The effect of surface neuromuscular electrical stimulation on patients with post-stroke dysphagia

Evidence based therapeutic and assessment techniques to rehabilitate post stroke dysphagia patients-A systematic review

PURPOSE

Dysphagia is most prevalent among post stroke aging adults. This systematic review was conducted to collect evidence-based data regarding assessment and therapeutic techniques used to rehabilitate post stroke dysphagia patients.

METHODS

Four major databases including PubMed, Cochrane Library, Science direct and Google scholar were searched systematically using the defined search strategy to target Randomized Controlled Trials conducted from January 2018 to 2023 using the pre-defined search strategy by three independent reviewers.

RESULTS

After following PRISMA guidelines, fifteen articles matched the inclusion criteria. Several evidence based therapies like Neuromuscular Electrical Stimulation Therapy, Effortful Swallowing Training, Tongue Pressure Strength and Accuracy Training, Electrical Stimulation of Hyoid Muscles, Modified Chin Tuck Against Resistance exercise, Oral Neuromuscular Training, and Conventional Speech Therapy with Functional Electrical Stimulation were used frequently for the treatment of old age post stroke dysphagia in different rehabilitation centers. Along with this, a list of different assessment methodologies and tools was made that were used including Functional Oral Intake Scale, Fiber optic Endoscopic Evaluation of Swallowing, Penetration Aspiration Scale, Pooling Scale, Video fluoroscopic Dysphagia Scale, Iowa Oral Performance Instrument, Mann Assessment of Swallowing Ability, and Repetitive Saliva Swallowing Test.

CONCLUSION

Dysphagia is known to be serious complication of stroke. This systematic review shows a significant impact of therapeutic techniques on post stroke dysphagia patients and demonstrates that neuromuscular electrical stimulation therapy is one of the most effective therapeutic techniques used to rehabilitate post stroke dysphagia patients.

Residual effect of sequential 4-channel neuromuscular electrical stimulation evaluated by high-resolution manometry

BACKGROUND

High-resolution manometry (HRM) can quantify swallowing pathophysiology to evaluate the status of the pharynx. Sequential 4-channel neuromuscular electrical stimulation (NMES) was recently developed based on the normal contractile sequences of swallowing-related muscles. This study aimed to examine the effects of sequential 4-channel NMES for compensatory application during swallowing and to observe the residual effects after the application of NMES using HRM.

RESULTS

Sequential 4-channel NMES significantly improved the HRM parameters, with respect to the maximal pressure and area of the velopharynx (VP), maximal pressure and area of the mesopharynx (MP), and upper esophageal sphincter (UES) activation and nadir duration. Furthermore, the improvement in the pressure and area variables of the VP and MP showed a tendency to maintain even when measured after NMES, but there are no significant differences.

CONCLUSIONS

The present study suggests that the sequential 4-channel NMES application of the suprahyoid and infrahyoid muscles during swallowing improves the pressure, area, and time variables of the oropharynx, as measured by HRM, and it is likely that the effects may persist even after stimulation. Trial Registration Clinicaltrials.gov, registration number: NCT02718963 (initial release: 03/20/2016, actual study completion date: 06/24/2016, last release: 10/20/2020).

The impact of physical therapy on dysphagia in neurological diseases: a review

A neurogenic dysphagia is dysphagia caused by problems with the central and peripheral nervous systems, is particularly prevalent in conditions such as Parkinson's disease and stroke. It significantly impacts the quality of life for affected individuals and causes additional burdens, such as malnutrition, aspiration pneumonia, asphyxia, or even death from choking due to improper eating. Physical therapy offers a non-invasive treatment with high efficacy and low cost. Evidence supporting the use of physical therapy in dysphagia treatment is increasing, including techniques such as neuromuscular electrical stimulation, sensory stimulation, transcranial direct current stimulation, and repetitive transcranial magnetic stimulation. While initial studies have shown promising results, the effectiveness of specific treatment regimens still requires further validation. At present, there is a lack of scientific evidence to guide patient selection, develop appropriate treatment regimens, and accurately evaluate treatment outcomes. Therefore, the primary objectives of this review are to review the results of existing research, summarize the application of physical therapy in dysphagia management, we also discussed the mechanisms and treatments of physical therapy for neurogenic dysphagia.

