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

Exploring the diagnostic accuracy and applicability of the Gugging Swallowing Screen in children with feeding and/or swallowing disorders

BACKGROUND

The Gugging Swallowing Screen (GUSS) is a bedside dysphagia screening tool that has been designed to determine the risk of aspiration in acute stroke patients. There is no evidence in the literature for the GUSS for the pediatric population. The present study aimed to determine the diagnostic accuracy of GUSS as a screening tool in the Greek language for children with dysphagia.

METHODS

Eighty-Greek-Cypriot children aged 3-12 years who had dysphagia participated in this retrospective study. The translated into Greek GUSS was administered twice (pre- and post-therapy) to each patient throughout 24 sessions of dysphagia therapy.

KEY RESULTS

The GUSS showed a high internal consistency (Cronbach's α = 0.826), good test-retest reliability (rs = 0.767), convergent validity compared to the Greek Pediatric Eating Assessment tool-10 (PEDI-EAT-10) total score (rs = -0.365), and inter-rater reliability (κ = 0.863). A total cutoff points equal to 13.00 was also calculated. Aspiration was identified by the GUSS with low sensitivity and high specificity (PPV 100%, NPV 57%, LR+ NA, LR- 0.79); dysphagia/penetration was identified with high sensitivity and low specificity (PPV 33%, NPV 100%, LR+ 0.102, LR- NA).

CONCLUSIONS & INFERENCES

The pediatric version of GUSS has been found to be a valuable tool in identifying the risk of aspiration as that of adults. It proved to be used as a good screening guide for selecting and confirming the existence of dysphagia from instrumental assessments. This is the first study of the pediatric version of GUSS, and future studies on this topic are needed.

Therapeutic singing-induced swallowing exercise for dysphagia in advanced-stage Parkinson's disease

Background

With longer life spans and medical advancements, the rising number of patients with advanced-stage Parkinson's disease (PD) warrants attention. Current literature predominantly addresses dementia and fall management in these patients. However, exploring the impact of swallowing function on patients with advanced PD is crucial. Previous research has demonstrated notable enhancements in the quality of life related to voice for participants following a group singing-intervention program. To further elucidate the effect of individual singing-induced swallowing exercises, our study aimed to investigate the quantitative and qualitative effects of therapeutic singing on swallowing function in patients with advanced PD in comparison to a matched usual care control group. The hypothesis of this study is that therapeutic singing-induced swallowing exercises can assist to maintain swallowing function in patients with advanced PD.

Methods

This prospective matched control study compared the effects of a 6-week therapeutic singing-based swallowing intervention on swallowing function and quality of life in patients with advanced PD. The intervention group received individual sessions with a music therapist and conventional individual physical therapy. The control group received the same standard physical therapy for 6 weeks without music intervention. The primary outcome measure was Video Fluoroscopic Dysphagia Scale (VDS).

Results

The study revealed that the intervention group maintained swallowing function, whereas the control group experienced deterioration, indicating significant time-dependent changes in Penetration-Aspiration Scale (PAS), National Institutes of Health-Swallowing Safety Scale (NIH-SSS), and VDS. Analysis of PAS and NIH-SSS liquid food scores in both groups showed significant time effects. However, the intervention group exhibited no significant differences between the pre- and post-tests, indicating preservation of the swallowing function. VDS of liquid food indicated an interaction effect between time and group in the pharyngeal phase and total scores. The Swallowing-Quality of Life showed significant time-effect improvement in the intervention group.

Conclusion

Therapeutic singing exercises may help maintain swallowing function in advanced PD patients, potentially enhancing quality of life related to swallowing in those with advanced-stage diseases.

Clinical trial registration

https://cris.nih.go.kr/cris/search/listDetail.do, identifier KCT0008644.

Management and Treatment for Dysphagia in Neurodegenerative Disorders

Patients with neurodegenerative disorders (NDDs) often experience functional dysphagia, which may involve dysfunction in a specific phase of swallowing or in the entire process. This review outlines the approach to dysphagia in the setting of NDDs. Distinguishing the etiology of dysphagia can be difficult, and it is important to always look out for signs pointing to NDD as the cause. Thorough diagnostic work-up is essential, and it includes a comprehensive history and physical examination, alongside swallowing function tests, such as fiberoptic endoscopic evaluation of swallowing, videofluoroscopic swallowing study, and high-resolution manometry. Management requires a multidisciplinary approach with a treatment plan tailored to each patient. This involves dietary guidance, swallowing rehabilitation, and surgery in cases in which improvement with rehabilitation is inadequate. Surgery may involve altering certain pharyngolaryngeal structures to facilitate swallowing and reduce the risk of aspiration (swallowing improvement surgery) or separating the airway and digestive tract while sacrificing laryngeal function, with the main goal of preventing aspiration (aspiration prevention surgery). Proper management stems from recognizing the impact of these disorders on swallowing and consistently finding ways to improve the quality of life of patients.

