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Effectiveness of Neuromuscular Electrical Stimulation on Post-Stroke Dysphagia: A Systematic Review of Randomized Controlled Trials
To determine whether the use of both videofluoroscopic swallowing study (VFSS) and radionuclide salivagram was beneficial for detecting aspiration-induced pneumonia in children with swallowing difficulty.
From 2001 to 2016, children who underwent both VFSS and salivagram consecutively for suspected aspiration or dysphagia were included in the study. Demographic data, findings of VFSS and salivagram, and medical records were reviewed.
Aspiration pneumonia (AP) was present in 34 out of 110 children; 48 showed positive aspiration findings in VFSS and 33 showed positive aspiration findings in salivagram. Among the 62 children who were negative of aspiration in VFSS, 12 (19.4%) showed positive aspiration findings in salivagram. Four out of 12 children were diagnosed with AP. The aspiration findings in both VFSS and salivagram were significantly related to AP. However, the aspiration findings in the two tests were weakly consistent. Even if one test showed negative aspiration, it was helpful to additionally detect AP using another test, which showed positive aspiration finding. If aspiration findings were positive in only one of the two tests, the probability of AP was 38.5%, whereas if they were positive in both tests, the probability increased to 66.7%. If the aspiration findings were negative in both tests, AP did not occur with a probability of 90%.
Salivagram is a valuable tool for monitoring of aspiration in children with swallowing difficulties. It could be helpful in assessment of children at a high risk of AP, even if the VFSS showed negative aspiration findings. Thus, testing for AP using both VFSS and salivagram is desirable.
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To demonstrate the usefulness of early videofluoroscopic swallowing study (VFSS) and to investigate change patterns in dietary methods in stroke patients with dysphagia.
The VFSS was performed within 7 days of stroke onset in neurologically stable patients. The patients were divided into three groups according to type of brain lesion: cortical lesion (CL), subcortical lesion (SCL), and brainstem/cerebellar lesion (BCL). Based on the VFSS results, this study investigated change patterns in feeding method and discrepancies in the aspiration risk predicted by the Water Swallowing Test (WST) and the VFSS. Complications, such as aspiration pneumonia, were also evaluated.
A total of 163 patients met the inclusion criteria and the VFSS was performed within 7 days of stroke. Patients considered at risk for aspiration (Penetration-Aspiration Scale [PAS] scores of 6 to 8) were found in all three groups using the VFSS (47.5% of the CL group, 59.3% of the SCL group, and 47.9% of the BCL group). After early VFSS, 79.7% of the patients were assessed to require restricted feeding methods. A 19.0% discrepancy was found between the WST and VFSS results. At 3-week follow-up after the VFSS, aspiration pneumonia was observed in 12 patients (7.4%) with restricted feeding methods.
Early VFSS during the acute period can facilitate determination of the most appropriate feeding method, and support effective dysphagia management for stroke patients.
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To explore both the early prediction and diagnosis of dysphagia in preterm infants as an important developmental aspect as well as the prevention of respiratory complications, we developed the simple and-easy-to-apply Dysphagia Screening Test for Preterm Infants (DST-PI) to predict supraglottic penetration and subglottic aspiration.
Fifty-two infants were enrolled in a videofluoroscopic swallowing study (VFSS) due to clinical suspicions of dysphagia. Thirteen items related to supraglottic penetration or subglottic aspiration were initially selected from previous studies for the DST-PI. Finally, 7 items were determined by linear logistic regression analysis. Cutoff values, sensitivity, specificity, and the area under the ROC curve (AUC) of the DST-PI for predicting supraglottic penetration or subglottic aspiration were calculated using a ROC curve. For inter-rater reliability, the kappa coefficient was calculated.
Seven items were selected: ‘gestational age,’ ‘history of apnea,’ ‘history of cyanosis during feeding,’ ‘swallowing pattern,’ ‘coughs during or after feeding,’ ‘decreased oxygen saturation within 3 minutes of feeding,’ and ‘voice change after feeding.’ The Spearman correlation coefficient between the DST-PI and the penetration-aspiration scale (PAS) was 0.807 (p<0.001). The sensitivity and specificity at different cutoff values for detecting supraglottic penetration and subglottic aspiration were 96.6% and 76.9% at 3.25, and 88.9% and 75.8% at 6.25, respectively.
The DST-PI is a valid and reliable dysphagia screening test for supraglottic penetration or subglottic aspiration in preterm infants that is easy to apply in a clinical context.
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To investigate the feasibility of the use of the oropharyngeal airway (OPA) during intermittent oroesophageal tube (IOET) feeding.