Neuromuscular Electrical Stimulation for Post-Stroke Dysphagia Treatment: A Systemic Evaluation and Meta-Analysis of Randomized Controlled Trials

Neuromuscular electrical stimulation (NMES) is a novel treatment method that stimulates patients' swallowing functions. This systemic review was designed to evaluate the impact of NMES on dysphagia in stroke patients. Databases including PubMed, Embase, Web of Science, and Cochrane Library were searched from the date of establishment to January 28th, 2022. Two investigators identified all included studies and compared the swallowing function after NMES treatment with traditional therapy (TT). The Cochrane risk bias assessment tool was utilized to analyze the quality of included studies. Research outcomes included Swallowing Quality of Life (SWAL-QoL), Penetration-Aspiration Scale (PAS), Functional Oral Intake Scale (FOIS), Dysphagia Outcomes and Severity Scale (DOSS), the Repeat Salivary Swallowing Test (RSST), and Water Swallowing Test (WST). We extracted the mean and standard deviation of specific outcomes at the baseline level and after the treatment in both NMES and TT groups for subsequent meta-analysis. 9 randomized controlled trials (RCTs) and quasi-RCTs were included, and remarkable differences were found between patients treated with or without NMES in respect of FOIS scores (SMD = 0.48; 95% CI 0.26-0.70, P < 0.0001), PAS scores (SMD = - 0.56; 95% CI 1.01-0.10, P = 0.02), and SWAL-QoL scores (SMD = 0.57; 95% CI 0.00-1.14, P = 0.05). No significant difference was manifested in WST, RSST, and DOSS (SMD: - 0.02; 95% CI  0.38-0.35, P = 0.93). Evidence suggests that NMES is more effective for post-stroke dysphagia patients than treatment without NMES.

Transcutaneous electrical stimulation for gastrointestinal motility disorders

BACKGROUND/PURPOSE

Gastrointestinal (GI) dysmotility is categorized by muscle or nerve dysfunctions in any portion of the GI tract, which leads to abnormalities in GI motor and sensory function. Symptoms may vary depending on the organ affected and can be debilitating. Treatment usually involves diet and lifestyle changes. Pharmacotherapy is limited in effectiveness with various side effects. Transcutaneous electrical stimulation (TES), a noninvasive, needleless technique that provides electrical stimulation using cutaneous non-needle electrodes, has become increasingly popular. It has been shown to be beneficial in treating GI motility disorders.

METHODS

This review paper navigates through the different TES techniques, including transcutaneous peripheral nerve (vagal/sacral/tibial nerves) electrical stimulation, transcutaneous electrical acustimulation (stimulation via acupuncture point), transcutaneous interferential current therapy, and transcutaneous electrical nerve stimulation.

KEY RESULTS

As we delve deeper, we explore the promising effects of TES on dysphagia, gastroesophageal reflux disease, functional dyspepsia, gastroparesis, postoperative ileus, constipation, and irritable bowel syndrome. The literature at hand speaks volumes about the therapeutic prowess of this noninvasive technique.

CONCLUSION & INFERENCES

The time is ripe to evaluate further the full therapeutic potential of TES, a noninvasive, nonpharmaceutical, nonsurgical, and home-based self-administrative technique in managing GI motility disorders.

Comparison of efficacy of non-pharmacological intervention for post-stroke dysphagia: a systematic review and Bayesian network meta-analysis

Increasingly, non-pharmacological interventions are being identified and applied to post-stroke dysphagia. Nevertheless, there is insufficient evidence to assess which type of interventions are more effective. In this study, the randomized controlled trials of non-pharmacological interventions on post-stroke dysphagia were retrieved from the relevant databases. Including 96 studies and 12 non-drug treatments. Then, and the network meta-analysis is carried out by statistical software. The results show: In the aspects of videofluoroscopic swallowing study (VFSS), Standardized Swallowing Assessment (SSA), swallowing-quality of life (SWAL-QOL), Water swallow test (WST); Acupuncture + electrotherapy + rehabilitation training, acupuncture + rehabilitation training + massage, electrotherapy + rehabilitation training, acupuncture + electrotherapy + rehabilitation training, electrotherapy, acupuncture + rehabilitation training + acupoints sticking application have significant effects in post-stroke dysphagia. Compared with other interventions, they have more advantages in improving the above indicators. A substantial number of high-quality randomized clinical trials are still necessary in the prospective to validate the therapeutic effectiveness of non-pharmacological interventions in post-stroke dysphagia and the results of this Bayesian network meta-analysis.

