strength Training (EMST) is a simple device-driven exercise therapy for swallowing training. This study investigates the effectiveness of EMST in a group of post-irradiated NPC patients. This prospective cohort, including twelve patients with previous irradiation for NPC and with swallowing disturbance, was performed between 2019 and 2021 in a single institution. Patients were trained with EMST for 8 weeks. Non-parametric analyses examined effects of EMST on primary outcome, maximum expiratory pressure. Secondary outcomes were measured with Penetration-aspiration scale, Yale pharyngeal residue severity rating scale (YPRSRS) by flexible endoscopic evaluation of swallowing, and Eating Assessment Tool (EAT-10) and M.D. Anderson Dysphagia Inventory questionnaire. Twelve patients, with a mean (SD) age of 64.3 (8.2) were recruited. There was no patient dropout with 88.9% overall compliance of training. Maximum expiratory pressure improved by 41% (median 94.5 to 133.5 cmH2O, p = 0.003). There was reduction in Penetration-aspiration scale with thin liquid (median 4 to 3, p = 0.026), and in YPRSRS at pyriform fossa with mildly thick liquid (p = 0.021) and at vallecula with thin liquid (p = 0.034), mildly thick liquid (p = 0.014) and pureed meat congee (p = 0.016). Questionnaire scores did not significantly change statistically. EMST is an easy-to-use and effective exercise therapy to improve airway safety and swallowing function in post-irradiated NPC survivors.

Therapeutic effects of deep pharyngeal electrical stimulation combined with modified masako maneuver on aspiration in patients with stroke

BACKGROUND

Stroke patients often experience difficulty swallowing.

OBJECTIVE

To assist in the improvement of dysphagia symptoms by introducing a novel approach to the treatment of patients with post-stroke aspiration.

METHODS

A total of 60 patients with post-stroke aspiration were enrolled and divided into an experimental group (n = 30) and a control group (n = 30). The control group received standard treatment, sham intraoral stimulation, and the Masako maneuver, while the experimental group was administered standard treatment, deep pharyngeal electrical stimulation (DPES), and a modified Masako maneuver. Changes in their Functional Oral Intake Scale (FOIS) and Rosenbek scale scores were observed.

RESULTS

The FOIS scores of both groups increased significantly after treatment (p < 0.01, respectively). The Rosenbek scale scores of both groups decreased significantly after treatment, with the experimental group scoring significantly lower than the control group (1.01±0.09 vs. 2.30±0.82) (p < 0.05). After treatment, the overall response rate in the experimental group (93.33%) was significantly higher than that in the control group (83.33%) (p < 0.001).

CONCLUSION

In terms of effectively improving dysphagia in aspiration patients after stroke, DPES combined with modified Masako maneuver is clinically recommended.

Brazilian Consensus on Sleep-Focused Speech-Language-Hearing Sciences - 2023 Brazilian Sleep Association

Introduction  This consensus aimed to develop a structured document presenting the role of sleep-focused Speech-Language-Hearing (SPH) Sciences (SPHS). The recommendations were based on the expertise of specialists and on evidence in the literature, aiming to guide the coverage of this area and the consequent improvement in the quality of the professionals' approach. Methods  A Delphi method was conducted with 49 SLH pathologists (SLHP), four sleep physicians, one dentist, one physical therapist, and one methodologist. Four Delphi panel rounds were conducted in Google Forms. The items were analyzed based on the panelists' percentage of agreement; consensuses were reached when ⅔ (66.6%) of valid responses were on a same on a same answer (either "agree" or "disagree"). Results  Participants voted on 102 items. The mean consensus rate was 89.9% ± 10.9%. The essential topics were the importance of professional training, the SLH diagnosis, and the SLH treatment of sleep disorders. It was verified that all fields of the SLHS are related to the area of sleep; that sleep-focused SLH pathologists (SLHP) are the responsible for assessing, indicating, and conducting specific orofacial myofunctional therapy for sleep-disordered breathing alone or in combination with other treatments; that SLHP are included in interdisciplinary teams in the area of sleep in public and private services. Discussion  The Brazilian consensus on sleep-focused SLHS is a landmark in this area. This consensus described the scope of action of sleep-focused SLHP and systematized recommendations being useful as a reference for the professional practice in the area of sleep.

