Surface Electromyographic Biofeedback and the Effortful Swallow Exercise for Stroke-Related Dysphagia and in Healthy Ageing

Sally K Archer,Christina H Smith,Di J Newham

doi:10.1007/s00455-020-10129-8

Abstract

Dysphagia is common after stroke, leading to adverse outcome. The Effortful Swallow (ES) is recommended to improve swallowing but it is not known if dysphagic patients can increase muscle activity during the exercise or if age affects performance. Providing surface electromyographic (sEMG) biofeedback during dysphagia therapy may enhance exercise completion, but this has not been investigated and the technique’s acceptability to patients is not known. Aims: To determine if age or post-stroke dysphagia affect the ability to increase submental muscle activity during the ES, if sEMG biofeedback improves ES performance and if sEMG is an acceptable addition to therapy. In a Phase I study submental sEMG amplitudes were measured from 15 people with dysphagia < 3 months post-stroke and 85 healthy participants aged 18–89 years during swallowing (NS) and when they performed the ES with and without sEMG biofeedback. Participant feedback was collected via questionnaire. Measurements were compared with repeated measures ANOVA and age effects were examined with linear regression. Both groups produced significantly greater muscle activity for the ES than NS (p < 0.001) and significantly increased activity with biofeedback (p < 0.001) with no effect of age. Participant feedback about sEMG was very positive; over 98% would be happy to use it regularly. The ES is a physiologically beneficial dysphagia exercise, increasing muscle activity during swallowing. sEMG biofeedback further enhances performance and is considered an acceptable technique by patients. These findings support the potential application of sEMG biofeedback and the ES in dysphagia therapy in stroke, justifying further investigation of patient outcome.

Highlights

Oropharyngeal dysphagia, or difficulty with swallowing, affects around 50% of acute stroke patients [1], is associated with an 11-fold increase in the risk of pneumonia [2], is an independent predictor of mortality and is associated with poor nutrition, dehydration, increased length of stay, institutionalisation and poor quality of life [3,4,5,6].Speech and language therapists (SLTs) recommend behavioural therapy techniques for dysphagia in which patients work to gain volitional control of previously automatic movements with the aim of restoring swallowing ability, airway protection and quality of life [7]
Technical difficulties arose during the surface electromyographic (sEMG) recording for one who was transferred to a different hospital before a second session could be conducted
This study has shown for the first time that dysphagic stroke patients are able to significantly increase their muscle activity for the Effortful Swallow (ES) exercise

Summary

Introduction

Speech and language therapists (SLTs) recommend behavioural therapy techniques for dysphagia in which patients work to gain volitional control of previously automatic movements with the aim of restoring swallowing ability, airway protection and quality of life [7]. Feedback is vital for motor learning to be successful as the learner adapts subsequent behaviour according to the difference between the actual and the desired output [9,10,11]. It is accepted that individuals generate motor commands that will maximise the reward they receive [11], so it follows that accurate feedback is essential and the right behaviour is rewarded to shape learning.

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