Neuromuscular Electrical Stimulation in Conjunction with Conventional Swallowing Therapy in the Treatment of Dysphagia Caused by Multiple Sclerosis: A Single-Case Experimental Design

INTRODUCTION

Dysphagia as a consequence of multiple sclerosis (MS) puts individuals at higher risk of dehydration, malnutrition, and aspiration pneumonia. This study intended to investigate the effects of a combined program of neuromuscular electrical stimulation (NMES) and conventional swallowing therapy to improve swallow safety and efficiency, oral intake, and physical, emotional, and functional impacts of dysphagia in people with dysphagia and MS.

METHODS

In this single-case experimental study with ABA design, two participants with dysphagia caused by MS underwent 12 sessions therapy during 6 weeks following a baseline of 4 evaluation sessions. They were evaluated 4 more times in the follow-up phase after therapy sessions. Scores of Mann Assessment of Swallowing Ability (MASA), DYsphagia in MUltiple Sclerosis (DYMUS), and timed test of swallowing capacity were obtained at baseline, during treatment, and in the follow-up phases. The Dysphagia Outcome and Severity Scale (DOSS) based on videofluoroscopic swallow studies, Persian-Dysphagia Handicap Index (Persian-DHI), and Functional Oral Intake Scale (FOIS) were also completed before and after treatment. Visual analysis and percentage of nonoverlapping data were calculated.

RESULTS

MASA, DYMUS, FOIS, and DHI scores indicated significant improvement in both participants. Although the scores of the timed test of swallowing capacity in participant 1 (B.N.) and DOSS in participant 2 (M.A.) showed no changes, considerable improvements including reducing the amount of residue and the number of swallows required to clear bolus were seen in the posttreatment videofluoroscopic records of both participants.

CONCLUSION

NMES in conjunction with conventional dysphagia therapy based on motor learning principles could improve the swallowing function and decrease disabling effects of dysphagia on different aspects of life in participants with dysphagia caused by MS.

Effects of transcutaneous neuromuscular electrical stimulation on post-stroke dysphagia: a systematic review and meta-analysis

Background

Dysphagia is one of the common complications after stroke. It is closely related to lung infection and malnutrition. Neuromuscular electrical stimulation (NMES) is widely used in the treatment of post-stroke dysphagia, but the evidence-based medical evidence of NMES is limited. Therefore, this study aimed to evaluate the clinical efficacy of NMES in patients with post-stroke dysphagia by systematic review and meta-analysis.

Methods

We searched the CNKI, Wanfang, VIP, SinoMed, PubMed, Embase, Cochrane Library, and Web of Science databases for all randomized controlled trials (RCTs) of NMES in the treatment of post-stroke dysphagia from the establishment of the database to 9 June 2022. The risk of bias assessment tool recommended by Cochrane and the GRADE method was used to assess the risk of bias and the quality of evidence. RevMan 5.3 was used for statistical analysis. Sensitivity and subgroup analyses were performed to evaluate the intervention effect more specifically.

Results

A total of 46 RCTs and 3,346 patients with post-stroke dysphagia were included in this study. Our meta-analysis showed that NMES combined with routine swallowing therapy (ST) could effectively improve swallowing function in Penetration-Aspiration Scale (MD = -0.63, 95% CI [-1.15, -0.12], P = 0.01), Functional Oral Intake Scale (MD = 1.32, 95% CI [0.81, 1.83], P < 0.00001), Functional Dysphagia Scale (MD = - 8.81, 95% CI [-16.48, -1.15], P = 0.02), the Standardized Swallowing Assessment (MD = -6.39, 95% CI [-6.56, -6.22], P < 0.00001), the Videofluoroscopic Swallow Study (MD = 1.42, 95% CI [1.28, 1.57], P < 0.00001) and the Water swallow test (MD = -0.78, 95% CI [-0.84, -0.73], P < 0.00001). Furthermore, it could improve the quality of life (MD = 11.90, 95% CI [11.10, 12.70], P < 0.00001), increase the upward movement distance of hyoid bone (MD = 2.84, 95% CI [2.28, 3.40], P < 0.00001) and the forward movement distance of hyoid bone (MD = 4.28, 95% CI [3.93, 4.64], P < 0.00001), reduce the rate of complications (OR = 0.37, 95%CI [0.24, 0.57], P < 0.00001). Subgroup analyses showed that NMES+ST was more effective at 25 Hz, 7 mA or 0-15 mA, and at courses ( ≤ 4 weeks). Moreover, patients with an onset of fewer than 20 days and those older than 60 years appear to have more positive effects after treatment.