Gastrointestinal Dysfunction in Stroke

Gastrointestinal (GI) complications are seen in over 50% of ischemic stroke survivors; the most common complications are dysphagia, constipation, and GI bleeding. The bidirectional relationship of the gut-brain axis and stroke has recently gained traction, wherein stroke contributes to gut dysbiosis (alterations in the normal host intestinal microbiome) and gut dysbiosis perpetuates poor functional neurologic outcomes in stroke. It is postulated that the propagation of proinflammatory cells and gut metabolites (including trimethylamine N-oxide and short-chain fatty acids) from the GI tract to the central nervous system play a central role in gut-brain axis dysfunction. In this review, we discuss the known GI complications in acute ischemic stroke, our current knowledge from experimental stroke models for gut-brain axis dysfunction in stroke, and emerging therapeutics that target the gut-brain axis.

Clinical Practice Guidelines for Oropharyngeal Dysphagia

OBJECTIVE

Dysphagia is a common clinical condition characterized by difficulty in swallowing. It is sub-classified into oropharyngeal dysphagia, which refers to problems in the mouth and pharynx, and esophageal dysphagia, which refers to problems in the esophageal body and esophagogastric junction. Dysphagia can have a significant negative impact one's physical health and quality of life as its severity increases. Therefore, proper assessment and management of dysphagia are critical for improving swallowing function and preventing complications. Thus a guideline was developed to provide evidence-based recommendations for assessment and management in patients with dysphagia.

METHODS

Nineteen key questions on dysphagia were developed. These questions dealt with various aspects of problems related to dysphagia, including assessment, management, and complications. A literature search for relevant articles was conducted using Pubmed, Embase, the Cochrane Library, and one domestic database of KoreaMed, until April 2021. The level of evidence and recommendation grade were established according to the Grading of Recommendation Assessment, Development and Evaluation methodology.

RESULTS

Early screening and assessment of videofluoroscopic swallowing were recommended for assessing the presence of dysphagia. Therapeutic methods, such as tongue and pharyngeal muscle strengthening exercises and neuromuscular electrical stimulation with swallowing therapy, were effective in improving swallowing function and quality of life in patients with dysphagia. Nutritional intervention and an oral care program were also recommended.

CONCLUSION

This guideline presents recommendations for the assessment and management of patients with oropharyngeal dysphagia, including rehabilitative strategies.

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.

Statistical Power and Swallowing Rehabilitation Research: Current Landscape and Next Steps

Despite rapid growth in the number of treatments to rehabilitate dysphagia, studies often demonstrate mixed results with non-significant changes to functional outcomes. Given that power analyses are infrequently reported in dysphagia research, it remains unclear whether studies are adequately powered to detect a range of treatment effects. Therefore, this review sought to examine the current landscape of statistical power in swallowing rehabilitation research. Databases were searched for swallowing treatments using instrumental evaluations of swallowing and the penetration-aspiration scale as an outcome. Sensitivity power analyses based on each study's statistical test and sample size were performed to determine the minimum effect size detectable with 80% power. Eighty-nine studies with 94 treatment comparisons were included. Sixty-seven percent of treatment comparisons were unable to detect effects smaller than d = 0.80. The smallest detectable effect size was d = 0.29 for electrical stimulation, d = 0.49 for postural maneuvers, d = 0.52 for non-invasive brain stimulation, d = 0.61 for combined treatments, d = 0.63 for respiratory-based interventions, d = 0.70 for lingual strengthening, and d = 0.79 for oral sensory stimulation. Dysphagia treatments examining changes in penetration-aspiration scale scores were generally powered to reliably detect larger effect sizes and not smaller (but potentially clinically meaningful) effects. These findings suggest that non-significant results may be related to low statistical power, highlighting the need for collaborative, well-powered intervention studies that can detect smaller, clinically meaningful changes in swallowing function. To facilitate implementation, a tutorial on simulation-based power analyses for ordinal outcomes is provided ( https://osf.io/e6usd/ ).

Rehabilitation of Airway Protection in Individuals With Movement Disorders: A Telehealth Feasibility Study

PURPOSE

Airway protective deficits (swallowing and cough) greatly reduce health and quality of life and are a pervasive consequence of neurodegenerative movement disorders. Expiratory muscle strength training (EMST) and cough skill training (CST) are two treatment approaches to improve airway protection; however, many patients are unable to access these treatments. Telehealth may improve access to care, but it remains unknown whether these treatments are feasible and efficacious via telehealth. This study aimed to determine the practical feasibility and preliminary treatment effect of EMST and CST via telehealth.