Ten patients, who were evaluated using the videofluoroscopic swallowing study (VFSS), were enrolled. One patient withdrew from the study during the study period. Tube insertion time with and without OPA use was recorded in the same patients in a random order during the VFSS. Patients who could safely undergo IOET feeding were then randomly allocated to 2 groups (OPA and non-OPA). Satisfaction Questionnaire with Gastrostomy Feeding (SAGA-8) scores and pneumonia incidence were assessed on the 3rd and 10th day after the VFSS. Non-parametric analysis was used for statistical analyses.
The IOET insertion time was significantly shorter in the OPA group than in the non-OPA group (17.72±5.79 vs. 25.41±10.41 seconds; p=0.017). Complications were not significantly different between the 2 groups (p=0.054). Furthermore, although there were no significant differences in the SAGA-8 scores (25.50±2.38 vs. 21.40±3.13; p=0.066), which reflect the patient/caregiver satisfaction and the ease of tube insertion, patients in the OPA group tended to be more satisfied with the feeding procedure.
Although the small size of the study cohort is a limitation of our study, the use of the OPA appears to be beneficial during IOET feeding in patients with dysphagia.
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To describe the correlation between the functional dysphagia scale and aspiration pneumonia and which characteristics influence the occurrence of aspiration pneumonia in patients with idiopathic Parkinson disease.
Fifty-three patients with idiopathic Parkinson disease were prospectively evaluated in this study. Disease severity and functional status were measured by modified Hoehn and Yahr (H&Y) staging, Schwab and England activities of daily living (S-E ADL) scale and Korean version of Mini-Mental State Examination (K-MMSE). Swallowing function was evaluated by the functional dysphagia scale (FDS) and the penetration-aspiration scale (PAS) based on a videofluoroscopic swallowing study. The patients were followed up for 3 months and divided into two groups according to the occurrence of aspiration pneumonia. The correlation between the variables and aspiration pneumonia was analyzed.
Eight patients of the 53 patients were allocated to the aspiration pneumonia group and 45 patients to the non-aspiration pneumonia group. The patients in the aspiration pneumonia group had significantly higher H&Y staging, and scored lower on S-E ADL scale and K-MMSE. The patients in the aspiration pneumonia group had significantly higher scores on FDS and PAS. A multiple logistic regression analysis showed that the S-E ADL scale and the FDS were associated with the occurrence of aspiration pneumonia in the patients with Parkinson disease.
Given that the FDS can quantitatively assess the functional problems associated with dysphagia, it can be clinically effective in predicting the occurrence of aspiration pneumonia, and the FDS and the S-E ADL scale could be predictive variables for aspiration pneumonia in patients with Parkinson disease.
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Spasmodic dysphonia is defined as a focal laryngeal disorder characterized by dystonic spasms of the vocal cord during speech. We described a case of a 22-year-old male patient who presented complaining of idiopathic difficulty swallowing that suddenly developed 6 months ago. The patient also reported pharyngolaryngeal pain, throat discomfort, dyspnea, and voice change. Because laryngoscopy found no specific problems, an electrodiagnostic study and videofluoroscopic swallowing study (VFSS) were performed to find the cause of dysphagia. The VFSS revealed continuous twitch-like involuntary movement of the laryngeal muscle around the vocal folds. Then, he was diagnosed with spasmodic dysphonia by VFSS, auditory-perceptual voice analysis, and physical examination. So, we report the first case of spasmodic dysphonia accompanied with difficulty swallowing that was confirmed by VFSS.
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To identify risk factors for dysphagia in tongue cancer patients. Dysphagia is a common complication of surgery, radiotherapy, and chemotherapy in tongue cancer patients. Previous studies have attempted to identify risk factors for dysphagia in patients with head and neck cancer, but no studies have focused specifically on tongue cancer patients.
This study was conducted on 133 patients who were diagnosed with tongue cancer and who underwent a videofluoroscopy swallowing study (VFSS) between January 2007 and June 2012 at the Asan Medical Center. Data collected from the VFSS were analyzed retrospectively. Patients with aspiration were identified.
Patients showed a higher incidence of inadequate tongue control, inadequate chewing, delayed oral transit time, aspiration or penetration, vallecular pouch and pyriform residue, and inadequate laryngeal elevation after surgery. Moreover, male gender, extensive tumor resection, a higher node stage, and more extensive lymph node dissection were major risk factors for aspiration in tongue cancer patients.