Conclusion

NMES combined with ST could effectively increase the forward and upward movement distance of the hyoid bone, improve the quality of life, reduce the rate of complications, and improve the swallowing function of patients with post-stroke dysphagia. However, its safety needs to be further confirmed.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, identifier: CRD42022368416.

Exploration of treatment methods for patients with post-stroke dysphagia: a network meta-analysis

To compare the effects of various therapies in patients with post-stroke dysphagia.

DATA SOURCES

We searched databases between January 1980 and 2022.

STUDY ELIGIBILITY CRITERIA

Randomized controlled trials (RCTs) on therapy for dysphagia after stroke.

STUDY APPRAISAL AND SYNTHESIS METHODS

The outcomes were improvement in dysphagia, case fatality, and chest infection or pneumonia, reported as OR (odd ratio), 95% CrI (confidence interval), and SUCRA (the surface under the cumulative ranking curve analysis) score. Forty-two randomized controlled trials (2,993 patients, seven therapies, and one control) were included. In the improvement of dysphagia analysis, the following therapies were superior to the control: Acupuncture, behavioral interventions, drug therapy, neuromuscular electrical stimulation (NMES) and pharyngeal electrical stimulation (PES). In the case fatality analysis, OR and 95% CrI indicated none of the therapies were superior to the control. In the chest infection or pneumonia analysis, OR values showed that no therapy was superior to the control. Our Network Meta-analysis suggests that commonly used therapies for dysphagia after stroke have equal efficacies.

Review of the effectiveness of neuromuscular electrical stimulation in the treatment of dysphagia - an update

BACKGROUND

Neuromuscular electrical stimulation (NMES) has been used as a treatment option in the therapy of dysphagia for several years. In a previous review of the literature, it was concluded that NMES might be a valuable adjunct in patients with dysphagia and in patients with vocal fold paresis. However, due to different stimulation protocols, electrode positioning and various underlying pathological conditions, it was difficult to compare the studies which were identified and it was concluded that more empirical data is needed to fully understand the benefits provided by NMES. The purpose of this systematic review is, therefore, to evaluate recent studies regarding a potential effectiveness of transcutaneous NMES applied to the anterior neck as a treatment for dysphagia considering these different aspects.

METHOD

For this systematic review, a selective literature research in PubMed has been carried out on 5^th May 2021 using the terms electrical stimulation AND dysphagia and screened for inclusion criteria by two reviewers in Rayyan. The search resulted in 62 hits.

RESULTS

Studies were excluded due to their publication language; because they did not meet inclusion criteria; because the topical focus was a different one; or because they did not qualify as level 2 studies. Eighteen studies were identified with varying patient groups, stimulation protocols, electrode placement and therapy settings. However, 16 studies have reported of beneficial outcomes in relation with NMES.

DISCUSSION

The purpose of this systematic review was to evaluate the most recent studies regarding a potential effectiveness of NMES as a treatment for oropharyngeal dysphagia considering different aspects. It could generally be concluded that there is a considerable amount of level 2 studies which suggest that NMES is an effective treatment option, especially when combined with TDT for patients with dysphagia after stroke and patients with Parkinson's disease, or with different kinds of brain injuries. Further research is still necessary in order to clarify which stimulation protocols, parameters and therapy settings are most beneficial for certain patient groups and degrees of impairment.

Therapeutic Effect and Optimal Electrode Placement of Transcutaneous Neuromuscular Electrical Stimulation in Patients with Post-Stroke Dysphagia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: To date, there is no conclusive evidence that transcutaneous neuromuscular electrical stimulation (TNMES) benefits patients with post-stroke dysphagia (PSD). In addition, the optimal TNMES electrode placement has not been well-established. This systematic review and meta-analysis were conducted to investigate these two research gaps. Methods: Five major databases were systematically searched for randomized controlled trials (RCTs) through January 2022. Effect sizes were computed using Hedges’ g statistic, which were then entered into the random-effects model to obtain pooled effect estimates. Results: Twenty-four RCTs met the eligibility criteria. On the improvement of swallowing function, TNMES alone was not superior to conventional swallowing therapies (CSTs); combined therapy of TNMES and CSTs significantly surpassed CSTs alone (standardized mean difference (SMD) = 0.91, 95% confidence interval (95% CI): 0.68 to 1.14, p < 0.0001; I2 = 63%). Moreover, significant pooled effect sizes were observed in subgroups with horizontal electrode placement above the hyoid bone (SMD = 0.94, 95% CI: 0.72 to 1.16; I2 = 0%) and horizontal electrode placement just above and below the hyoid bone (SMD = 0.87, 95% CI: 0.59 to 1.14; I2 = 0%). The largest pooled effect size was observed in the subgroup that individualized electrode placement according to dysphagia evaluation (SMD = 1.65, 95% CI: 0.38 to 2.91; I2 = 90%). Conclusion: TNMES should be used in combination with CSTs for PSD. Horizontal electrode placement should target suprahyoid muscles or both suprahyoid and thyrohyoid muscles.