METHOD

Twenty participants with movement disorders completed 4 weeks of EMST and 2 weeks of CST, including two clinician-directed treatment sessions via telehealth and 3 days of home practice per week. Feasibility was calculated for each treatment. Practical feasibility was defined as completing treatment (EMST or CST) and obtaining the relevant outcome measures-a proxy of maximum expiratory pressure (pMEP) for EMST and peak expiratory flow rate (PEFR) for CST-within a 30-min session/period. Session factors that may have influenced feasibility were examined. Preliminary treatment effect was defined as changes in pMEP and PEFR.

RESULTS

Time taken to obtain pMEP and complete EMST was 17.48 min, and time taken to obtain PEFR and complete CST was 17.69 min. pMEP, single voluntary cough PEFR, and sequential voluntary cough PEFR increased from pre- to posttreatment.

CONCLUSIONS

Findings suggest that the delivery of EMST and CST is feasible via telehealth and yield improvements to pMEP and PEFR. This has important implications for expanding service delivery of airway protective interventions and reducing health care disparities in people with neurodegenerative movement disorders.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.21357669.

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

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

Post-stroke Dysphagia: Prognosis and Treatment-A Systematic Review of RCT on Interventional Treatments for Dysphagia Following Subacute Stroke

Purpose

Post-stroke dysphagia is an underdiagnosed but relevant complication, associated with worse outcome, dependency and quality of life of stroke survivors. Detailed mechanisms of post-stroke dysphagia are not very well understood, but established therapeutic concepts are needed. Different interventional studies have been published dealing with post-stroke dysphagia. This systematic review wants to collect and give an overview over the published evidence.

Methods

PubMed, Embase, Cochrane, CINAHL were searched for relevant interventional studies on post-stroke dysphagia in the (sub-)acute setting (within 3 months of stroke onset). The search has been filtered for randomized trials with an inactive control and the relevant data extracted.

Results

After initially finding 2,863 trials, finally 41 trials have been included. Seven different therapeutic concepts have been evaluated (Acupuncture, behavioral/physical therapy, drug therapy, neuromuscular electrical stimulation, pharyngeal electrical stimulation, transcranial direct current stimulation and repetitive transcranial magnetic stimulation). Studies of all modalities have shown some effect on post-stroke dysphagia with several studies raising concerns about the potential bias.

Conclusion

The amount and quality of studies are not enough to suggest certain therapies. Some therapeutical concepts (intensive physical therapy, transcranial magnetic stimulation, drug therapy) seem to be good potential therapeutic options, but further research is needed.

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.

European Stroke Organisation and European Society for Swallowing Disorders guideline for the diagnosis and treatment of post-stroke dysphagia

Post-stroke dysphagia (PSD) is present in more than 50% of acute stroke patients, increases the risk of complications, in particular aspiration pneumonia, malnutrition and dehydration, and is linked to poor outcome and mortality. The aim of this guideline is to assist all members of the multidisciplinary team in their management of patients with PSD. These guidelines were developed based on the European Stroke Organisation (ESO) standard operating procedure and followed the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. An interdisciplinary working group identified 20 relevant questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if not enough evidence was available to provide recommendations based on the GRADE approach. We found moderate quality of evidence to recommend dysphagia screening in all stroke patients to prevent post-stroke pneumonia and to early mortality and low quality of evidence to suggest dysphagia assessment in stroke patients having been identified at being at risk of PSD. We found low to moderate quality of evidence for a variety of treatment options to improve swallowing physiology and swallowing safety. These options include dietary interventions, behavioural swallowing treatment including acupuncture, nutritional interventions, oral health care, different pharmacological agents and different types of neurostimulation treatment. Some of the studied interventions also had an impact on other clinical endpoints such as feedings status or pneumonia. Overall, further randomized trials are needed to improve the quality of evidence for the treatment of PSD.

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.

Effect of Combined Respiratory Muscle Training (cRMT) on Dysphonia following Single CVA: A Retrospective Pilot Study

BACKGROUND

Although dysphonia is less prevalent than dysphagia following cerebrovascular accidents, dysphonia does contribute to the burden of disease resulting from stroke. Strengthening muscles of the larynx and respiratory tract through respiratory muscle training (RMT) has proven effective in improving voice after neurological insult. However, approaches to strengthen only the expiratory muscle groups (EMST) dominate the clinical study literature, with variable outcomes. By focusing on exhalation, the contribution of inspiratory muscles to phonation may have been overlooked. This study investigated the effect of combined respiratory muscle training (cRMT) to improve voice function in stroke patients.