Tongue cancer patients have difficulties in the pharyngeal phase as well as the oral phase of swallowing. These difficulties can worsen after tongue cancer surgery. Gender, the extent of tumor resection, and lymph node metastasis affect swallowing in tongue cancer patients. Physicians should take these risk factors into account when administering swallowing therapy to tongue cancer patients.
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To compare the swallowing functions according to the lesion locations between brain tumor and stroke patients.
Forty brain tumor patients and the same number of age-, lesion-, and functional status-matching stroke patients were enrolled in this study. Before beginning the swallowing therapy, swallowing function was evaluated in all subjects by videofluoroscopic swallowing study. Brain lesions were classified as either supratentorial or in-fratentorial. We evaluated the following: the American Speech-Language-Hearing Association (ASHA) National Outcome Measurement System (NOMS) swallowing scale, clinical dysphagia scale, functional dysphagia scale (FDS), penetration-aspiration scale (PAS), oral transit time, pharyngeal transit time, the presence of vallecular pouch residue, pyriform sinus residue, laryngopharyngeal incoordination, premature spillage, a decreased swal-lowing reflex, pneumonia, and the feeding method at discharge.
The incidence of dysphagia was similar in brain tumor and stroke patients. There were no differences in the results of the various swallowing scales and other parameters between the two groups. When compared brain tumor patients with supratentorial lesions, brain tumor patients with infratentorial lesions showed higher propor-tion of dysphagia (p=0.01), residue (p<0.01), FDS (p<0.01), PAS (p<0.01), and lower ASHA NOMS (p=0.02) at initial evaluation. However, there was no significant difference for the swallowing functions between benign and malig-nant brain tumor patients.
Swallowing function of brain tumor patients was not different from that of stroke patients according to matching age, location of lesion, and functional status. Similar to the stroke patients, brain tumor patients with infratentorial lesions present poor swallowing functions. However, the type of brain tumor as malignancy does not influence swallowing functions.
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To investigate the relationship between removable dentures and swallowing and describe risks.
Twenty-four patients with removable dentures who were referred for videofluoroscopic swallowing study (VFSS) were enrolled. We evaluated the change of swallowing function using VFSS before and after the removal of the removable denture. The masticatory performance by Kazunori's method, sensation of oral cavity by Christian's method, underlying disease, and National Institutes of Health Stroke Scale for level of consciousness were collected. Functional dysphagia scales, including the oral transit time (OTT), pharyngeal transit time (PTT), percentage of oral residue, percentage of pharyngeal residue, oropharyngeal swallow efficiency (OPSE), and presence of aspiration were measured.
Four patients dropped out and 20 patients were analyzed (stroke, 13 patients; pneumonia, 3 patients; and others, 4 patients). The mean age was 73.3±11.4 years. There were significant differences before and after the removal of the denture for the OTT. OTT was significantly less after the removal of the denture (8.87 vs. 4.38 seconds, p=0.01). OPSE increased remarkably after the removal of the denture, but without significance (18.24%/sec vs. 25.26%/sec, p=0.05). The OTT and OPSE, while donning a removable denture, were correlated with the masticatory performance (OTT, p=0.04; OPSE, p=0.003) and sensation of oral cavity (OTT, p=0.006; OPSE, p=0.007).
A removable denture may have negative effects on swallowing, especially OTT and OPSE. These affects may be caused by impaired sensation of the oral cavity or masticatory performance induced by the removable denture.
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To evaluate the effects of physical properties of foods on the changes of viscosity and mass as well as the particle size distribution after mastication.
Twenty subjects with no masticatory disorders were recruited. Six grams of four solid foods of different textures (banana, tofu, cooked-rice, cookie) were provided, and the viscosity and mass after 10, 20, and 30 cycles of mastication and just before swallowing were measured. The physical properties of foods, such as hardness, cohesiveness, and adhesiveness, were measured with a texture analyzer. Wet sieving and laser diffraction were used to determine the distribution of food particle size.
When we measured the physical characteristics of foods, the cookie was the hardest food, and the banana exhibited marked adhesiveness. Tofu and cooked-rice exhibited a highly cohesive nature. As the number of mastication cycles increased, the masses of all foods were significantly increased (p<0.05), and the viscosity was significantly decreased in the case of banana, tofu, and cooked-rice (p<0.05). The mass and viscosity of all foods were significantly different between the foods after mastication (p<0.05). Analyzing the distribution of the particle size, that of the bolus was different between foods. However, the curves representing the particle size distribution for each food were superimposable for most subjects.
The viscosity and particle size distribution of the bolus were different between solid foods that have different physical properties. Based on this result, the mastication process and food bolus formation were affected by the physical properties of the food.