Individualized Nutritional Support for Hospitalized Patients With Oropharyngeal Dysphagia After Stroke: A Randomized Controlled Trial

Objectives

Post-stroke dysphagia may cause aspiration pneumonia, malnutrition, dehydration, and other complications. However, data on the effects of nutritional supplementation and its value after stroke are insufficient. We aimed to evaluate the effect of an individualized 1-week nutrition intervention program on swallowing function and nutritional status in stroke patients with oropharyngeal dysphagia.

Methods

This study comprised the control group receiving oral nutritional support and continuous nasogastric tube feeding according to the results of the water swallow test (WST). The intervention group additionally underwent a volume-viscosity swallowing test (V-VST) and intermittent oroesophageal tube feeding based on WST. The outcomes were measured after 7 days of intervention, including the improvement of swallowing function assessment by WST, biochemical parameters, such as total serum protein, serum albumin, hemoglobin levels and body composition. This trial was registered with the Chinese Clinical Trial Registry, identifier ChiCTR 2100054054.

Results

In total, 173 participants completed the study between September 1, 2020, and April 30, 2021. Patients receiving individualized nutritional support showed a more significant improvement in the total effective rate of swallowing function (95.3% vs. 85.1%, P < 0.05). After the intervention, the total serum protein level (0.97 ± 0.41 vs. −0.83 ± 0.47 g/L; P < 0.05), serum albumin level (0.33 ± 0.28 vs. −1.39 ± 0.36 g/L; P < 0.001) and lean tissue mass (0.13 ± 0.35 vs. −1.00 ± 0.40 g/L; P < 0.05) increased in the intervention group. The decrease of hemoglobin levels in the control group was more evident (−6.17 ± 1.63 vs. −0.64 ± 1.40 g/L; 95%CI, −9.78 to −1.28; P = 0.001). The difference of phase angle between the two groups was statistically significant (5.93 ± 0.88° vs. 5.77 ± 0.78°; P = 0.035), but not in body fat mass.

Conclusions

In stroke patients with oropharyngeal dysphagia, the use of individualized nutritional support based on V-VST and intermittent oroesophageal tube feeding during the first week of hospitalization improved swallowing function and maintained nutritional status.

Clinical Trial Registration

https://clinicaltrials.gov/, identifier: ChiCTR 2100054054.

Neurostimulation in People with Oropharyngeal Dysphagia: A Systematic Review and Meta-Analyses of Randomised Controlled Trials-Part I: Pharyngeal and Neuromuscular Electrical Stimulation

Objective. To assess the effects of neurostimulation (i.e., neuromuscular electrical stimulation (NMES) and pharyngeal electrical stimulation (PES)) in people with oropharyngeal dysphagia (OD). Methods. Systematic literature searches were conducted to retrieve randomised controlled trials in four electronic databases (CINAHL, Embase, PsycINFO, and PubMed). The methodological quality of included studies was assessed using the Revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Results. In total, 42 studies reporting on peripheral neurostimulation were included: 30 studies on NMES, eight studies on PES, and four studies on combined neurostimulation interventions. When conducting meta analyses, significant, large and significant, moderate pre-post treatment effects were found for NMES (11 studies) and PES (five studies), respectively. Between-group analyses showed small effect sizes in favour of NMES, but no significant effects for PES. Conclusions. NMES may have more promising effects compared to PES. However, NMES studies showed high heterogeneity in protocols and experimental variables, the presence of potential moderators, and inconsistent reporting of methodology. Therefore, only conservative generalisations and interpretation of meta-analyses could be made. To facilitate comparisons of studies and determine intervention effects, there is a need for more randomised controlled trials with larger population sizes, and greater standardisation of protocols and guidelines for reporting.