METHODS

Recorded data of twenty patients with dysphonia following stroke were allocated to an intervention (IG) or a control group (CG) based upon whether they chose cRMT or not while awaiting pro bono voice therapy services. The intervention group (n = 10) was treated daily with three 5-minute sessions of combined resistive respiratory muscle training for 28 days, while the control group (n = 10) received no cRMT or other exercise intervention. Perceptual and acoustic measurements as well as a pulmonary function test were assessed pre-and post-intervention.

RESULTS

The intervention group demonstrated significant improvements after 28 days of cRMT in peak flow (127%), patient self-perception of voice improvement (84.41%), as well as in five of the six categories of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) overall severity (63.22%), breathiness (61.06%), strain (63.43%), pitch range (48.11%) and loudness (57.51%), compared to the control group who did not receive treatment. Furthermore, cRMT also led to significant improvements in maximum phonation time (212.5%), acoustic parameters of vocal intensity, and total semitone range (165.45%).

CONCLUSIONS

This pilot study shows promise of the feasibility and effectiveness of cRMT to lessen the signs and symptoms of dysphonia while simultaneously improving breath support.

Effect of respiratory muscle training on dysphagia in stroke patients-A retrospective pilot study

BACKGROUND

Dysphagia is prevalent with cerebrovascular accidents and contributes to the burden of disease and mortality. Strengthening dysfunctional swallow muscles through respiratory muscle training (RMT) has proven effective in improving swallow effectiveness and safety. However, approaches to strengthen only the expiratory muscle groups (EMST) dominate the clinical study literature, with variable outcomes. This study investigated the effect of simultaneous inspiratory-expiratory muscle strengthening to improve swallowing function in stroke patients.

METHODS

Recorded data of 20 patients receiving pro bono medical care for dysphagia following stroke were allocated to intervention (IG) or control group (CG) based upon whether they chose combined RMT (cRMT) or not while awaiting swallow therapy services. The intervention group was treated with three 5-minute sessions of resistive respiratory muscle training for 28 days, while the control group received no RMT or other exercise intervention. Respiratory and swallow outcomes were assessed pre- and post-intervention and included Mann Assessment of Swallowing Ability (MASA), fiberoptic endoscopic evaluation of swallowing (FEES) with penetration-aspiration scale (PAS), functional oral intake scale (FOIS), patient visual analogue scale (VAS), and peak expiratory flow (PEF).

RESULTS

After 28 days, the intervention group demonstrated greater improvements (P value < 0.05) in PEF (IG: 168.03% vs CG: 17.47%), VAS (IG: 103.85% vs CG: 27.54%), MASA (IG: 37.28% vs CG: 6.92%), PAS (IG: 69.84% vs CG: 12.12%), and FOIS (IG: 93.75% vs CG: 21.21%).

CONCLUSION

cRMT is a feasible and effective method to improve signs and symptoms of dysphagia while improving airway protection.

LEVEL OF EVIDENCE

3.

Interventions for oropharyngeal dysphagia in acute and critical care: a systematic review and meta-analysis

PURPOSE

To determine the effectiveness of dysphagia interventions compared to standard care in improving oral intake and reducing aspiration for adults in acute and critical care.

METHODS

We searched electronic literature for randomised and quasi-randomised trials and bibliography lists of included studies to March 2020. Study screening, data extraction, risk of bias and quality assessments were conducted independently by two reviewers. Meta-analysis used fixed effects modelling. The systematic review protocol is registered and published.

RESULTS

We identified 22 studies (19 stroke, 2 intensive care stroke and 1 general intensive care) testing 9 interventions and representing 1700 patients. Swallowing treatment showed no evidence of a difference in the time to return to oral intake (n = 33, MD (days) - 4.5, 95% CI - 10.6 to 1.6, 1 study, P = 0.15) (very low certainty) or in aspiration following treatment (n = 113, RR 0.79, 95% CI 0.44 to 1.45, 4 studies, I² = 0%, P = 0.45) (low certainty). Swallowing treatment showed evidence of a reduced risk of pneumonia (n = 719, RR 0.71, 95% CI 0.56 to 0.89, 8 studies, I² = 15%, P = 0.004) (low certainty) but no evidence of a difference in swallowing quality of life scores (n = 239, MD - 11.38, 95% CI - 23.83 to 1.08, I ² = 78%, P = 0.07) (very low certainty).