Comprehensive insights into the multifaceted roles of the transient receptor potential vanilloid 1 channel in the digestive system

The transient receptor potential vanilloid (TRPV) channel, a family of calcium transporters comprising six distinct members (TRPV1-6), takes on a paramount role in maintaining intracellular Ca2+ homeostasis in mammalian cells. Notably, TRPV1, among its counterparts, has emerged as the subject of extensive scrutiny, owing to its pervasive presence in diverse cellular, tissue, and organ settings. This ubiquitous distribution underscores its fundamental involvement in the genesis of pain, making it a central focus in pain-related research. However, recent investigations have unveiled that TRPV1's functional significance transcends the realm of pain modulation, extending its influence to encompass a wide spectrum of physiological and pathological processes. The ambit of TRPV1's influence encompasses not only pain responses but also embraces the intricate domains of nervous system disorders, cancer metastasis, as well as afflictions pertaining to the skin and heart. Moreover, compelling evidence now demonstrates that TRPV1 also wields substantial sway in the domain of digestive diseases, further highlighting its versatility and far-reaching impact on human health. Therefore, this comprehensive review endeavors to delve into the multifaceted roles played by TRPV1 in the various organs constituting the digestive system.

Therapeutic Effect on Swallowing Function and on Hydration Status of a New Liquid Gum-Based Thickener in Independently-Living Older Patients with Oropharyngeal Dysphagia

ThickenUp® Gel Express (TUGE) is a new, xanthan- and acacia-gum-based, liquid, thickening product. In independently living older adults with oropharyngeal dysphagia (OD), we assessed: (1) the rheological properties of TUGE; (2) its therapeutic effect at four viscosity levels (achieved by 5 g, 10 g, 20 g and 30 g of TUGE in water + Omnipaque X-ray contrast) versus thin liquid; and (3) the effect on hydration status and gastrointestinal tolerance after fourteen days. Shear viscosity of TUGE was measured in SI units (mPa·s at 50 s-1). The Penetration Aspiration Scale (PAS) score and the swallow response at each viscosity level was assessed with videofluoroscopy (VFS), and in the 14-day study we assessed fluid intake, hydration, and tolerance. Thickened fluids with TUGE were unaffected (-0.3%) by α-salivary amylase (α-SA). The shear viscosity values with VFS were 49.41 ± 2.38, 154.83 ± 10.22, 439.33 ± 11.72 and 672.5 ± 35.62 mPa·s. We studied 60 independently living adults (70 ± 11.4 years) with mild OD (PAS 4.1 ± 2.2, 25% aspirations). TUGE caused a shear-viscosity-dependent improvement in PAS at 150-670 mPa·s and in safety of swallow, slightly increased oral residue, did not affect pharyngeal residue and reduced time to laryngeal vestibule closure (-27%) at 670 mPa·s. Fluid intake with TUGE (1488 mL/day) was well tolerated, and hydration status improved. In conclusion, TUGE was unaffected by α-SA and strongly improved safety of swallow in a viscosity-dependent manner without affecting pharyngeal residue. Fourteen-day treatment of thickened fluids with TUGE is safe and well tolerated and improves hydration status in older adults with dysphagia.

Quantitative Textural and Rheological Data on Different Levels of Texture-Modified Food and Thickened Liquids Classified Using the International Dysphagia Diet Standardisation Initiative (IDDSI) Guideline

Diet modification is a common compensation strategy to promote swallowing safety in patients with swallowing difficulties. The International Dysphagia Diet Standardisation Initiative (IDDSI) guideline provides qualitative descriptions on texture-modified food and thickened liquid. This study aimed to establish quantitative textural and rheological data on different IDDSI levels based on common Chinese ingredients and dishes. Textural and rheological properties of 226 samples of various food textures and 93 samples of various liquid consistencies were obtained using a texture profile analysis (TPA) and viscometer, respectively. The establishment of such quantitative data can be used for future texture-modified food product development and research purposes.

Economic Evaluation of Clinical, Nutritional and Rehabilitation Interventions on Oropharyngeal Dysphagia after Stroke: A Systematic Review

Background: Post-stroke oropharyngeal dysphagia (PS-OD) and its complications increase healthcare costs, suggesting that its appropriate management is cost-effective. We aimed to assess the efficiency of healthcare interventions in PS-OD management. Methods: A systematic review was conducted following PRISMA recommendations. Four databases were searched from inception through 30 June 2021. Outcome measures were cost-effectiveness and cost-savings of healthcare interventions. English and Spanish literature were included. Narrative and tables were used to present and synthesise evidence. Quality was evaluated using the CHEERS Statement. Results: A total of 244 studies were identified, and 10 were included. Screening and diagnosis of PS-OD studies found: (1) adjusted reduction in hospitalisation costs when assessed during the first admission day; (2) non-significant reduction in hospitalisation costs with OD management after thrombolysis; and (3) videofluoroscopy as the most cost-effective screening method (compared to bedside evaluation and a combination of both). Two studies showed cost-effective rehabilitation programmes, including OD management. Pelczarska et al. showed an incremental cost–utility ratio of texture-modified diets using a gum-based thickener of 20,977 PLN (4660€) following a dynamic model, and Kotecki et al. commercially prepared thickened fluids that were 44% to 59% less expensive than in situ prepared fluids. Elia et al. showed home enteral nutrition was cost-effective (£12,817/QALY), and Beavan et al. showed higher nutrient intake and low increase in hospitalisation costs using looped-nasogastric tubes (£5.20 for every 1% increase). Heterogeneity between studies precluded a quantitative synthesis. Conclusions: Included studies suggest that healthcare interventions aiming to prevent OD complications are cost-effective. However, studies assessing novel strategies are needed.