An overview of dysphagia rehabilitation for stroke patients

ABSTRACT Background: Dysphagia is characterized by difficulty in the swallowing pattern at any stage of this neuromuscular process. It is a frequent symptom after stroke. Objective: This study aimed to investigate the most commonly used phonoaudiological interventions as therapy for the treatment of swallowing disorders in patients with dysphagia after stroke. Methods: We performed a review of studies indexed in MEDLINE-PubMed, LILACS, Cochrane, and Clinical trials.gov focusing on speech-language interventions for adult dysphagic patients after stroke between January 2008 and January 2021. Results: Thirty-six articles of clinical trials were selected. Eleven different types of therapies have been studied. Studies on the efficacy of therapeutic interventions for the rehabilitation of adult patients with dysphagia after stroke are still scarce. Most techniques are combined with conventional therapy, so the effectiveness of the other techniques alone cannot be assessed. Conclusions: Therapeutic interventions should be selected in accordance with the possibilities and limitations of the patients, and especially with the findings of the clinical evaluation and with its objective.

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.

Jaw-retraction exercise increases anterior hyoid excursion during swallowing in older adults with mild dysphagia

OBJECTIVES

The present study aimed to evaluate the effectiveness of a newly designed jaw-retraction exercise for strengthening the geniohyoid muscle and thus improving the anterior movement of the hyoid bone during swallowing.

BACKGROUND

Although previous studies suggest a relationship between anterior hyoid excursion and upper esophageal sphincter (UES) opening, there are currently no reports of physical exercises without the use of special equipment that can effectively improve this movement of the hyoid bone during swallowing.

MATERIALS AND METHODS

This before-after study included patients presenting to the authors' hospital with mild dysphagia (Level 5 on the Dysphagia Outcome and Severity Scale). The participants were instructed to perform a jaw-retraction exercise designed to strengthen the geniohyoid muscle. Each participant was instructed to perform two sets of the exercise daily for four weeks, with each set consisting of five repetitions. Before and after the four-week training period, videofluoroscopic swallowing studies were performed and later analysed.

RESULTS

Twenty-five patients with a median age of 77 were included. The median peak anterior hyoid position before and after exercise were 129.82 and 132.74 (%C2-C4 length), respectively, and this increase was found to be significant (P = .007). The median extent of UES opening before and after exercise were 8.6 and 9.3 (mm), respectively, and this increase was also found to be significant (P = .040).

CONCLUSION

Our findings demonstrate that the jaw-retraction exercise can effectively improve the anterior movement of the hyoid bone. This exercise may be effective in individuals with oral frailty when signs of swallowing disorders are observed.

Electrical, taste, and temperature stimulation in patients with chronic dysphagia after stroke: a randomized controlled pilot trial

The objective of present study was compare a traditional swallowing therapy program with a new combined swallowing therapy program including neuromuscular electrical stimulation in patients with oropharyngeal dysphagia after stroke. This pilot study included eight patients with chronic oropharyngeal dysphagia after stroke. These patients underwent traditional therapy with gustative-thermic-tactile stimulation (group A), or a new combined program adding neuromuscular electrical stimulation (group B). Study participants were evaluated before and after the intervention using fiberoptic endoscopic evaluation of swallowing with temporal measures of posterior oral spillage and whiteout time, functional oral intake scale and a visual analog scale classifies an individual's swallowing ability. The two groups did not differ in terms of posterior oral spillage time, whiteout time and functional oral intake scale. Subjects in group B exhibited significant increases in visual analog scale scores. However, both groups demonstrated improvement with decreases in posterior oral spillage time, increased whiteout time, and increased functional oral intake scale and visual analog scale scores. There was no difference in the parameters studied in both therapeutic programs in individuals with chronic oropharyngeal dysphagia after stroke.