CONCLUSION

There is limited evidence for the effectiveness of swallowing treatments in the acute and critical care setting. Clinical trials consistently measuring patient-centred outcomes are needed.

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

OBJECTIVE

To examine the efficacy of combined inspiratory and expiratory respiratory muscle training (RMT) with respect to the swallowing function, pulmonary function, functional performance, and dysarthria in patients with stroke.

DESIGN

Prospective, randomized controlled trial.

SETTING

Tertiary hospital.

PARTICIPANTS

The trial included 21 subjects (12 men, 9 women) aged 35 to 80 years presenting with 6 months history of unilateral stroke, respiratory muscle weakness (≥70% predicted maximal inspiratory pressure (MIP) and/or ≤70% maximal expiratory pressure (MEP)), dysphagia, or dysarthria. These subjects were randomly assigned to the control (n = 10, rehabilitation) and experimental (n = 11, rehabilitation with RMT) groups.

INTERVENTION

Inspiratory RMT starting from 30% to 60% of MIP and expiratory RMT starting from 15% to 75% of MEP for 5 days/week for 6 weeks.

MAIN OUTCOME MEASURES

MIP, MEP, pulmonary function, peak cough flow, perception of dyspnea, Fatigue Assessment Scale, Modified Rankin Scale, Brunnstrom stage, Barthel index, Functional Oral Intake Scale (FOIS), and parameters of voice analysis.

RESULTS

Significant differences were observed between both groups in terms of MIP, forced vital capacity (FVC), and forced expiratory volume per second (FEV1) of the percentage predicted. Significant difference was found with respect to the change in fatigue, shimmer percent, amplitude perturbation quotient, and voice turbulence index (VTI) according to the acoustic analysis in the RMT group. The FEV1/FVC ratio was negatively correlated with jitter percent, relative average perturbation, pitch perturbation quotient, and VTI; the maximum mid-expiratory flow (MMEF) and MMEF% were also negatively correlated with VTI. Significant differences among participants of the same group were observed while comparing the Brunnstrom stage before and after training of the affected limbs and the Barthel scale and FOIS scores in both the groups.

CONCLUSIONS

Altogether, 6-week combined inspiratory and expiratory RMT is feasible as adjuvant therapy for stroke patients to improve fatigue level, respiratory muscle strength, lung volume, respiratory flow, and dysarthria.Clinical trial registration number (Clinical Trial Identifier): NCT03491111.

Effects of Expiratory Muscle Strength Training on Videofluoroscopic Measures of Swallowing: A Systematic Review

Purpose Expiratory muscle strength training (EMST) is increasingly utilized in dysphagia rehabilitation; however, little is known about the effects of this approach on swallowing function or physiology. We conducted a systematic review to appraise and synthesize evidence regarding the effects of EMST on videofluoroscopic measures of swallowing in individuals with medical diagnoses, in which dysphagia is a concern. Method A literature search was conducted according to Cochrane guidelines. Of 292 nonduplicate articles, 11 were judged to be relevant for review. These underwent detailed review for study quality, risk of bias evaluation, and synthesis of swallowing outcomes. Results The selected articles described EMST in a variety of patient populations using either the EMST150 or the Phillips Threshold positive expiratory pressure device. The typical protocol involved five sets of five breaths through the device (25 breaths/day), 5 days per week for 4 weeks. Exercise loads were set between 50% and 75% depending on the population, and treatment was typically supervised by a clinician weekly. The Penetration-Aspiration Scale was the most commonly reported videofluoroscopic outcome measure. Conclusions differed as to whether or not swallowing improved following a course of EMST. Differences in videofluoroscopy protocols, methods of summarizing participant performance, and statistical approaches across studies meant that meta-analysis of swallowing outcomes could not be completed. Conclusion This review failed to find clear evidence regarding the effects of EMST on videofluoroscopic measures of swallowing. Heterogeneity in the etiologies and baseline severity of dysphagia across studies and in the methods used to measure swallowing outcomes was a particular barrier to data synthesis.