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To investigate swallowing laterality in hemiplegic patients with stroke and recovery of dysphagia according to the laterality.
The sample was comprised of 46 dysphagic patients with hemiplegia after their first stroke. The sample's videofluoroscopic swallowing study (VFSS) was reviewed. Swallowing laterality was determined by the anterior-posterior view of VFSS. We measured width difference of barium sulfate liquid flow in the pharyngoesophageal segment. If there was double or more the width of that from the opposite width in the pharyngoesophageal segment more than twice on three trials of swallowing, then it was judged as having laterality. Subjects were assigned to no laterality (NL), laterality that is ipsilateral to hemiplegic side (LI), and laterality that is contralateral to hemiplegic side (LC) groups. We measured the following: prevalence of aspiration, the 8-point penetration-aspiration scale, and the functional dysphagia scale of the subjects at baseline and follow up.
Laterality was observed in 45.7% of all patients. Among them, 52.4% were in the hemiplegic direction. There was no significant difference between groups at baseline in all measurements. When we compared the changes in all measurements on follow-up study, there were no significant differences between groups.
Through this study, we found that there was no significant relation between swallowing laterality and the severity or prognosis of swallowing difficulty. More studies for swallowing laterality on stroke patients will be needed.
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To examine the effects of a bedside exercise program on the recovery of swallowing after a stroke.
Fifty stroke patients with dysphagia (<6 months post-stroke) were enrolled and classified into two groups, the experimental (25 subjects) and control groups (25 subjects). The control group was treated with conventional swallowing therapy. The experimental group received additional bedside exercise training, which consisted of oral, pharyngeal, laryngeal, and respiratory exercises, 1 hour per day for 2 months, and they were instructed regarding this program through the nursing intervention. All patients were assessed for their swallowing function by Videofluoroscopic Swallowing Study (VFSS), using the New VFSS scale, the level of functional oral intake, the frequency of dysphagia complications, the presence (or not) of tube feeding, the mood state and quality of life before the treatment and at 2 months after the treatment.
After 2 months of treatment, the experimental group showed a significant improvement in the swallowing function at the oral phase in the New VFSS Scale than that of the control group (p<0.05). Further, they also showed less depressive mood and better quality of life than the control group. However, there was no significant change in the incidence of dysphagia complication and the presence (or not) of tube feeding between the two groups.
Bedside exercise program showed an improvement of swallowing function and exhibited a positive secondary effect, such as mood state and quality of life, on subacute stroke patients with dysphagia. For improvement of rehabilitation results on subacute stroke patients with dysphagia, this study suggests that additional intensive bedside exercise would be necessary.
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To investigate whether patterns of swallowing difficulties were associated with the location of the brain lesion, cognitive function, and severity of stroke in stroke patients.
Seventy-six patients with first-time acute stroke were included in the present investigation. Swallowing-related parameters, which were assessed videofluoroscopically, included impairment of lip closure, decreased tongue movement, amount of oral remnant, premature loss of food material, delay in oral transit time, laryngeal elevation, delay in pharyngeal triggering time, presence of penetration or aspiration, and the amount of vallecular and pyriform sinus remnants. The locations of brain lesions were classified into the frontal, parietotemporal, subcortical, medulla, pons, and cerebellum. The degree of cognitive impairment and the severity of stroke were assessed by the Mini Mental Status Examination (MMSE) and the National Institute of Health Stroke Scale (NIHSS), respectively.
An insufficient laryngeal elevation, the amount of pyriform sinus, and vallecular space remnant in addition to the incidence of aspiration were correlated with medullary infarction. Other swallowing parameters were not related to lesion topology. Lip closure dysfunction, decreased tongue movement, increased oral remnant and premature loss were associated with low MMSE scores. A delayed oral transit time were associated with NIHSS scores.
In-coordination of the lip, the tongue, and the oropharynx were associated with the degree of cognitive impairment and the stroke severity rather than with the location of the lesion, whereas incomplete laryngeal elevation and aspiration were predominant in medullary lesions.
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To examine the effects of age, gender and bolus consistency in normal populations using the temporal measurement of Pharyngeal Transit Duration (PTD), which reflects the duration of bolus flow from the ramus of the mandible to the upper esophageal sphincter.
40 normal and healthy subjects had Videofluoroscopic Swallowing Examinations (VFSEs) of 5 ml thin and nectar thick liquids, and puree consistencies. A slow motion and frame by frame analysis was performed. Three-way analysis of variance (ANOVA) was performed to examine the main effect and interactions, and paired t-tests for the three consistency comparisons.