Compensatory Effects of Sequential 4-Channel Neuromuscular Electrical Stimulation for the Treatment of Acute, Subacute, and Chronic Dysphagia in a Prospective, Double-Blinded Randomized Clinical Trial

Background. The precise mechanism of 2-channel neuromuscular electrical stimulation (NMES) treatment is unknown, and controversy remains over its efficacy. The sequential 4-channel NMES was newly developed based on normal contractile sequences of swallowing-related muscles. Objective. To assess the clinical efficacy of sequential 4-channel NMES during swallowing. Methods. In this prospective RCT, 52 inpatients with dysphagia (acute, subacute, and chronic state) after stroke, brain tumor, or encephalitis were enrolled. Participants who underwent a videofluoroscopic swallowing study (VFSS) and clinical evaluation were enrolled and were randomly assigned to the 4-channel NMES or sham group. The 4-channel NMES and sham groups swallowed thin and honey-like fluids under NMES (sequential stimulation on suprahyoid and infrahyoid) and sham stimulation, respectively. The procedures were evaluated with the VFSS. Pre- and post-treatment evaluations were performed with the videofluoroscopic dysphagia scale (VDS), penetration-aspiration scale (PAS), Likert scale, and kinematic analysis. Results. The 4-channel NMES group showed significantly greater improvements than the sham group with respect to oral VDS, pharyngeal VDS, total VDS, and PAS (P < .05). Furthermore, the Likert scale for satisfaction, easiness, and discomfort for swallowing showed favorable results for the 4-channel NMES group (P < .05). In the kinematic analysis, the peak speed point, distance, and velocity of hyoid movement were significantly greater in the 4-channel NMES group (P < .05). Conclusions. Sequential 4-channel NMES activating the suprahyoid, thyrohyoid, and other infrahyoid muscles during swallowing showed significant clinical improvement with respect to VDS, PAS, and kinematic analysis. Therefore, sequential 4-channel NMES is a potential new functional electrical stimulation system for the treatment of dysphagia.

Effectiveness of Different Application Parameters of Neuromuscular Electrical Stimulation for the Treatment of Dysphagia after a Stroke: A Systematic Review

Background: Dysphagia causes severe complications among people with a stroke. Physiotherapy allows the cure of this pathology, and among the tools it offers is neuromuscular electrical stimulation. However, this is a technique that has not been protocolized. Therefore, it was considered necessary to carry out a systematic review on the efficacy of the various parameters of application of the neuromuscular electrical stimulation in dysphagia generated after a stroke. Methods: A systematic search for publications was conducted in March 2020 in the Pubmed, Cinahl, Medline, Web of Science and Scopus databases, using as search terms: Electric stimulation therapy, Deglutition disorders and Stroke. Results: 21 articles were obtained in which the application of neuromuscular electrical stimulation was applied in isolation (n = 7) or in combination with other techniques such as strengthening exercises and manual therapy techniques (n = 14), with this second modality of treatment having greater benefits for patients. Conclusion: The greatest efficacy of this technique is reached when applied at 60-80 Hz, 700 μs of pulse duration, at the motor intensity threshold and in sessions of 20–30 min.

Effects of Transcutaneous Neuromuscular Electrical Stimulation on Swallowing Disorders: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of the study was to evaluate the efficacy of transcutaneous neuromuscular electrical stimulation on swallowing disorders.

DESIGN

MEDLINE/PubMed, Embase, CENTRAL, Web of science, and PEDro were searched from their earliest record to August 1, 2019. All randomized controlled trials and quasi-randomized controlled trial were identified, which compared the efficacy of neuromuscular electrical stimulation plus traditional therapy with traditional therapy in swallowing function. The Grading of Recommendations Assessment, Development and Evaluation approach was applied to evaluate the quality of evidence.

RESULTS

Eight randomized controlled trials and three quasi-randomized controlled trials were included. These studies demonstrated a significant, moderate pooled effect size (standard mean difference = 0.62; 95% confidence interval = 0.06 to 1.17). Studies stimulating suprahyoid muscle groups revealed a negative standard mean difference of 0.17 (95% confidence interval = -0.42, 0.08), whereas large effect size was observed in studies stimulating the infrahyoid muscle groups (standard mean difference = 0.89; 95% confidence interval = 0.47 to 1.30) and stimulating the suprahyoid and infrahyoid muscle groups (standard mean difference = 1.4; 95% confidence interval = 1.07 to 1.74). Stimulation lasting 45 mins or less showed a large, significant pooled effect size (standard mean difference = 0.89; 95% confidence interval = 0.58 to 1.20). The quality of evidences was rated as low to very low.

CONCLUSIONS

There is no firm evidence to conclude on the efficacy of neuromuscular electrical stimulation on swallowing disorders. Larger-scale and well-designed randomized controlled trials are needed to reach robust conclusions.