Use of the Penetration-Aspiration Scale in Dysphagia Research: A Systematic Review

The penetration-aspiration scale (PAS) is an 8-point scale used to characterize the depth and response to airway invasion during videofluoroscopy. Though widely used in the field of deglutition, there is a lack of consensus regarding the statistical properties of the scale. In order to better understand the state of the literature and the statistical use of the PAS, a systematic review was undertaken to descriptively examine trends in statistical and reporting practices of the PAS since its inception. Online databases were searched for studies citing the original PAS article, which yielded 754 unique articles. Of these, 183 studies were included in the review. Results showed inconsistencies in the statistical use of the scale; 79 studies treated the PAS as ordinal, 71 as categorical, and 49 as interval. Ten types of categorizations were identified. Reporting of power analyses (9%), as well as inter- (26%) and intra-rater (17%) reliability, was uncommon. Among studies that administered multiple bolus volumes or consistencies, 55% reported PAS analyses at the participant/group level only. This review confirms the existence of discrepancies in the statistical treatment of the PAS. A lack of consensus among researchers limits comparisons between studies. The approach to handling this scale dictates the statistical tests used, potentially affecting results and interpretations. Consistent application of statistically sound approaches to PAS analyses is vital for the future of deglutition research.

High elevation training mask as a respiratory muscle strength training tool for dysphagia

BACKGROUND

Expiratory muscle strength training (EMST) is a treatment for swallowing dysfunction due to its activation of the suprahyoid muscles. Current EMST devices have numerous limitations.

OBJECTIVE

The purpose was to evaluate the utility of elevation training mask as an alternative respiratory muscle strength training (RMST) device.

METHODS

A closed system, simulating expiration was designed. Air was delivered through a pressure gauge with a measurement range of 0-15 psi. The EMST150TM and the Elevation Training Mask 2.0^® (ETM) maximal resistance levels were measured and compared.

RESULTS

EMST150 produced increasing expiratory resistance pressures of 0.3, 0.6, 1.2, 1.9 and 2.1 psi, which correspond to its indicator of 30, 60, 90, 120 and 150 cmH2O. The ETM resistance pressure produced expiratory resistance pressures of 0.1 and 0.2 psi at simulated altitudes of 3000 and 6000 feet, respectively. A stable expiratory resistance pressure of 0.25 psi was measured at simulated altitudes of 9000, 12,000, 15,000 and 18,000 feet.

CONCLUSION

ETM provides adjustable expiratory muscle strength resistance pressures. Further investigation is necessary to evaluate safety, compliance and clinical efficacy in patients with swallowing dysfunction.

SIGNIFICANCE

ETM can serve as an effective treatment modality for pulmonary dysfunction and swallowing disorders through RMST.

Swallowing therapy for dysphagia in acute and subacute stroke

BACKGROUND

Dysphagia (swallowing problems), which is common after stroke, is associated with increased risk of death or dependency, occurrence of pneumonia, poor quality of life, and longer hospital stay. Treatments provided to improve dysphagia are aimed at accelerating recovery of swallowing function and reducing these risks. This is an update of the review first published in 1999 and updated in 2012.

OBJECTIVES

To assess the effects of swallowing therapy on death or dependency among stroke survivors with dysphagia within six months of stroke onset.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (26 June 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library (searched 26 June 2018), MEDLINE (26 June 2018), Embase (26 June 2018), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (26 June 2018), Web of Science Core Collection (26 June 2018), SpeechBITE (28 June 2016), ClinicalTrials.Gov (26 June 2018), and the World Health Organization International Clinical Trials Registry Platform (26 June 2018). We also searched Google Scholar (7 June 2018) and the reference lists of relevant trials and review articles.

SELECTION CRITERIA

We sought to include randomised controlled trials (RCTs) of interventions for people with dysphagia and recent stroke (within six months).

DATA COLLECTION AND ANALYSIS

Two review authors independently applied the inclusion criteria, extracted data, assessed risk of bias, used the GRADE approach to assess the quality of evidence, and resolved disagreements through discussion with the third review author (PB). We used random-effects models to calculate odds ratios (ORs), mean differences (MDs), and standardised mean differences (SMDs), and provided 95% confidence intervals (CIs) for each.The primary outcome was functional outcome, defined as death or dependency (or death or disability), at the end of the trial. Secondary outcomes were case fatality at the end of the trial, length of inpatient stay, proportion of participants with dysphagia at the end of the trial, swallowing ability, penetration aspiration score, or pneumonia, pharyngeal transit time, institutionalisation, and nutrition.