Older subjects had a significantly longer PTD than younger subjects (p<0.01). In addition, men had significantly shorter PTDs than women (p<0.01). Puree showed a significantly longer PTD than the other two consistencies, regardless of age and gender (p<0.05).
PTD is an indicative of motor weakness in pharyngeal swallowing secondary to aging. In addition, the results supported the assumption that there is a functional difference in pharyngeal swallowing between men and women. It is expected that the results of this study will be used for further investigation of patients with dysphagia.
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To determine the major risk factors and abnormal videofluoroscopic swallowing study (VFSS) findings associated with aspiration in patients with head and neck cancer (HNC).
Risk factors associated with aspiration were investigated retrospectively in 241 patients with HNC using medical records and pre-recorded VFSS. Age, gender, lesion location and stage, treatment factors, and swallowing stage abnormalities were included.
Aspiration occurred in 50.2% of patients. A univariate analysis revealed that advanced age, increased duration from disease onset to VFSS, higher tumor stage, increased lymph node stage, increased American Joint Committee on Cancer (AJCC) stage, operation history, chemotherapy history, and radiotherapy history were significantly associated with aspiration (p<0.05). Among them, advanced age, increase AJCC stage, operation history, and chemotherapy history were significantly associated with aspiration in the multivariate analysis (p<0.05). Delayed swallowing reflex and reduced elevation of the larynx were significantly associated with aspiration in the multivariate analysis (p<0.05).
The major risk factors associated with aspiration in patients with HNC were advanced age, higher AJCC stage, operation history, and chemotherapy history. A VFSS to evaluate aspiration is needed in patients with NHC who have these risk factors. Delayed swallowing reflex and reduced elevation of the larynx were major abnormal findings associated with aspiration. Dysphagia rehabilitation should focus on these results.
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To investigate the clinical usefulness of the Schedule for Oral-Motor Assessment (SOMA) in children with dysphagia by comparing findings of SOMA with those of the videofluoroscopic swallowing study (VFSS).
Both SOMA and VFSS were performed in 33 children with dysphagia (21 boys and 12 girls; mean age 17.3±12.1 months) who were referred for oropharyngeal evaluation. Ratings of oral-motor functions indicated by SOMA were based upon the cutting score of each specific texture of food (puree, semi-solids, solids, cracker, liquid-bottle, and liquid-cup). Abnormalities of either the oral phase, or the pharyngeal phase as indicated by VFSS were assessed by a physician and a speech-language pathologist.
There was significant consistency between the findings of SOMA and the oral phase evaluation by VFSS (Kappa=0.419, p=0.023). SOMA reached 87.5% sensitivity, 66.6% specificity, and 95.4% positive predictive value when compared with the oral phase of the VFSS. We were able to evaluate oral-motor function by using SOMA in 6 children who were unable to complete the oral phase evaluation by VFSS, due to fear and crying during the study. The findings of SOMA failed to show any consistency with the pharyngeal phase evaluation by VFSS (Kappa=-0.105, p=0.509).
These results suggest that SOMA is a reliable method for evaluation of oral-motor function in children with dysphagia. In particular, SOMA is recommended for children that were unable to complete the oral phase evaluation by VFSS due to poor cooperation.
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To investigate the therapeutic effects of repetitive electrical stimulation of the suprahyoid muscles in brain-injured patients with dysphagia.
Twenty-eight brain-injured patients who showed reduced laryngeal elevation and supraglottic penetration or subglottic aspiration during a videofluoroscopic swallowing study (VFSS) were selected. The patients received either conventional dysphagia management (CDM) or CDM with repetitive electrical stimulation of the suprahyoid muscles (ESSM) for 4 weeks. The videofluoroscopic dysphagia scale (VDS) using the VFSS and American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) swallowing scale (ASHA level) was used to determine swallowing function before and after treatment.
VDS scores decreased from 29.8 to 17.9 in the ESSM group, and from 29.2 to 16.6 in the CDM group. However, there was no significant difference between the groups (p=0.796). Six patients (85.7%) in the ESSM group and 14 patients (66.7%) in the CDM group showed improvement according to the ASHA level with no significant difference between the ESSM and CDM groups (p=0.633).
Although repetitive neuromuscular electrical stimulation of the suprahyoid muscles did not further improve the swallowing function of dysphagia patients with reduced laryngeal elevation, more patients in the ESSM group showed improvement in the ASHA level than those in the CDM group. Further studies with concurrent controls and a larger sample group are required to fully establish the effects of repetitive neuromuscular electrical stimulation of the suprahyoid muscles in dysphagia patients.
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