Effect of Neuromuscular Electrical Stimulation on Masseter Muscle Thickness and Maximal Bite Force Among Healthy Community-Dwelling Persons Aged 65 Years and Older: A Randomized, Double Blind, Placebo-Controlled Study

Aim: This study investigated the effect of neuromuscular electrical stimulation (NMES) on masseter muscle thickness and maximal bite force among healthy community-dwelling elderly persons older than 65 years. Materials and methods: A total of 40 participants were randomly assigned to the experimental and placebo groups. In the experimental group, NMES was applied to both masseter muscles, and electrical signals were gradually increased until the participants felt a grabbing sensation (range 6.0–7.5 mA) in the masseter muscle. The placebo group, in contrast, underwent NMES in the same manner and procedure as the experimental group with less electrical intensity (0.5 mA). All interventions were administered five times a week for six weeks, 20 min per day. The outcomes were masseter muscle thickness assessed using ultrasound and maximal bite force using a bite force meter. The level of significance was set as p < 0.05. Results: The experimental group showed a significant increase in both masseter muscle thickness and maximal bite force as compared with the placebo group (p = 0.002 and 0.019, respectively). Moreover, the degree of change in the masseter muscle thickness and maximal bite force significantly increased in the experimental and placebo groups (p < 0.001, both). Conclusions: This study demonstrated that NMES could be an effective modality for increasing masseter muscle thickness and maximal bite force in healthy older adults.

Comparative efficacy of nonpharmaceutical therapy in the treatment of dysphagia after stroke: A protocol for systematic review

BACKGROUND

Dysphagia is one of the major post-stroke complications that can severely damage a patient's quality of life. An increasing number of studies have demonstrated that many kinds of nonpharmacological treatments can be used for post-stroke dysphagia. However, there is not enough evidence evaluating the effectiveness and safety of these interventions. This study will conduct a systematic review, and Bayesian network meta-analysis, of nonpharmacological treatments in order to provide evidence for a future study investigating more options for post-stroke dysphagia.

METHODS

Randomized controlled trials (RCTs) of adult patients aged >18 years old who meet the criteria for a diagnosis of post-stroke dysphagia will be included, regardless of gender, nationality, or education level. Four Chinese databases (CNKI, SinoMed, Wanfang Database, and the Chinese Scientific Journal Database) and four English databases (Web of Science, MEDLINE, Embase, and the Cochrane Library) will be searched. Two independent reviewers will evaluate the title summary for each RCT. Disagreements will be discussed with a third commentator. Standard pairwise meta-analysis, including heterogeneity analysis, subgroup analysis, and sensitivity analysis, will be performed using the RevMan 5.3 software, and the risk of bias assessment will be conducted based on the methodological quality of the included trials recommended by the Cochrane Handbook 5.1. The Bayesian network meta-analysis will be performed using R-3.3.2 software. The quality evaluation of this study will be completed using the World Health Organization's Grading of Recommendations, Assessment, Development, and Evaluation.

RESULTS

This study will summarize all the selected trials aimed at estimating the effectiveness, as well as safety, of applying nonpharmacological treatments to post-stroke dysphagia.

CONCLUSION

This systematic review will provide evidence to assess the validity and safety of applying different types of nonpharmacological treatments for post-stroke dysphagia, which may provide clinicians with more choices in the treatment of this disease.

PROSPERO REGISTRATION NUMBER

CRD42019119368.

Efficacy of neuromuscular electrical stimulation on Wilson's disease patients with dysphagia

[Purpose] Dysphagia is a neurological symptom that is observed in more than half of patients with Wilson’s disease. It is often associated with aspiration pneumonia, dehydration, and malnutrition, resulting in drastic reduction of the quality of life. Neuromuscular electrical stimulation could be an adjunct therapy for dysphagia treatment. However, there is limited data about the application of NMES for dysphagia in Wilson’s disease. Thus, we explored the potential application of NMES for dysphagia treatment in Wilson’s disease. [Participants and Methods] Sixty Wilson’s disease patients who suffered from dysphagia were randomized into two groups. Swallowing function training was taught to the control group (n=30) while Neuromuscular electrical stimulation therapy was given to treatment group (n=30). Eight weeks post treatment, using the water swallow test and the Standardized Swallowing Assessment, the swallowing function was determined. [Results] None of the patients experienced discomfort before, during or after the intervention. After 8 weeks of therapy, when compared to the control, an increased improvement in swallowing function was noted for the treatment group. [Conclusion] Neuromuscular electrical stimulation treatment can improve swallowing function in Wilson’s disease patients afflicted with dysphagia. Therefore, it has the potential to be a form of therapy in clinical practice.

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.