MAIN RESULTS

We added 27 new studies (1777 participants) to this update to include a total of 41 trials (2660 participants).We assessed the efficacy of swallowing therapy overall and in subgroups by type of intervention: acupuncture (11 studies), behavioural interventions (nine studies), drug therapy (three studies), neuromuscular electrical stimulation (NMES; six studies), pharyngeal electrical stimulation (PES; four studies), physical stimulation (three studies), transcranial direct current stimulation (tDCS; two studies), and transcranial magnetic stimulation (TMS; nine studies).Swallowing therapy had no effect on the primary outcome (death or dependency/disability at the end of the trial) based on data from one trial (two data sets) (OR 1.05, 95% CI 0.63 to 1.75; 306 participants; 2 studies; I² = 0%; P = 0.86; moderate-quality evidence). Swallowing therapy had no effect on case fatality at the end of the trial (OR 1.00, 95% CI 0.66 to 1.52; 766 participants; 14 studies; I² = 6%; P = 0.99; moderate-quality evidence). Swallowing therapy probably reduced length of inpatient stay (MD -2.9, 95% CI -5.65 to -0.15; 577 participants; 8 studies; I² = 11%; P = 0.04; moderate-quality evidence). Researchers found no evidence of a subgroup effect based on testing for subgroup differences (P = 0.54). Swallowing therapy may have reduced the proportion of participants with dysphagia at the end of the trial (OR 0.42, 95% CI 0.32 to 0.55; 1487 participants; 23 studies; I² = 0%; P = 0.00001; low-quality evidence). Trial results show no evidence of a subgroup effect based on testing for subgroup differences (P = 0.91). Swallowing therapy may improve swallowing ability (SMD -0.66, 95% CI -1.01 to -0.32; 1173 participants; 26 studies; I² = 86%; P = 0.0002; very low-quality evidence). We found no evidence of a subgroup effect based on testing for subgroup differences (P = 0.09). We noted moderate to substantial heterogeneity between trials for these interventions. Swallowing therapy did not reduce the penetration aspiration score (i.e. it did not reduce radiological aspiration) (SMD -0.37, 95% CI -0.74 to -0.00; 303 participants; 11 studies; I² = 46%; P = 0.05; low-quality evidence). Swallowing therapy may reduce the incidence of chest infection or pneumonia (OR 0.36, 95% CI 0.16 to 0.78; 618 participants; 9 studies; I² = 59%; P = 0.009; very low-quality evidence).

AUTHORS' CONCLUSIONS

Moderate- and low-quality evidence suggests that swallowing therapy did not have a significant effect on the outcomes of death or dependency/disability, case fatality at the end of the trial, or penetration aspiration score. However, swallowing therapy may have reduced length of hospital stay, dysphagia, and chest infections, and may have improved swallowing ability. However, these results are based on evidence of variable quality, involving a variety of interventions. Further high-quality trials are needed to test whether specific interventions are effective.

Establishing a Multidisciplinary Head and Neck Clinical Pathway: An Implementation Evaluation and Audit of Dysphagia-Related Services and Outcomes

Head and neck cancer (HNC) guidelines recommend regular multidisciplinary team (MDT) monitoring and early intervention to optimize dysphagia outcomes; however, many factors affect the ability to achieve these goals. The aims of this study were to explore the barriers/facilitators to establishing and sustaining a MDT HNC care pathway and to examine the dysphagia-related speech-language pathology (SLP) and dietetic components of the pathway. Using the Consolidated Framework for Implementation Research (CFIR), a mixed methods study design was used to evaluate an established MDT HNC pathway. Ten MDT members provided perceptions of facilitators/barriers to implementing and sustaining the pathway. Patients attending the SLP and dietetic components of the pathway who commenced treatment between 2013 and 2014 (n = 63) were audited for attendance, outcome data collected per visit, and swallowing outcomes to 24-month post-treatment. Dysphagia outcomes were compared to a published cohort who had received intensive prophylactic dysphagia management. Multiple CFIR constructs were identified as critical to implementing and sustaining the pathway. Complexity was a barrier. Patient attendance was excellent during treatment, with low rates of non-compliance (< 15%) to 24 months. Collection of clinician/patient outcome tools was good during treatment, but lower post-treatment. Dysphagia outcomes were good and comparable to prior published data. The pathway provided patients with access to regular supportive care and provided staff opportunities to provide early and ongoing dysphagia monitoring and management. However, implementing and sustaining a HNC pathway is complex, requiring significant staff resources, financial investment, and perseverance. Regular audits are necessary to monitor the quality of the pathway.